Erectile Dysfunction
Erectile dysfunction is the inability to achieve or maintain an erection adequate for sexual intercourse.
Definitions and How Common
Erectile dysfunction is defined as the inability to obtain and/or maintain an erection satisfactory for sexual intercourse.
Although numbers vary significantly from one study to the next, the 2016 National Health and Wellness Survey found that 42% of men in the US reported some degree of erectile dysfunction.
Yes. Age is likely the main factor contributing to erectile dysfunction. Essentially all men will experience erectile dysfunction at some point in life if they live long enough.
Causes and Types
Erectile dysfunction can be broadly classified into various types, including vasculogenic (arterial insufficiency, veno-occlusive dysfunction), neurogenic, and psychogenic. Vasculogenic and/or neurogenic are often called “organic” erectile dysfunction, while psychogenic may be a cause alone or in combination with organic erectile dysfunction.
Psychogenic erectile dysfunction is very common and may be an issue alone or in combination with organic erectile dysfunction. It may start if someone experiences an episode of erectile dysfunction and then becomes concerned about future episodes. This may lead to a ‘spectator phenomenon’ where the individual wonders, “is it going to happen this time?” This often leads to further erectile dysfunction in a negative spiral.
Psychogenic erectile dysfunction is also very common among younger men and among those with anxiety, depression, ADHD, or other similar psychological conditions.
A normal erection occurs when either nerve stimulation from the brain or direct stimulation of the penis occurs. This leads to a release of a chemical known as nitric oxide. This chemical relaxes the muscles in the penis which allows an increase in blood flow, and equally importantly, a relaxation of the space where blood can pool in the penis. If sufficient pressure and stimulation is achieved, this results in compression of veins which normally act as drains for the penis. When these are compressed, the blood stays trapped in the penis.
In cases of neurogenic erectile dysfunction, the nerves are unable to send a signal to the penis to cause an erection. A good example of this is like when a man has his prostate removed for cancer. In these cases, the nerves going to the penis are damaged or removed.
In cases of vasculogenic erectile dysfunction, there are several potential causes. In some instances, the arteries going into the penis are damaged or don’t have sufficient flow. More commonly though, the ‘endothelial’ cells in the penis don’t function as well, and the muscle which normally should be able to relax the penis is scarred to where the penis can’t fully relax. This then prevents the body from closing the drainage veins of the penis, which then leads to erectile dysfunction. This is the most common cause of erectile dysfunction overall.
Associated Conditions
Normal Physiologic Conditions
Erectile dysfunction is most commonly linked to aging, as all men will develop ED at some point if they live long enough.
Medical Conditions
It is also associated with most conditions linked to cardiovascular or cerebrovascular disease such as hypertension, dyslipidemia, and diabetes, among others. It is also linked to Peyronie’s disease, which is a condition resulting in penile deformity, curvature, and/or length loss.
Essentially any condition which results in impairment in health (particularly when severe), such as infections, malignancies, autoimmune diseases, or other similar issues will lead to ED. This can be permanent but most often resolves once the underlying condition improves.
Surgeries or Procedures
Several surgeries and procedures can result in temporary or permanent changes in erectile function. Surgeries most commonly associated include those involving the prostate (BPH procedures or prostatectomy for malignancy), or those in the deep pelvis (select colon surgeries).
Many medications are associated with erectile dysfunction. Some of the most common ones are those which lower the blood pressure or decrease nerve sensitivity. These can include beta blockers, diuretics, calcium channel blockers, gabapentin/pregabalin types of medications, narcotics, antipsychotics, and most antidepressants.
Testing
Men with ED have a higher rate of low testosterone compared to those without. Because of this, some men will elect to have their testosterone levels checked. In men who have low testosterone, supplementing with additional testosterone can improve erectile function modestly. It is important to recognize though that testosterone supplementation will not likely dramatically improve erectile function, and men with testosterone levels in the normal range are usually not recommended for treatment with testosterone.
Because erectile dysfunction is linked to cardiovascular disease, men with ED who have not had a lipid panel (cholesterol) obtained should have one performed. This test will check the levels of both ‘good’ (HDL) and ‘bad’ (LDL) cholesterol to determine if the levels are at a point where treatment may be warranted.
Erectile dysfunction is very common among men with diabetes. Because of this, testing for diabetes may be appropriate if it has not been previously checked. Although there are multiple ways to check for diabetes, one common test is an HbA1c. This test evaluates blood glucose levels over a longer period of time.
