Causes of Erectile Dysfunction
Erectile Dysfunction Causes and Treatment In Depth
Courtesy of National Kidney and Urologic Diseases Information
Clearinghouse, U.S. National Institutes of Health
Erectile dysfunction, sometimes called "impotence," is the repeated
inability to get or keep an erection firm enough for sexual intercourse. The
word "impotence" may also be used to describe other problems that interfere
with sexual intercourse and reproduction, such as lack of sexual desire and
problems with ejaculation or orgasm. Using the term erectile dysfunction
makes it clear that those other problems are not involved.
Erectile dysfunction, or ED, can be a total inability to achieve
erection, an inconsistent ability to do so, or a tendency to sustain only
brief erections. These variations make defining ED and estimating its
incidence difficult. Estimates range from 15 million to 30 million,
depending on the definition used. According to the National Ambulatory
Medical Care Survey (NAMCS), for every 1,000 men in the United States, 7.7
physician office visits were made for ED in 1985. By 1999, that rate had
nearly tripled to 22.3. The increase happened gradually, presumably as
treatments such as vacuum devices and injectable drugs became more widely
available and discussing erectile function became accepted. Perhaps the most
publicized advance was the introduction of the oral drug sildenafil citrate
(Viagra) in March 1998. NAMCS data on new drugs show an estimated 2.6
million mentions of Viagra at physician office visits in 1999, and one-third
of those mentions occurred during visits for a diagnosis other than ED.
In older men, ED usually has a physical cause, such as disease, injury,
or side effects of drugs. Any disorder that causes injury to the nerves or
impairs blood flow in the penis has the potential to cause ED. Incidence
increases with age: About 5 percent of 40-year-old men and between 15 and 25
percent of 65-year-old men experience ED. But it is not an inevitable part
of aging.
ED is treatable at any age, and awareness of this fact has been growing.
More men have been seeking help and returning to normal sexual activity
because of improved, successful treatments for ED. Urologists, who
specialize in problems of the urinary tract, have traditionally treated ED;
however, urologists accounted for only 25 percent of Viagra mentions in
1999.
How does an erection occur?
The penis contains two chambers called the corpora cavernosa, which run
the length of the organ (see figure 1). A spongy tissue fills the chambers.
The corpora cavernosa are surrounded by a membrane, called the tunica
albuginea. The spongy tissue contains smooth muscles, fibrous tissues,
spaces, veins, and arteries. The urethra, which is the channel for urine and
ejaculate, runs along the underside of the corpora cavernosa and is
surrounded by the corpus spongiosum.
Erection begins with sensory or mental stimulation, or both. Impulses
from the brain and local nerves cause the muscles of the corpora cavernosa
to relax, allowing blood to flow in and fill the spaces. The blood creates
pressure in the corpora cavernosa, making the penis expand. The tunica
albuginea helps trap the blood in the corpora cavernosa, thereby sustaining
erection. When muscles in the penis contract to stop the inflow of blood and
open outflow channels, erection is reversed.
What causes erectile dysfunction (ED)?
Since an erection requires a precise sequence of events, ED can occur
when any of the events is disrupted. The sequence includes nerve impulses in
the brain, spinal column, and area around the penis, and response in
muscles, fibrous tissues, veins, and arteries in and near the corpora
cavernosa.
Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as
a result of disease, is the most common cause of ED. Diseases—such as
diabetes, kidney disease, chronic alcoholism, multiple sclerosis,
atherosclerosis, vascular disease, and neurologic disease—account for about
70 percent of ED cases. Between 35 and 50 percent of men with diabetes
experience ED.
Lifestyle choices that contribute to heart disease and vascular problems
also raise the risk of erectile dysfunction. Smoking, being overweight, and
avoiding exercise are possible causes of ED.
Also, surgery (especially radical prostate and bladder surgery for
cancer) can injure nerves and arteries near the penis, causing ED. Injury to
the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by
harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora
cavernosa.
In addition, many common medicines—blood pressure drugs, antihistamines,
antidepressants, tranquilizers, appetite suppressants, and cimetidine (an
ulcer drug)—can produce ED as a side effect.
Experts believe that psychological factors such as stress, anxiety,
guilt, depression, low self-esteem, and fear of sexual failure cause 10 to
20 percent of ED cases. Men with a physical cause for ED frequently
experience the same sort of psychological reactions (stress, anxiety, guilt,
depression). Other possible causes are smoking, which affects blood flow in
veins and arteries, and hormonal abnormalities, such as not enough
testosterone.
How is ED diagnosed?
Patient History
Medical and sexual histories help define the degree and nature of ED. A
medical history can disclose diseases that lead to ED, while a simple
recounting of sexual activity might distinguish among problems with sexual
desire, erection, ejaculation, or orgasm.
Using certain prescription or illegal drugs can suggest a chemical cause,
since drug effects account for 25 percent of ED cases. Cutting back on or
substituting certain medications can often alleviate the problem.
