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An in-depth report on the causes, diagnosis, treatment, and prevention of erectile dysfunction.
Erectile dysfunction (ED), formerly called impotence, can affect men of all ages, although it is much more common among older men. It is normal for men to occasionally experience erectile dysfunction. However, if the problem becomes chronic, it can have adverse effects on relationships, emotional health, and self-esteem. Erectile dysfunction may also be a symptom of an underlying health condition. If erectile dysfunction becomes an on-going problem, it is important to talk to your doctor.
Causes of Erectile Dysfunction
Erectile dysfunction is usually treated with a PDE5 inhibitor drug such as: :
These drugs are generally safe and effective for most men. They may not be appropriate for men with certain health conditions, such as severe heart disease, heart failure, history of stroke or heart attack, or uncontrolled high blood pressure or diabetes. Men who take nitrate drugs cannot use PDE5 inhibitors, and these drugs can also interact with other medications. Talk to your doctor about whether PDE5 inhibitor drugs are a safe choice for you.
Other treatments for erectile dysfunction include:
It is very important to treat any underlying health conditions that may be causing erectile dysfunction. It is also important to engage in healthy lifestyle behaviors by eating right, staying physically active, reducing stress, and stopping smoking and substance abuse.
Erectile dysfunction (formerly called impotence) is the inability to achieve or maintain an erection sufficiently rigid for sexual intercourse. Sexual drive and the ability to have an orgasm are not necessarily affected. Because all men have erection problems from time to time, doctors diagnose erectile dysfunction if a man fails to maintain an erection satisfactory for intercourse on at least 25% of attempts.
Erectile dysfunction is not new in either medicine or human experience, but it is often not easily or openly discussed. Cultural expectations of male sexuality inhibit many men from seeking help for a disorder that can usually benefit from medical treatment.
The Structure of the Penis. The penis is composed of the following structures:
These structures are made up of erectile tissue. Erectile tissue is rich in tiny pools of blood vessels called cavernous sinuses. Each of these vessels are surrounded by smooth muscles and supported by elastic fibrous tissue composed of a protein called collagen.
Erectile Function and Nitric Oxide. The penis is either flaccid or erect depending on the state of arousal. In the flaccid, or unerect, penis, the following normally occurs:
During arousal the following occurs:
A proper balance of certain chemicals, gases, and other substances is critical for erectile health.
Collagen. The protein collagen is the major component in structural tissue in the body, including in the penis. Excessive amounts of collagen can, however, form scar tissue, which can impair erectile function.
Oxygen. Oxygen-rich blood is one of the most important components for erectile health. Oxygen levels vary widely from very low levels in the flaccid state to very high levels in the erect state. During sleep, a man can normally have three to five erections per night, bringing oxygen-rich blood to the penis. The primary cause of oxygen deprivation is ischemia -- the blockage of blood vessels. The same blood flow-reducing conditions that lead to heart disease, such as atherosclerosis, may also contribute to erectile dysfunction.
Testosterone and Other Hormones. Normal levels of hormones, especially testosterone, are essential for libido (sex drive) and erectile function, although their exact role is not clear.
Over the past decades, the medical perspective on the causes of erectile dysfunction (ED) has shifted. Common belief used to attribute almost all cases of ED to psychological factors. Now doctors believe that up to 85% of ED cases are caused by medical or physical problems. Only 15% are completely psychologically based. Sometimes, erectile dysfunction is due to a combination of physical and psychological causes.
A number of medical conditions share a common problem with erectile dysfunction -- the impaired ability of blood vessels to open and allow normal blood flow.
Heart disease, atherosclerosis, high blood pressure, and high cholesterol levels are major risk factors for erectile dysfunction. Peripheral artery disease (PAD), a form of atherosclerosis, is very common in men who have erectile dysfunction. In fact, erectile problems may be a warning sign of these conditions in men at risk for atherosclerosis. Men who experience ED have a greater risk for angina, heart attack, and stroke.