Treatments
One of the easiest methods to improve erectile function is to do aerobic exercise. In some studies, this can improve erectile function equivalent to about half of what a Viagra-like medication can do. It also has numerous additional health benefits and can result in improved erectile function and sexual desire (libido) within the first week of starting treatment.
Oral phosphodiesterase-5 inhibitors (PDE5) are among the most common treatments used for ED. Each of the pills has slightly different advantages and disadvantages (see following link for a graphical comparison):
Advantages and disadvantages
Viagra (sildenafil)
- Most published data available.
- Currently off-patent (i.e., less expensive).
- Results in temporary higher rate of blue-green color visual changes compared to some other PDE5s.
- Less effective when taken with a fatty meal
- Effective ~1 hour after taking the medication.
- Has a window of effectiveness of roughly 6-12 hours.
Levitra/Staxyn (vardenafil)
- Typically more expensive than Viagra or Cialis but less than Stendra.
- Option for orally disintegrating tablet.
- Has higher risks of a certain cardiac finding known as QT prolongation. In most cases, this is not an issue; however, in men taking other medications known to prolong the QT interval, this may cause an issue.
Cialis (tadalafil)
- Currently off-patent (i.e., less expensive).
- Takes about 1-2 hours before it becomes effective.
- Can be taken with food without significantly impacting its efficacy.
- Effective for approximately 36 hours.
- FDA approved for both on-demand or daily use.
- May have some benefits for urinary symptoms as well.
- Higher rate of muscle / lower back types of pain (temporary).
- Lower rates of visual changes / facial flushing compared to some other PDE5s.
Stendra (avanafil)
- Fastest acting PDE5 (can be effective within 30 minutes)
- On-patent (i.e., more expensive)
- Shortest acting of the above medications
Other key details about PDE5s:
- The pills help to achieve and/or maintain an erection but do not directly cause an erection. Stimulation is still required to achieve an erection.
- Men who do not get any degree of spontaneous erection usually do not respond to PDE5s and may require stronger treatments.
- Generic versions of the above mediations are equally effective, so long as they are purchased through traditional pharmacies.
Intraurethral suppositories are medications which are placed in the opening of the penis. These commonly include medications such as alprostadil, phentolamine, and papaverine, among others. The therapies are generally less effective than intracavernosal injection therapies and can result in penile aching and burning in some men. The advantage of these treatments is that they do not require an injection into the penis.
Intracavernosal injection therapies (ICI) are medications which are directly injected into the penis by the patient. These are among the strongest non-surgical therapies available for erectile dysfunction and are typically performed if things such as oral pills are ineffective. These treatments also need to be more carefully administered, as a dose which is too high can result in priapism (prolonged erection), which can be a dangerous condition.
Vacuum erection devices are a mechanical therapy which pulls blood into the penis using a vacuum tube. The erection can then be maintained by using a constriction band. These can be used in cases of severe erectile dysfunction. Downsides to this therapy include that it often results in a colder, blue, floppier type of erection (temporary).
Constriction bands may be used to help trap blood in the penis. These may be used alone or in combination with other therapies. One potential risk with constriction bands though is narrowing or scarring of the penis at the site of placement. This risk is particularly recognized in men with Peyronie’s disease.
Penile prostheses are internal implants which result in a fully rigid erection. They do not negatively (or positively) impact sensation, orgasm, or ejaculation. They are typically reserved for cases of ED which do not respond to more conservative therapies. Satisfaction rates are high with implants in men who are appropriately selected. One of the most notable risks with an implant is the possibility for infection. Among surgeons with high-volume experience, this risk is usually <2-3%.
Not sure which treatment is right for you? Stop the guess work and ask the specialist.
Prognosis
In some cases, erectile dysfunction will improve with time. This is particularly the case in men with psychogenic causes, or in those who are experiencing a separate medical issue or recent treatment which is impacting erections. If a medication is contributing to erectile dysfunction, in some cases this can be switched to an alternative treatment.
In other cases, the erectile dysfunction may not fully improve. This is often true if erectile dysfunction is due to aging, in men with certain conditions (cardiovascular disease, diabetes), or among those who have undergone certain surgical procedures.
Unfortunately, at the present time, there are no known cures for erectile dysfunction. Most treatments are designed to improve symptoms (improve erections), but at the present time, no therapies have been shown to cure the condition.
Most likely, yes. Living a healthy lifestyle, including maintaining a balanced diet, appropriate weight control, treating comorbid conditions, and regulalry exercising will significantly slow down the rate of development of erectile dysfunction.
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