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Erectile Dysfunction What is erectile dysfunction? What other issues are potentially considered erectile dysfunction? How common is erectile dysfunction? How do erections develop? What cause erectile dysfunction to occur? How is erectile dysfunction diagnosed? How is erectile dysfunction treated? What kinds of medications may cause ED as a side effect? What is meant by lifestyle changes? What is hormonal therapy for erectile dysfunction? What about herbal supplements for ED? What drug therapies can be used to assist in erections? What are penile injections? What is MUSE? What is a vacuum pump? What are the surgical options for erectile dysfunction? What is sex therapy counseling? What are common medications or other substances that can cause ED? What brand of nitrates should I be concerned about if I want to take Viagra©? For additional information What is erectile dysfunction? Erectile dysfunction (ED) is a condition in which men have difficulty achieving or maintaining an erection in their penis sufficient for satisfactory sexual intercourse. Another term often used for erectile dysfunction is impotence. Every man should expect to experience problems achieving satisfactory erections occasionally, but normally those are passing or temporary situations. And it's also normal as men age for the frequency, rigidity and duration of erections to lessen. However, in contrast to past thinking that impotence was an inevitable consequence of aging, today it's believed that sexual function can be maintained or restored for many men of any age. ED is considered to be present when erection difficulties become chronic, occurring consistently over a period of time. Its severity can range from mild (that is, your erections are less rigid and shorter in duration than they might be) to total (you can't achieve erections at any time). ED as a medical condition is often defined as a situation in which you are consistently unable to achieve and maintain a satisfactory erection for intercourse over a period of at least two months. Development of ED can reflect a wide range of causes, including medical issues such as nerve damage that interferes with electrical impulses, vascular problems that impair blood flow, medical conditions such as hypertension, side effects from medications to treat other problems, injuries, hormonal imbalances and psychological problems. Today, doctors have an array of treatment options, including medications to facilitate erections, mechanical devices that can help create them, and penile implant surgery. The urologists of Hartford Specialists have strong experience in evaluation and treatment of erectile dysfunction. They have been leaders in developing techniques to treat it, providing a full range of diagnostic and therapeutic options to help men with this very personal problem. (return to top) What other issues are potentially considered erectile dysfunction? It should be noted that some doctors define erectile dysfunction as covering a broad range of problems, including Peyronie's disease (which is associated with build-up of scar tissue in the penis and curved, painful erections) and premature ejaculation, but in common parlance ED refers to the inability to achieve an erection for satisfactory intercourse. Some doctors prefer the term erectile dysfunction rather than impotence for similar reasons, feeling that impotence is associated with a broader range of problems. This article focuses specifically on the inability to achieve a satisfactory erection, and uses the terms erectile dysfunction and impotence to refer to that problem. (return to top) How common is erectile dysfunction? It's estimated that in the United States, between 15 million and 30 million men are affected by erectile dysfunction, depending upon how broadly the term is interpreted. In a study called the Massachusetts Male Aging Study, published in the mid-1990s, some 17 percent of men between the ages of 40 and 70 reported experiencing mild ED, as many as 34 percent reported experiencing moderate ED and as many as 15 percent reported experiencing complete ED. Age is clearly a factor. In another study, the National Ambulatory Medical Care Survey, five percent of 40-year-old men reported experiencing ED while 25 percent of 65-year-old men reported it. Statistics suggest that the rates of ED are increasing, but this may be because the availability of new treatment options are causing more men to seek help. Since sildenafil citrate (better known by the brand name Viagra®) was introduced in 1998, it has been prescribed for more than 16 million men world-wide. (return to top) How do erections develop? The development of an erection is a complex process involving sensory or mental stimulation perceived at the brain, signals sent via nerve pathways to the genital area, and the opening and closing of blood vessels at the penis. Central to an erection are two chambers called the corpora cavernosa, which begin in the lower abdomen and, running parallel to the urethra, extend to the full length of the penis. Surrounded by a membrane called the tunica albuginea, the corpora consist of spongy tissue containing smooth muscle and fibrous tissues, spaces, veins and arteries. In the flaccid or non-erection state the arteries are constricted, kept from filling with blood by tight muscle tissue. When the brain experiences stimulation, it sends signals down the nerve pathways to relax the corpora muscles, allowing blood to enter and fill the spaces, causing the expansion and stiffening of the penis that becomes an erection. At the same time, the veins leaving the area become blocked, trapping the blood within the penis. The tunica albuginea serves