Erectile dysfunction (impotence)

What is erectile dysfunction (ED)?

Erectile dysfunction (ED), also known as impotence, is a type of sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual activity. ED can have psychological consequences as it can be tied to relationship difficulties and self-image.

A physical cause can be identified in about 80% of cases. These include cardiovascular disease, diabetes mellitus, neurological problems such as following prostatectomy, hypogonadism, and drug side effects. Psychological impotence is where erection or penetration fails due to thoughts or feelings; this is somewhat less frequent, in the order of about 10% of cases. In psychological impotence, there is a strong response to placebo treatment. The term erectile dysfunction is not used for other disorders of erection, such as priapism.

Treatment involves addressing the underlying causes, lifestyle modifications, and addressing psychosocial issues. In many cases, a trial of pharmacological therapy with a PDE5 inhibitor, such as sildenafil, can be attempted. In some cases, treatment can involve inserting prostaglandin pellets into the urethra, injecting smooth muscle relaxants and vasodilators into the penis, a penile prosthesis, a penis pump, or vascular reconstructive surgery. It is the most common sexual problem in men.

What causes an erection?

An erection is the result of increased blood flow into your penis. Blood flow is usually stimulated by either sexual thoughts or direct contact with your penis.

When a man becomes sexually excited, muscles in their penis relax. This relaxation allows for increased blood flow through the penile arteries. This blood fills two chambers inside the penis called the corpora cavernosa. As the chambers fill with blood, the penis grows rigid. Erection ends when the muscles contract and the accumulated blood can flow out through the penile veins.

ED can occur because of problems at any stage of the erection process. For example, the penile arteries may be too damaged to open properly and allow blood in.

What causes erectile dysfunction?

Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles and blood vessels. Erectile dysfunction can result from a problem with any of these. Likewise, stress and mental health concerns can cause or worsen erectile dysfunction.

Sometimes a combination of physical and psychological issues causes erectile dysfunction. For instance, a minor physical condition that slows your sexual response might cause anxiety about maintaining an erection. The resulting anxiety can lead to or worsen erectile dysfunction.

Physical causes of erectile dysfunction

In many cases, erectile dysfunction is caused by something physical. Common causes include:

• Heart disease
• Clogged blood vessels (atherosclerosis)
• High cholesterol
• High blood pressure
• Diabetes
• Obesity
• Metabolic syndrome — a condition involving increased blood pressure, high insulin levels, body fat around the waist and high cholesterol
• Parkinson’s disease
• Multiple sclerosis
• Certain prescription medications
• Tobacco use
• Peyronie’s disease — development of scar tissue inside the penis
• Alcoholism and other forms of substance abuse
• Sleep disorders
• Treatments for prostate cancer or enlarged prostate
• Surgeries or injuries that affect the pelvic area or spinal cord

Psychological causes of erectile dysfunction

The brain plays a key role in triggering the series of physical events that cause an erection, starting with feelings of sexual excitement. A number of things can interfere with sexual feelings and cause or worsen erectile dysfunction. These include:

• Depression, anxiety or other mental health conditions
• Stress
• Relationship problems due to stress, poor communication or other concerns

What are the symptoms of ED?

You may have erectile dysfunction if you regularly have:

• trouble getting an erection
• difficulty maintaining an erection during sexual activities
• reduced interest in sex

Other sexual disorders related to ED include:

• premature ejaculation
• delayed ejaculation
• anorgasmia, which is the inability to achieve orgasm after ample stimulation

You should talk to your doctor if you have any of these symptoms, especially if they’ve lasted for two or more months. Your doctor can determine if your sexual disorder is caused by an underlying condition that requires treatment.

How does age affect incidence of ED?

Up to 30 million American men are affected by ED, according to the National Institute of Diabetes and Digestive and Kidney Diseases. The prevalence of ED increases with age. ED affects:

• 12 percent of men younger than 60
• 22 percent of men in their 60s
• 30 percent of men 70 or older

Although the risk of ED increases with age, ED is not inevitable as you get older. It may be more difficult to get an erection as you age, but that doesn’t necessarily mean you will develop ED. In general, the healthier you are, the better your sexual function.

Read more: Is erectile dysfunction an inevitable result of aging? »

ED can also occur among younger men. A 2013 study found that one in four men seeking their first treatment for ED were under the age of 40. The researchers found a stronger correlation between smoking and illicit drug use and ED in men under 40 than among older men. That suggests that lifestyle choices may be a main contributing factor for ED in younger men.

An analysis of researchTrusted Source on ED in men under 40 found that smoking was a factor for ED among 41 percent of men under the age of 40. Diabetes was the next most common risk factor and was linked to ED in 27 percent of men under 40.

Does riding a bicycle cause ED?

Questions remain about the effects on men’s health of riding a bicycle.

Some research has raised concerns that men who regularly cycle for long hours could have a higher risk of ED, in addition to other men’s health issues such as infertility and prostate cancer.

The most recent study to investigate this found that there was no link between riding a bike and ED, but it did find an association between longer hours of cycling and the risk of prostate cancer.

Prostate disease and ED

Prostate cancer does not cause ED.

However, prostate surgery to remove the cancer and radiation therapy to treat prostate cancer can cause ED.

Treatment of non-cancerous, benign prostate disease can also cause the condition.

Risk factors

As you get older, erections might take longer to develop and might not be as firm. You might need more direct touch to your penis to get and keep an erection.