Physical Examination
A physical examination can give clues to systemic problems. For example, if
the penis is not sensitive to touching, a problem in the nervous system may
be the cause. Abnormal secondary sex characteristics, such as hair pattern
or breast enlargement, can point to hormonal problems, which would mean that
the endocrine system is involved. The examiner might discover a circulatory
problem by observing decreased pulses in the wrist or ankles. And unusual
characteristics of the penis itself could suggest the source of the
problem—for example, a penis that bends or curves when erect could be the
result of Peyronie's disease.
Laboratory Tests
Several laboratory tests can help diagnose ED. Tests for systemic diseases
include blood counts, urinalysis, lipid profile, and measurements of
creatinine and liver enzymes. Measuring the amount of free testosterone in
the blood can yield information about problems with the endocrine system and
is indicated especially in patients with decreased sexual desire.
Other Tests
Monitoring erections that occur during sleep (nocturnal penile tumescence)
can help rule out certain psychological causes of ED. Healthy men have
involuntary erections during sleep. If nocturnal erections do not occur,
then ED is likely to have a physical rather than psychological cause. Tests
of nocturnal erections are not completely reliable, however. Scientists have
not standardized such tests and have not determined when they should be
applied for best results.
Psychosocial Examination
A psychosocial examination, using an interview and a questionnaire, reveals
psychological factors. A man's sexual partner may also be interviewed to
determine expectations and perceptions during sexual intercourse.
How is ED treated?
Most physicians suggest that treatments proceed from least to most
invasive. For some men, making a few healthy lifestyle changes may solve the
problem. Quitting smoking, losing excess weight, and increasing physical
activity may help some men regain sexual function.
Cutting back on any drugs with harmful side effects is considered next.
For example, drugs for high blood pressure work in different ways. If you
think a particular drug is causing problems with erection, tell your doctor
and ask whether you can try a different class of blood pressure medicine.
Psychotherapy and behavior modifications in selected patients are
considered next if indicated, followed by oral or locally injected drugs,
vacuum devices, and surgically implanted devices. In rare cases, surgery
involving veins or arteries may be considered.
Psychotherapy
Experts often treat psychologically based ED using techniques that decrease
the anxiety associated with intercourse. The patient's partner can help with
the techniques, which include gradual development of intimacy and
stimulation. Such techniques also can help relieve anxiety when ED from
physical causes is being treated.
Drug Therapy
Drugs for treating ED can be taken orally, injected directly into the penis,
or inserted into the urethra at the tip of the penis. In March 1998, the
Food and Drug Administration (FDA) approved Viagra, the first pill to treat
ED. Since that time, vardenafil hydrochloride (Levitra) and tadalafil (Cialis)
have also been approved. Additional oral medicines are being tested for
safety and effectiveness.
Viagra, Levitra, and Cialis all belong to a class of drugs called
phosphodiesterase (PDE) inhibitors. Taken an hour before sexual activity,
these drugs work by enhancing the effects of nitric oxide, a chemical that
relaxes smooth muscles in the penis during sexual stimulation and allows
increased blood flow.
While oral medicines improve the response to sexual stimulation, they do
not trigger an automatic erection as injections do. The recommended dose for
Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg,
depending on the patient. The recommended dose for either Levitra or Cialis
is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is
insufficient. A lower dose of 5 mg is available for patients who take other
medicines or have conditions that may decrease the body's ability to use the
drug. Levitra is also available in a 2.5 mg dose.
None of these PDE inhibitors should be used more than once a day. Men who
take nitrate-based drugs such as nitroglycerin for heart problems should not
use either drug because the combination can cause a sudden drop in blood
pressure. Also, tell your doctor if you take any drugs called
alpha-blockers, which are used to treat prostate enlargement or high blood
pressure. Your doctor may need to adjust your ED prescription. Taking a PDE
inhibitor and an alpha-blocker at the same time (within 4 hours) can cause a
sudden drop in blood pressure.
Oral testosterone can reduce ED in some men with low levels of natural
testosterone, but it is often ineffective and may cause liver damage.
Patients also have claimed that other oral drugs—including yohimbine
hydrochloride, dopamine and serotonin agonists, and trazodone—are effective,
but the results of scientific studies to substantiate these claims have been
inconsistent. Improvements observed following use of these drugs may be
examples of the placebo effect, that is, a change that results simply from
the patient's believing that an improvement will occur.
Many men achieve stronger erections by injecting drugs into the penis,
causing it to become engorged with blood. Drugs such as papaverine
hydrochloride, phentolamine, and alprostadil (marketed as Caverject) widen
blood vessels. These drugs may create unwanted side effects, however,
including persistent erection (known as priapism) and scarring.
Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed
on the penis.
A system for inserting a pellet of alprostadil into the urethra is
marketed as Muse. The system uses a prefilled applicator to deliver the
pellet about an inch deep into the urethra. An erection will begin within 8
to 10 minutes and may last 30 to 60 minutes. The most common side effects
are aching in the penis, testicles, and area between the penis and rectum;
warmth or burning sensation in the urethra; redness from increased blood
flow to the penis; and minor urethral bleeding or spotting.
