Erectile dysfunction (ED)

Patient Information

Erectile dysfunction (ED)

Overview:

Erectile dysfunction (ED) is defined as the ongoing inability to achieve or maintain an erection sufficient for sexual intercourse. It is not uncommon, and affects as many as 15-30 million men in the Untied States today. Although increasing age is a risk factor, ED is itself is not an inevitable part of aging. ED is, in most cases, treatable.

For many men today, ED is one of the earliest signs of cardiovascular disease – and warrants attention by a healthcare provider.

Risk Factors

Penile erection results from a complex sequence of events involving nerves, arteries, veins, muscles and tissues of the penis. Dysfunction involving any of these can result in difficulty achieving and maintaining an erection.

Today, the most common causes of ED are diseases and health conditions that affect the entire body, on a systems-level, such as diabetes (Types I and II), high blood-pressure, and high cholesterol/lipids, all of which contribute to cardiovascular disease, atherosclerosis, and neuropathy which impair the health and function of tissues and nerves of the penis. Smoking and obesity play a causative role via these same mechanisms.

Other common causes of ED include the use of medications which, often as a side effect, impair the nerves and blood flow to the penis. Some surgeries, and radiotherapy to the pelvis, also have the potential to injure nerves and arteries related to erectile function, and cause ED. Advances in surgical techniques or prostatectomy, including the nerve-sparing radical prostatectomy, and post-prostatectomy erectile-function rehabilitation protocols, – have reduced the likelihood of long-term ED after prostatectomy.

ED can also occur from purely psychological causes (psychogenic ED), but this accounts for only a small minority of cases- less than 10%. Men with psychogenic ED are more commonly younger than the majority of ED patients, and often report anxieties and other difficulties associated with the interpersonal aspects of intercourse.

Common causes of erection problems include:

  Diseases and conditions such as diabetes, high blood pressure, heart or thyroid conditions, poor blood flow, depression, or neurologic disorders (such as multiple sclerosis or Parkinson's disease)

  Medications such as blood pressure medications (especially beta-blockers), heart medications (such as digoxin), some peptic ulcer medications, sleeping pills, and antidepressants

  Nerve damage from prostate surgery

  Nicotine, alcohol, or cocaine use

  Poor communication with your partner

  Repeated feelings of doubt and failure or negative communication that reinforce the erection problems

  Spinal cord injury

  Stress, fear, anxiety, or anger

  Unrealistic sexual expectations, which make sex a task rather than a pleasure

Erection problems tend to become more common as you age, but they can affect men at any age and at any time in their lives. Physical causes are more common in older men, while psychological causes are more common in younger men.

Low levels of testosterone rarely lead to erection problems, but may reduce a man's sex drive.

Treatment of Erectile Dysfunction

Simple lifestyle changes, such as smoking cessation, weight loss and even modest but regular exercise, very often improve, and can often resolve, ED symptoms. Improvement in these domains serves to improve blood flow, tissue health, and nerve function of penile tissues.

Adjustments related to medications that adversely affect erectile function should be considered whenever possible. When psychological factors are believed to be contributing cause of ED– particularly in men who are experiencing anxiety or depression – psychological counseling is recommended.

When the aforementioned strategies prove insufficient to address ED symptoms, medical therapies are warranted. The simplest treatments include use of a class of medications known as oral phosphodiesterase inhibitors (Viagra Levitra and Cialis). These drugs enhance the effects of nitric oxide, a natural molecule within the body that relaxes the smooth muscle of the penis, to enable increased blood to flow and result in erection. Some patients, such as those who have a history of angina (heart-related chest pain), and/or some heart conditions, should not take these medications, and should consult their urologist before trying these. 

Another relatively simple, non-invasive treatment for ED includes use of a vacuum erection device (‘penile pump’), to assist with achieving erection for intercourse. Men who can, on their own, achieve even partial erections, are better candidates for use of this device. 

When the aforementioned treatments prove insufficient, other treatment options that can be tried include self-injection therapy- use of erection-inducing medications that the patient learns to inject directly into the side of his penis, using a very small, fine needle/ syringe. Just as oral phosphodiesterase inhibitor medications do, these drugs facilitate engorgement of the penis with blood, thereby causing it to become firm. Two key benefits of self injection therapy are that, unlike with oral medications, the dose can be more controlled and increased as needed. Another benefit is that, because the drug is injected directly into the target (penile) tissues, little if any of the drug enters the circulation, thereby reducing the likelihood of systemic side effects.

Surgery is another option, particularly when the aforementioned more conservative approaches fail to adequately improve erectile function. Implant of an inflatable penile prosthesis is a common, and often very satisfactory treatment option. Benefits of this option include the avoidance of medications and injections, a very natural appearance and feel of the penis in both the flaccid and erect states, and, complete control over the onset and duration of the erection. Implant surgery generally does not interfere with penile sensation and orgasmic function.

For some select, and often rare causes of ED, vascular and/or reconstructive surgery to improve blood flow to or from the penis is indicated to treat ED.

Alternative treatments, such as nutritional supplements, herbal remedies and acupuncture, are considered by some to be useful. However, for the majority of these therapies, efficacy is unproven, and due to the lack of FDA regulation of these products, the specific ingredients, quality, and/or treatment dosage are not reliable, and hence, these should be used with caution and only after consultation with a physician.

In sum, erectile dysfunction (ED) is often symptomatic of underlying health problems, and warrants evaluation by a physician. Today, a variety of treatment options exist for ED, and men should not forgo evaluation and treatment by a urologist for this condition. 

  

Related Providers

• Associate Professor of Urology and Epidemiology & Biostatistics, • Chief of Urology, San Francisco General Hospital, • Director, UCSF Male Genitourinary Reconstruction and Trauma Surgery Fellowship, • Residency Program Associate Director
Professor and Vice Chair
 of Urology
Associate Professor and Director, Male Reproductive Health