Erectile Dysfunction (Impotence)

Erectile Dysfunction (ED) is defined as the inability to achieve or maintain an erection sufficient for mutually satisfying intercourse.  Erectile Dysfunction impacts more than a man's sexual activity.  The emotions and uncertainties that coincide with this condition often have a significant effect on a man's self-esteem, as well as, his relationship with his partner.  Although the incidence of Erectile Dysfunction increases with age, it is not an inevitable result of aging.  Erectile Dysfunction is a secondary condition linked to many medical conditions.

The first step in treating Erectile Dysfunction is that the individual understands the psychology, physiology and anatomy responsible for the ability to achieve and maintain an erection.  If we can comprehend these events than we can better understand the factors that are responsible for Erectile Dysfunction and address the questions concerning treatment.     

Normal Erectile Function

For something that appears so natural, an erection is a rather complicated process involving the coordination of the psychological, neurological and cardiovascular systems.  The penis because erect following a series of events.  First, the nerves are stimulated, a sensation known as arousal.  No matter what the nature of the stimulus, visual, mental or physical the brain coordinates the following series of events:

Nerve impulses transverse the length of the spinal cord to the pudendal nerve and on to the penis.  Smooth muscle within the walls of the penile arteries respond by relaxing.

Subsequently, the penile arteries dilate allowing up to eight times more blood to flow into the corpora cavernosum, (two parallel cylinders that transverse the length of the penis).

The cavernosum becomes engorged with blood expanding and lengthening the penis.

The expanding tissue then exerts a positive pressure compressing the veins that normally empty the blood from the penis, maintaining the blood in the penile tissue.

When ejaculation occurs or when arousal is discontinued the penis returns to its non-erect state.  

Causes of Erectile Dysfunction

Historically, when an individual consulted his physician concerning Erectile Dysfunction he was usually informed there were no known physiological answers concerning his condition.  Today, a generation of research has resulted in significant advances in both the diagnosis and treatment of Erectile Dysfunction. Physicians now understand that approximately eighty-five percent of Erectile Dysfunction is attributable to physical/organic conditions while only fifteen percent is due to psychological or mixed origin (both psychological and organic).  Some important causes of physiological ED are as follows:

Vascular Disease is the leading cause of Erectile Dysfunction . Vascular disorders including arteriosclerosis (hardening of the arteries), hypertension, hypercholestremia and other conditions which interfere with the blood flow to the penis.  Additionally, "venous leakage" also contributes to poor erections.  This condition occurs when the penile veins are unable to constrict efficiently during an erection.  When these veins "leak" blood escapes to the periphery resulting in a poor erection

Diabetes is another common cause of Erectile Dysfunction. Approximately fifty percent of men with diabetes (insulin dependent) experience some degree of Erectile Dysfunction after the age of fifty-five.  Diabetes results in poor circulation and/or peripheral neuropathy.  When the nerves are involved sexual stimuli are not transmitted appropriately to or from the brain and Erectile Dysfunction develops.

Prescription medications often cause Erectile Dysfunction as a side effect.  Some two hundred known medications fall into this category including:

Substance Abuse can also negatively effect male potency.  The chronic use of cocaine, marijuana, alcohol, steroids etc. often results in Erectile Dysfunction, as well as a decrease in desire.  Excessive tobacco use can also attribute to Erectile Dysfunction by accentuating the effects of other risk factor such as vascular disease or hypertension.

Radical Pelvic Surgery also result in Erectile Dysfunction. Surgical procedures involving the prostate gland, bladder or colon may interfere with the nerves involved in the erectile response.  Radiation therapy for cancer may also effect the erectile process.

Neurological diseases such as multiple sclerosis, Parkinson's disease, spinal cord injuries, long term effects of diabetes can also result in the disruption of the normal sequence of events necessary for an erection to occur. 

Deficiencies in the Endocrine System are another source of Erectile Dysfunction. Low levels of testosterone or thyroid hormone can interfere with the stimulation process necessary in the erection sequence.  Excessive production of prolactin by the pituitary gland may contribute to decreased levels of testosterone resulting in a lack of desire.  Diabetes once again enters the scenario as it is classified as an endocrine disorder.

Psychological Erectile Dysfunction is usually diagnosed when no physical causes can be defined.  Pure psychological ED usually occurs suddenly without warning as opposed to physical Erectile Dysfunction that may gradually develop over years.  Some common causes of psychological ED are as follows:

• Performance anxiety is one of the most common causes of psychological Erectile Dysfunction..  When a man feels pressured to achieve or maintain an erection, he will commonly become anxious and nervous when in a sexually demanding situation.  Stress increases the body's production of catecholamines such as adrenaline and nor- adrenaline, which act as erection inhibitors.  The release of these inhibitors further contributes to failure resulting in more anxiety.  Therefore, the cycle begins, increased stress resulting in increased catecholomines that further inhibits the erectile process.
• Depression is another cause of psychogenic Erectile Dysfunction.  Unfortunately, many of the popular antidepressant medications (for a list see prescription medications in the next section) have side effects which include erectile failure.