to contain the blood within the corpora, helping to maintain the erection. Once stimulation has been completed — usually, that is, by orgasm — the process is reversed, the corpora muscles tighten to block the inflow of blood, the outflow is resumed and the penis becomes flaccid once more. (return to top) What cause erectile dysfunction to occur? Erectile dysfunction can result when any of the nerve, muscular, arterial, venous or fibrous tissues involved in the process of creating an erection are damaged or otherwise interfered with. Diseases such as diabetes and multiple sclerosis can affect nerve function, interfering with the signals to start an erection. Arterial disease such as hypertension and atherosclerosis can restrict the flow of blood to the penis, causing a diminished ability to fill the corpora cavernosa. Failure of the penile veins to block the outflow of blood can keep it from becoming trapped in the corpora. Many commonly used drugs, including blood pressure medications, antidepressants and antihistamines can cause erectile dysfunction as a side effect by interfering with either nerve signals or blood flow. Hormonal abnormalities — most notably low levels of testosterone — can cause erectile dysfunction. Substance abuse, such as heavy use of alcohol, marijuana and other drugs, can cause erectile dysfunction. Smoking can interfere with the flow of blood in veins and arteries and contribute to ED problems. Injury or surgery such as radical prostatectomy for cancer can damage the penile nerves, arteries, smooth muscle and other tissues, causing their inability to function. Depression, low self-esteem, stress, anxiety and fear of sexual failure can contribute to failure to achieve erection. Diseases such as diabetes and atherosclerosis are believed to be responsible for perhaps 70 percent of problems with erectile dysfunction, and for more than 90 percent in men over the age of 50. Whereas at one time psychological issues were believed the most common factor in impotence, today anxiety and other psychological issues are considered responsible for about 20 percent of ED problems. Of course, anxiety and fear of failure can become an added, self-fulfilling element for many men once they have experienced failure to achieve a satisfactory erection, regardless of the cause. As noted, all men should expect to experience a problem with erectile function occasionally. Some doctors consider a failure rate of less that 20 percent to be non-worrisome, and of more than 50 percent to warrant medical attention. (return to top) How is erectile dysfunction diagnosed? The urologists of Hartford Specialists can help in the diagnosis of erectile dysfunction using some of the following: Review of your history, both medical and sexual A physical examination to look for systemic problems, such as atherosclerosis Identification of possible causal factors (such as medication conflicts, alcohol habits or underlying disease, such as diabetes) Blood tests to measure such factors as anemia, creatine, liver enzymes, testosterone and prolactin Urinalysis to evaluate protein and sugar levels Blood flow studies, including ultrasound to measure the flow of blood, vasodilatation to stimulate an erection with a drug injection and caversonography to visualize functioning of the penile veins using a medical dye and x-ray imaging Nocturnal penile tumescence monitoring tests to determine the presence, frequency and strength of the erections that normally occur during a night's sleep Psychological evaluation to consider stress, anxiety regarding sexual preference, depression or other psychological factors Your doctor may well want to interview your sexual partner as well to gain additional insights. (return to top) How is erectile dysfunction treated? Treatment possibilities for erectile dysfunction can range from solutions as simple as changing medications that are interfering with erections to surgery to implant a device to assist you in creating erections. In between are changes in lifestyle, prescription of medications such as Viagra®, therapies such as penile injections, the use of a mechanical device called a vacuum pump and psychological counseling. Surgery to repair a vascular problem may be a possibility for some patients. Your doctor will likely want to start with the least dramatic treatment that seems appropriate, moving to more serious measures as results dictate. (return to top) What kinds of medications may cause ED as a side effect? It's possible that prescription or over-the-counter medications you may be taking for a range of problems are affecting your nerve or vascular functions or your hormone levels and creating erectile dysfunction problems. There is a long list of diuretics and antihypertensive medications, antidepressants, antihistamines, non-steroidal anti-inflammatory drugs, muscle relaxants and tranquillizers that can have this effect. Similarly, some medications for Parkinson's disease, cardiac irregularity, esophageal reflux disease, prostate cancers and other cancers and epilepsy may contribute to ED. (For a list of drugs that commonly cause erectile dysfunction, click here.) It's important to emphasize that not all drugs in these categories cause or contribute to ED. And, if you're on any medications for these diseases, it's especially important that you not discontinue taking them without consulting your doctor and having them evaluated for any association with ED. If you are taking a medication that contributes to ED as a side effect, it's possible that your prescription can be changed to eliminate the side effect. (return to top) What is meant by lifestyle changes? Eliminating some negative behaviors that contribute to erectile dysfunction specifically