Various risk factors can contribute to erectile dysfunction, including:

• Medical conditions, particularly diabetes or heart conditions
• Tobacco use, which restricts blood flow to veins and arteries, can — over time — cause chronic health conditions that lead to erectile dysfunction
• Being overweight, especially if you’re obese
• Certain medical treatments, such as prostate surgery or radiation treatment for cancer
• Injuries, particularly if they damage the nerves or arteries that control erections
• Medications, including antidepressants, antihistamines and medications to treat high blood pressure, pain or prostate conditions
• Psychological conditions, such as stress, anxiety or depression
• Drug and alcohol use, especially if you’re a long-term drug user or heavy drinker

Prevention

The best way to prevent erectile dysfunction is to make healthy lifestyle choices and to manage any existing health conditions. For example:

• Work with your doctor to manage diabetes, heart disease or other chronic health conditions.
• See your doctor for regular checkups and medical screening tests.
• Stop smoking, limit or avoid alcohol, and don’t use illegal drugs.
• Exercise regularly.
• Take steps to reduce stress.
• Get help for anxiety, depression or other mental health concerns.

Complications

Complications resulting from erectile dysfunction can include:

• An unsatisfactory sex life
• Stress or anxiety
• Embarrassment or low self-esteem
• Relationship problems
• The inability to get your partner pregnant

Treatment

The good news is that there are many treatments for ED, and most men will find a solution that works for them. Treatments include:

Drug treatments

Men can take a group of drugs called PDE-5 (phosphodiesterase-5) inhibitors.

Most of these pills are taken 30 to 60 minutes before sex – the best known being the blue-colored pill sildenafil (Viagra). Other options are:

• vardenafil (Levitra)
• tadalafil (taken as a once-daily pill called Cialis)
• avanafil (Stendra)

PDE-5 inhibitors are only available on prescription. A doctor will check for heart conditions and ask about other medications being taken before prescribing.

Side-effects associated with PDE-5 inhibitors include:

• flushing
• visual abnormalities
• hearing loss
• indigestion
• headache

Less commonly used drug options include prostaglandin E1, which is applied locally by either injecting it into the penis or inserting it down the opening of the urethra.

Most men prefer a pill, however, so these locally acting drugs tend to be reserved for men who cannot take oral treatment.

Online pharmacies

It is possible to buy treatment over the internet for ED. However, caution is advised.

The United States (U.S.) Food and Drug Administration (FDA) has a consumer safety guide about this, including a recommendation to check that the online pharmacy:

• is located in the U.S. and licensed
• has a licensed pharmacist to answer questions.
• requires a prescription.
• offers direct contact with a person who can discuss any problems.

You can check whether the pharmacy is licensed using this list of Verified Internet Pharmacy Practice Sites (VIPPS).

The FDA also offers tips for spotting the dangers of an unsafe website, including watching out for the following clues:

• There is no way to contact the website by phone.
• Prices are dramatically lower than those offered by legal online pharmacies.
• Prescription drugs are offered without requiring a prescription – which is illegal.
• Personal information is not protected.

The FDA adds that these illegal sites may send drugs of unknown quality and origin, even sending the wrong drug or a dangerous product.

Vacuum devices

Vacuum erection devices are a mechanical way of producing an erection for men who do not want or cannot use drug treatments, or find they are not working.

The penis is made rigid by the use of a vacuum pump sealed around it that draws up blood. This is prevented from then leaving the penis by the use of an accompanying band.

The lack of spontaneity with the use of vacuum devices means that many men find other treatments for ED preferable.

Surgical treatments

There are several surgical treatment options:

• Penile implants: These are a final option reserved for men who have not had any success with drug treatments and other non-invasive options.
• Vascular surgery: Another surgical option for some men is vascular surgery, which attempts to correct some blood vessel causes of ED.

Surgery is a last resort and will only be used in the most extreme cases. Recovery time varies, but success rates are high.

Do dietary supplements and alternative treatments work?

The short answer is “no.”

No guidelines followed by doctors, nor any established sources of evidence, support the use of dietary supplements, such as herbal pills.

In addition to there being no evidence in favor of non-prescription alternatives for ED, the FDA has warned of hidden risks of “treatments” sold online.

Frequently Asked Questions

How do I know my ED is physical and not mental?

It’s hard to know. Health providers now realize that most men have an underlying physical cause of ED. For most patients, there are both physical and emotional factors that lead to ED. It is impossible to prove that there is no psychological part to a man’s ED.

If I worry about being able to get an erection, can I make a bad condition worse?

Nothing happens in the body without the brain. Worrying about your ability to get an erection can make it difficult to get one. This is called performance anxiety and can be overcome with education and treatment.

Can I combine treatment options?

This is often done. However, only combine treatments after talking with your health care provider about this. Erections can last too long with drug therapy, which is dangerous. Ask your doctor for proper instructions.

I was fine until I began taking this new drug, what should I do?

Never stop or change a prescription medication without first talking with your health care provider.

Many drugs can cause ED, but some cannot be changed because the drug’s benefits are too important for you. If you feel sure that a specific drug has caused the ED problem, ask your health care provider if you can change drugs. If you must stay on the drug that is causing the problem, there are ED treatments that can help.

What Questions Should I Ask My Health Care Provider?

• What is ED?
• What causes ED? Can it be prevented?
• Can you help me with ED, or do I need to see a specialist? If I need a specialist (Urologist), do you have a referral for me?
• What tests do you suggest to find the cause of my ED, and why?
• Can you check my heart and blood health?
• Are there any lifestyle changes that could help my symptoms?
• What types of treatments are available?
• What treatment do you suggest for me and why?
• What are the pros and cons of each type of treatment you suggest?
• What are the side effects?
• What happens if the first treatment doesn’t help?