Erectile dysfunction (ED)


Erectile dysfunction (ED) is defined as the recurrent or chronic 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 United States today. Although increasing age is a risk factor, ED is itself is not an inevitable part of aging.  Erection problems are more common in older men but can effect men at any age.   ED is, in most cases, treatable.

ED is more than a quality of life issue; numerous studies have indicated that men with ED are at increased risk of developing cardiovascular disease and even dying form cardiac disease.

Risk Factors

Penile erection is the result of a complex sequence of events involving nerves, arteries, veins, and erectile tissues of the penis. A man’s psychological state and his feelings about his relationship/partner(s) also have important implications for penile erection.  Issues with any of these systems can result in difficulty achieving and maintaining an erection.

One of the most important causes for ED is vascular disease; examples include diabetes (Types I and II), high blood-pressure, high cholesterol/lipids, tobacco use, obesity, and lack of exercise.  All of these conditions can lead to impaired response of the blood vessels responsible for controlling penile erection.  There is evidence that men who have vascular disease and make healthy lifestyle changes (e.g. increasing exercise, losing weight, quitting smoking) may experience improvement in erectile function.  It is important to remember that whatever is good for the heart is also good for the penis.

Other potential biological causes of ED include injury to nerves, certain medications, and low levels of testosterone.

A man’s psychological state is clearly an essential consideration when addressing issues of sexual function.  While ED that is purely psychological is not common, many men who experience difficulty with erections may develop anxiety or fear about being able to get an erection the next time they try.  This anxiety may lead to a stress response involving activation of the sympathetic nervous system and release of adrenaline, which will tend to make it even more difficult to get an erection.  Conflict with a partner (or the absence of a partner) will also tend to increase stress and potentially interfere with erectile function.

Common causes of erection problems include:

• 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, most commonly blood pressure medications (especially beta-blockers or thizides), anti-depressants (such as SSRI), anti-androgens, and a variety of other medications

• Nerve damage from pelvic surgery or radiation (e.g. treatment of prostate, bladder, or rectal cancer) or from conditions known to lead to neuropathy (e.g. HIV, diabetes)

• Nicotine, alcohol, or cocaine use

• Conflict with the sexual partner(s)

• 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

Treatment of Erectile Dysfunction

Simple lifestyle changes, such as smoking cessation, weight loss, and even modest but regular exercise very often improve ED symptoms.  In mild cases of ED this change alone may be sufficient to resolve the issue.  In more severe cases these changes may improve the efficacy of available medical options.  In any case these changes are good for the heart and overall longevity/health so should be considered by all men with ED.

Adjustment of medications that adversely affect erectile function should be considered whenever possible.

When psychological factors are believed to be the principle cause of ED– particularly in men who are experiencing anxiety or depression – psychological counseling is mandatory.  Consultation with a mental health professional with expertise in sexuality should be considered in all cases as this consultation is seldom harmful and the majority of patients will have some psychogenic or relational component to their sexual symptoms.

When the aforementioned strategies prove insufficient to address ED symptoms, medical therapies are warranted. The simplest treatments include use of a class of oral medications known as phosphodiesterase type 5 inhibitors (PDE5I, e.g. sildenafil, tadalafil, vardenafil, and avanafil). 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. These medications are generally very safe and reliable.   Men who use nitrates (found in certain heart medications and in some recreational drugs) should not use PDE5I.  Optimal use of PDE5I requires advice on timing and proper use of these drugs for maximal effect.

Another relatively simple, non-invasive treatment for ED includes use of a vacuum erection device (‘penile pump’), to assist with achieving erection for intercourse. These devices work by pulling blood into the penis; a tight constrictive ring is then placed at the base of the penis.  While generally safe, care should be taken not to overinflate the device nor to leave the constrictive ring on for prolonged periods as either of these may lead to penile damage.

Self-injection therapy is another option for managing ED; in this approach, the man is taught how to inject vasodilator medications directly into the side of his penis, using a very small, fine needle/ syringe.  These drugs increase penile blood flow which can lead to erection. While not generally as convenient as oral medications, self-injection tends to be more powerful and can be used by men who are taking nitrate medications.  The fact that the medication goes directly into the penis may also help to limit systemic side effects that may occur with medications taken by mouth.  The biggest risk of injections is the possibility of an erection that does not go away by itself (known as priapism).  If a man develops a prolonged (~4 hours or more) and painful erection he should be seen emergently as the penis may otherwise be permanently damaged.

When the aforementioned more conservative approaches fail to adequately improve erectile function surgical options may be considered. A device known as a penile prosthesis may be inserted and often leads to high patient and partner satisfaction.  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. The majority of penile implants placed in the United States are inflatable models but non-inflatable malleable options also exist.  Implant surgery generally does not interfere with penile sensation and orgasmic function.  Placement of a penile prosthesis carries the general risks of any operation, including the possibility of infection requiring device removal.  It is also important to recognize that the erect length of the penis after prosthesis surgery tends to be less than pre-ED length.

Alternative treatments, such as nutritional supplements, herbal remedies, and acupuncture, are options to consider. However, evidence supporting many of these treatments is spare and due to the lack of FDA regulation the quality of any given supplement is unclear. In several high profile cases allegedly “natural” ED treatments were found to contain erection medications; as these medications have certain side effects and drug interactions (specifically PDE5I and nitrates) there is potential for very serious reactions even with “natural”, non-prescription medications.

In sum, ED is a troubling condition that may be a sign of serious underlying health problems.  It is appropriate to discuss ED with your physician. A variety of management options exist; men and their partners may decide which if any of these are appropriate for their specific circumstances.