and living a healthy lifestyle generally can help you reduce your likelihood of ED problems. Some changes that may have an effect on your sexual performance include: Reducing or eliminating alcohol consumption or other substance abuse. Alcohol, marijuana and other drugs, even caffeine, can contribute to erectile dysfunction Quitting smoking. Tobacco use affects your vascular system and can contribute significantly to ED Exercising regularly. Among its many benefits, a program of regular exercise helps lower your blood pressure, improve your energy levels and reduce anxiety and depression. Reducing stress. Practice methods of relaxation through such measures as meditation, exercise, controlling substance abuse and setting realistic goals for yourself. Feeling better about yourself will help you deal with your erectile dysfunction problems. (return to top) What is hormonal therapy for erectile dysfunction? For men whose ED is diagnosed as associated with low levels of the hormone testosterone, supplements of the hormone may be appropriate. However, this is a less common cause of ED, and the number of men for whom it may be suitable is limited. Risks include the possibility of damage to the liver. (return to top) What about herbal supplements for ED? The herb yohimbe has been touted as an agent promising assistance with erections, but yohimbe has potentially serious side effects, including anxiety, hallucination, dizziness, headache, increased heart rate and elevated blood pressure. Its use is discouraged. Herbs such as ginkgo, ginseng and saw palmetto are also promoted as assisting with ED problems, but their effectiveness remains unproven. If you take any herb, be sure to consult with your physician regarding possible side effects and interactions with prescription drugs you are taking. (return to top) What drug therapies can be used to assist in erections? Sildenafil, better known by the brand name Viagra®, is not only considered a successful agent for assisting in development of erections, it has become the most-prescribed drug in the world. Taken as an oral medication, sildenafil does not cause an erection in and of itself. Instead, it helps amplify the physical process that begins when you experience stimulation that would normally lead to an erection. Specifically, taken 30 minutes or so before a sexual encounter, it intensifies the action of a chemical called nitric oxide in relaxing the smooth muscles of the penis, allowing blood to fill the corpora cavernosa. According to its manufacturer, Pfizer, Inc., studies show that it works for as many as 4 out of 5 men, and works in most men regardless of age or cause of ED. Normally, the drug's effects are good for as long as four hours, and it is safe to take as often as every day. However, doctors caution that sildenafil may not be appropriate for every man — especially those taking drugs containing nitrates, such as nitroglycerin for the heart disorder angina. Nitrates can come in pill, cream or patch form for angina prevention (for a list of known nitrate drugs, click here). Sildenafil combined with nitrates can cause a dramatic drop in blood pressure and potentially serious heart problems or death . The drug has not been shown to cause heart damage on its own. The exertion of sexual activity in some patients can lead to cardiac events. Sildenafil should also be used with caution when combined with alpha blockers (such as Cardura®, Hytrin® and Flomax©) prescribed to improve urine flow. Also, since ED may reflect a more serious, underlying disease like diabetes, it's important to consult with your doctor before taking sildenafil. There are other drugs similar to sildenafil currently in development, but they are still in the clinical trials stage, at best. (return to top) What are penile injections? Penile injections represent another drug therapy for assisting in development of erections, but rather than being oral medications these are topically applied. Specifically, in this treatment a fine needle is used by the man to inject an agent directly into his penis to open blood vessels, facilitating filling of the corpora cavernosa. Drugs prescribed may include paperavine hydrochloride, phentolmine, or a synthetic version of the hormone prostaglandin E called alprostadil. While the concept of injecting one's penis may seem somewhat frightening, the needle used is very fine and is barely felt. Drawbacks, however, can include scarring and the risk of creating an erection that will not go away — a condition called priapism. Priapism may require an emergency room visit to inject a drug to release the injection's effect. (return to top) What is MUSE? The Medicated Urethral System for Erection (MUSE) makes use of a similar topical medication to induce erections. In this case, the man uses a thin, disposable, prefilled applicator to place a tiny aprostadil pellet within the urethra. Placed one to two inches deep within the urethra, the aprostadil is absorbed by surrounding tissue to open up blood vessels, allow filling of the corpora and create an erection. MUSE can result in an erection within a few minutes, with the erection lasting as long as 60 minutes. While MUSE avoids the drawbacks of injections, it can cause discomfort in the form of aching and a burning sensation in the genitals, and it can cause minor urethral bleeding. (return to top) What is a vacuum pump? A vacuum pump is a mechanical device designed to induce an erection by creating a vacuum that draws blood into the penis. It consists of a hollow plastic cylinder in which the penis is placed, a pump that draws air out of the cylinder to induce blood flow into the corpora within the penis. A rubber tension ring, or strong rubber band is placed around