Anatomical Deviation of the Penis, Peyronies Disease, may also cause Erectile Dysfunction.  This condition usually develops from an inflammatory process and results in fibrous scaring of the penis.  (The cause of this process is not yet understood)  However, when an erection does occur, there is a bending of the penis secondary to the scar tissue.  This curvature may interfere with erectile capacity and/or ejaculation.                                                           

Treatment of Erectile Dysfunction

Until recently, individuals who sought medical treatment for Erectile Dysfunction were told "It's all in your head".  Physicians labeled these individuals with a psychological disorder and they were referred to counseling.  Today, there are many treatment options available, the treatment option you choose should be specific and responsive to your needs and expectations as well as your partners.  The following is a summary of the more popular treatment options available today:

Oral Medications one in particular Viagra® (Sildenafil Citrate) has change the course of treatment for Erectile Dysfunction. Never has so much enthusiasm surrounded a prescription medication.  In the first six months alone, Pfizer's sales of the blue diamond shaped tablet topped 50 million. Viagra® is dispensed as a pill and ingested orally.  Approximately 30-60 minutes later the drug is absorbed into the bloodstream. Viagra® then functions as an inhibitor to an enzyme found mainly in the penis.  By inhibiting this enzyme a series of natural occurring events, take place resulting in increased blood flow to the penis thus generating a fuller erection.  Since the medication increases the levels of a naturally occurring, process spontaneous erections do not occur.  Viagra® is essentially changing the way we treat Erectile Dysfunction. The medication is manufactured by Pfizer pharmaceuticals.                         

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Penile Injection Therapy uses a hypodermic needle to inject medication (mixture of papaverine, phentolamine and prostoglandin) into the side of the penis.

The drug relaxes the smooth muscle tissue of the penis allowing for an erection.  These injections can be painful, result in scare tissue formation at the injection site and cause priapism (prolonged and painful engorgement of the penis). The product is available through Pharmacia and Upjohn (Caverjet) and Scharz Pharma, Inc (EDEX) at approximately $18.00 per dose.

Urethral Inserts consists of a disposable applicator, small enough to fit into the urethra.  The applicator is inserted into the urethra approximately one inch and the medication (prostaglandin E-1) is released.  As a result, an erection occurs lasting 30-60 minutes.  Patient acceptance is still an issue secondary to expense and the low success rate as compared to other treatments for Erectile Dysfunction. The inserts are available through the pharmaceutical cap any Vivus Inc.

Vacuum Therapy works by placing a cylinder with an attached pump over the penis.  The pump creates a vacuum in the cylinder, which pulls blood into the penis to create an erection.  The cylinder is then removed while simultaneously a constriction band is placed at the base of the penis.  This will usually keep the penis erect for up to thirty minutes, These devices range from $150.00-400.00 and can be purchased through Mentor Urology, POST-T-VAC, Inc., American Med Tech, Inc.

Hormonal Therapy is used to treat the small percentage of individuals who have abnormally low levels of testosterone. During the initial consultation a physician will likely order hormone tests (LH and Prolactin) first to exclude other causes of low testosterone levels.  If appropriate, testosterone is available in a transdermal adhesive patch.  The patch is available through Androderm (SmithKline Beecham) and Testroderm (Alza Pharmaceuticals), at a cost of $20.00 per patch.

Vascular Surgery may involve both the arterial and venous systems.  Venous ligation has been reported to be effective in patients with venous leakage.  However, it is often difficult to diagnose individuals with this condition given are current testing capabilities; therefore, it is difficult to predict their outcome prior to surgery.  Arterial revasculation procedures are limited to congenital or traumatic vascular abnormalities.  Similar to venous testing, complete standardization diagnostic testing has not been established, so difficulties persists in predicting surgical results.

Penile Implants requires surgical insertion of a prosthetic device.  Three forms of penile prosthesis are currently available flexible, malleable and inflatable.

Flexible or Malleable rods consist of two semi-rigid, flexible rods which make the penis firm enough for intercourse.  There are also inflatable prosthetic devices that produce a more natural erection.  When an erection is desired the pump (located in the scrotum) is squeezed, this in turn inflates a cylinder creating an erection.  Following intercourse, the pump is released and the penis returns too normal.  These devices have been associated with postoperative infections, mechanical failure, silicon particle shedding and the risk of the initial surgery.  These prosthetics are available through American Medical Systems and Mentor Urology.

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Psychotherapy and/or Behavioral Therapy have been found to be beneficial in treating Erectile Dysfunction.  Although the majority of causes of Erectile Dysfunction are physical, there are quite frequently underlying psychosocial factors involved as well.  Psychotherapy and/or behavioral therapy may be helpful in individuals whom no organic cause for Erectile Dysfunction has been detected.  Therapy often focuses on complications surrounding performance anxiety, dysfunctional relationships, loss of a partner, psychotic disorders, substance abuse, etc.

Partners can provide support for individuals with Erectile Dysfunction.  The condition affects the relationships of more than 50 million Americans.  If you are a partner, you can make a difference through support and education.  For a list of Impotence Anonymous (IA®) and I-ANON® chapters, call 1-800-669-1603 or email to.

Note: All of the above mentioned treatments only treat Erectile Dysfunction, they do not treat the underlying illnesses or disorders responsible for the Erectile Dysfunction.  The prolonged use of some these treatments in individuals who have conditions such as those listed under causes of Erectile Dysfunction is inappropriate.  Please be responsible with your health.  Schedule regular appointments with your family physician and/or your urologist so they may address and treat the underlying conditions responsible for your Erectile Dysfunction.