Research on drugs for treating ED is expanding rapidly. Patients should
ask their doctor about the latest advances.
Vacuum Devices
Mechanical vacuum devices cause erection by creating a partial vacuum, which
draws blood into the penis, engorging and expanding it. The devices have
three components: a plastic cylinder, into which the penis is placed; a
pump, which draws air out of the cylinder; and an elastic band, which is
placed around the base of the penis to maintain the erection after the
cylinder is removed and during intercourse by preventing blood from flowing
back into the body (see figure 2).
One variation of the vacuum device involves a semirigid rubber sheath
that is placed on the penis and remains there after erection is attained and
during intercourse.
Surgery
Surgery usually has one of three goals:
- to implant a device that can cause the penis to
become erect
- to reconstruct arteries to increase flow of blood to
the penis
- to block off veins that allow blood to leak from the
penile tissues
Implanted devices, known as prostheses, can restore erection in many men
with ED. Possible problems with implants include mechanical breakdown and
infection, although mechanical problems have diminished in recent years
because of technological advances.
Malleable implants usually consist of paired rods, which are inserted
surgically into the corpora cavernosa. The user manually adjusts the
position of the penis and, therefore, the rods. Adjustment does not affect
the width or length of the penis.
Inflatable implants consist of paired cylinders, which are surgically
inserted inside the penis and can be expanded using pressurized fluid (see
figure 3). Tubes connect the cylinders to a fluid reservoir and a pump,
which are also surgically implanted. The patient inflates the cylinders by
pressing on the small pump, located under the skin in the scrotum.
Inflatable implants can expand the length and width of the penis somewhat.
They also leave the penis in a more natural state when not inflated.
Surgery to repair arteries can reduce ED caused by obstructions that
block the flow of blood. The best candidates for such surgery are young men
with discrete blockage of an artery because of an injury to the crotch or
fracture of the pelvis. The procedure is almost never successful in older
men with widespread blockage.
Surgery to veins that allow blood to leave the penis usually involves an
opposite procedure—intentional blockage. Blocking off veins (ligation) can
reduce the leakage of blood that diminishes the rigidity of the penis during
erection. However, experts have raised questions about the long-term
effectiveness of this procedure, and it is rarely done.
Hope through Research
Advances in suppositories, injectable medications, implants, and vacuum
devices have expanded the options for men seeking treatment for ED. These
advances have also helped increase the number of men seeking treatment. Gene
therapy for ED is now being tested in several centers and may offer a
long-lasting therapeutic approach for ED.
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
sponsors programs aimed at understanding the causes of erectile dysfunction
and finding treatments to reverse its effects. NIDDK's Division of Kidney,
Urologic, and Hematologic Diseases supported the researchers who developed
Viagra and continue to support basic research into the mechanisms of
erection and the diseases that impair normal function at the cellular and
molecular levels, including diabetes and high blood pressure.
Points to Remember
- Erectile dysfunction (ED) is the repeated inability
to get or keep an erection firm enough for sexual intercourse.
- ED affects 15 to 30 million American men.
- ED usually has a physical cause.
- ED is treatable at all ages.
- Treatments include psychotherapy, drug therapy,
vacuum devices, and surgery.
For More Information
American Urological Association (AUA)
1000 Corporate Boulevard
Linthicum, MD 21090
Phone: 1–866–RING–AUA (746–4282) or 410–689–3700
Fax: 410–689–3800
Email:
aua@auanet.org
Internet:
www.auanet.org
www.urologyhealth.org
AUA can refer you to a urologist in your area.
American Diabetes Association (ADA)
Attn: National Call Center
1701 North Beauregard Street
Alexandria, VA 22311
Phone: 1–800–DIABETES (342–2383)
Internet:
www.diabetes.org
ADA can help you find a doctor who specializes in diabetes care in your
area.
American Association of Sex Educators, Counselors, and Therapists (AASECT)
P.O. Box 1960
Ashland, VA 23005–1960
Phone: 804–752–0026
Fax: 804–752–0056
Internet:
www.aasect.org
Check the AASECT website to find a certified sexuality educator, counselor,
or therapist in your area.
The above information is provided by the---
National Kidney and Urologic Diseases Information Clearinghouse
3 Information Way
Bethesda, MD 20892–3580
Phone: 1–800–891–5390
TTY: 1–866–569–1162
Fax: 703–738–4929
Email:
nkudic@info.niddk.nih.gov
Internet:
www.kidney.niddk.nih.gov/
The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC)
is a service of the National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of
the U.S. Department of Health and Human Services. Established in 1987, the
Clearinghouse provides information about diseases of the kidneys and
urologic system to people with kidney and urologic disorders and to their
families, health care professionals, and the public. The NKUDIC answers
inquiries, develops and distributes publications, and works closely with
professional and patient organizations and Government agencies to coordinate
resources about kidney and urologic diseases.
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