the base of the penis once an erection is attained and the cylinder is removed. The ring, of course, is intended to inhibit blood from flowing out of the penis once the corpora is filled and must be removed. (return to top) What are the surgical options for erectile dysfunction? There are three surgical approaches to the treatment of erectile dysfunction, depending on the cause that has been identified: Arterial surgery. Vascular surgery may be appropriate for men who have had an injury or atherosclerotic blockage to the arteries that deliver blood to the penis, with the goal of restoring blood flow and the possibility of erections through the natural process. It's usually most effective with young men — that is, under 45 years of age — dealing with a specific blockage associated with an injury, and less effective with older men whose atherosclerosis-related blockage may be more extensive. Side effects can include scarring, numbness and shortening in the penis — issues that can be factors in continued ED. Venous ligation surgery. Venous surgery is intended to reduce the flow of blood out of the penis during erections by blocking off (ligating) veins that allow blood to "leak" during erections. The long-term effectiveness of this surgery is less than 50 percent, and it is rarely considered to be an appropriate option. Side effects include the risk of penile shortening Penile prostheses surgery. Penile prostheses surgery is performed to implant one of several prosthetic devices within the upper side of the penis to enable a man to experience erections. Three types of prostheses are most commonly used. Malleable implants involve surgically implanting permanently semi-rigid rods that can be flexed or straightened to create an erect penis. Easy to use and implantable with only local anesthetic, they extend the length of the penis and can approach a full-girth erection, but they can be kept bent, allowing concealment. Self-contained inflatable implants can be made erect or flaccid. Relying on a pump reservoir near the head of the penis to inflate and deflate it, the implant can expand the length and width of the penis, resulting in a more natural state. In its erect state, it's likely to be less rigid than other types. Also, they're more difficult to use than the malleable type, and they're more likely to break down. They can frequently be implanted with only a local anesthetic. Fully inflatable implants most closely replicate the process of natural erections, expanding the penis in length and width for erections and allowing a flaccid state. The devices include not just implanted inflatable cylinders but separate fluid reservoirs and separate pumps. But they're the most complex to use and the most likely to break down. Implantation usually involves a hospital stay and general anesthesia. (return to top) What is sex therapy counseling? If stress, anxiety or depression are considered to be significant factors in your erectile dysfunction problems, psychological counseling may be appropriate, both to help you deal with underlying issues and to learn techniques to help you overcome them. Counseling by a trained therapist may be able to help you overcome guilt or inhibiting attitudes that may have been instilled at an early age. Success is more likely when your counseling involves your partner. Communication, sensual and sexual exercises to practice at home can help you relax and develop an enjoyment of sexual encounters. Keep in mind that successful counseling may involve a series of therapy sessions rather than just one or two sessions. (return to top) What are common medications or other substances that can cause ED? Diuretics Thiazides Spironolactone Antihypertensives Methyldopa Clonidine Respirine Beta Blockers Guanethidine Verapamil Cardiac Clofibrate Gemfibrozil Digoxin Tranquilzers Phenothiazines Butyrophenones Antidepressants Tricyclic antidepressants Monoamine oxidase inhibitors Lithium Prozac Ulcer Medications Cimetidine Ranitidine Hormones Estrogens Progesterone Corticosteroids Cyproterone acetate Eulexin Proscar Gonadotropin-releasing hormone agonists Chemotherapy agents Cyclophosphamide Methotrexate Roferon-A Anticholinergics Disopyramide Anticonvulsants Miscellaneous Alcohol Amphetamines Baclofen Carbonic anhydrase inhibitors Metoclopramide Non-steroidal anti-inflammatories Opiates Tobacco (return to top) What brand of nitrates should I be concerned about if I want to take Viagra©? Cardilate Cartrax Deponit (transdermal) Dilatrate and Dilatrate SR Duotrate Imdur Ismo Iso-Bid Iso-D Isirdil Isotrate Miltrate and Miltrate 10 Minitran transdermal system Monoket Nitrek Nitro-Bid Nitrocin (sustained release) Nitrocine Nitrocot Nitro-Derm (transdermal) Nitrodisc (transdermal) Nitro-Dur Nitrogard Nitroglyn Nitrolingual Spray Nitrol Ointment (Appli Kit) Nitrong Nitropar Nitro Patch Nitropress Nitrostat Nitro-Time Onset-5 Papavatral Pennate Penta Cap #1 Pentrate Pentritol Peritrate Sorbide-10 Sorbitrate and Sorbitrate SR Tetrate-30 Transderm-Nitr o Transdermal-NTG Tridil (return to top) For additional information You can find additional information about erectile dysfunction at web sites sponsored by government agencies, societies and healthcare institutions. It should perhaps be noted that the World Wide Web is open to many sources posting questionable information and promises, and you are encouraged to seek information from established, reputable organizations. Likely sources include: American Urological Association Health Guide www.urologyhealth.org National Kidney and Urologic Diseases Information Clearinghouse www.niddk.nih.gov/health/kidney/nkudic.htm Sexual Function Health Council www.impotence.org

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