Erectile dysfunction is a very common problem in men with high blood pressure. Many of the drugs used to treat hypertension (such as diuretics, calcium channel blockers, and beta-blockers) may also cause ED.
Diabetes is a major risk factor for erectile dysfunction. Blood vessel and nerve damage are both common complications of diabetes. When the blood vessels or nerves of the penis are involved, erectile dysfunction can result. Diabetes is also associated with heart disease and chronic kidney disease, other risk factors for ED.
Obesity increases the risk for diabetes, heart disease, and erectile dysfunction.
Metabolic syndrome -- a cluster of conditions that includes obesity and abdominal fat, unhealthy cholesterol and triglyceride levels, high blood pressure, and insulin resistance -- is also a risk factor for erectile dysfunction in men older than 50 years.
Although benign prostatic hyperplasia (BPH or "enlarged prostate") does not cause erectile dysfunction, surgical and drug treatments for the condition can increase the risk for erectile dysfunction.
Low levels of the male hormone testosterone can be a contributing factor to erectile dysfunction in men who have other risk factors. (Low testosterone as the sole cause of erectile dysfunction affects only about 5% of men. In general, low testosterone levels are more likely to reduce sexual desire than to cause ED.) Pituitary gland abnormalities that cause high levels of the hormone prolactin are also associated with erectile dysfunction. Other hormonal and endocrinologic causes of erectile dysfunction include thyroid and adrenal gland problems.
Spinal cord injury and pelvic trauma, such as a pelvic fracture, can cause nerve damage that results in ED. Other conditions that can injure the spine and cause erectile dysfunction include spinal cord tumors, spina bifida, and a history of polio.
Certain types of surgery and radiation treatments can increase the risk for erectile dysfunction:
Note: Vasectomy does NOT cause erectile dysfunction.
Erectile dysfunction can be a side effect of certain medications. They include:
Anxiety. Anxiety has both emotional and physical consequences that can affect erectile function. It is among the most frequently cited contributors to psychological ED.
Stress. Even simple stress can affect sexual function.
Depression. Depression can reduce sexual desire and is associated with erectile dysfunction.
Relationship Problems. Troubles in relationships often have a direct impact on sexual functioning.
For most men, erectile dysfunction is primarily associated with older age. Nevertheless, ED is not inevitable with age. Severe erectile dysfunction often has more to do with age-related disease than age itself. In particular, older men are more likely to have heart disease, diabetes, and high blood pressure than younger men. Such conditions and some of their treatments are causes of erectile dysfunction.
Smoking. Smoking contributes to the development of erectile dysfunction, mainly because it increases the effects of other blood vessel disorders, including high blood pressure and atherosclerosis.
Alcohol Use. Heavy drinking can cause erectile dysfunction. Alcohol depresses the central nervous system and impairs sexual function.
Drug Abuse. Heroin, cocaine, methamphetamines, and marijuana can affect sexual function.
Weight and Sedentary Lifestyle. Obesity is a risk factor for erectile dysfunction. Lack of exercise and a sedentary lifestyle can lead to obesity and other health problems associated with erectile dysfunction.
Your doctor will ask about various physical and psychological factors that may be causing erectile dysfunction. The doctor will also perform a physical exam.
The doctor will ask about:
In addition, the doctor will ask about your sexual history, which may include:
If appropriate, the doctor may also interview your sexual partner.
The doctor will perform a physical exam, including examination of the genitals and a digital rectal examination (the doctor inserts a gloved and lubricated finger into the patient's rectum) to check for prostate abnormalities. The doctor should check your blood pressure, and evaluate your blood circulation by checking the pulses in your legs.
Because erectile dysfunction and atherosclerosis are often linked, it is important to check cholesterol levels. Similarly, the doctor may order tests for blood sugar (glucose) levels to check if diabetes is a factor. In some cases, blood tests may be used to measure testosterone levels to determine if there are hormone problems. The doctor may also test for thyroid and gland dysfunction. For more sophisticated tests, the doctor may refer the patient to a urologist or endocrinologist.
Many physical and psychological situations can cause erectile dysfunction, and brief periods of ED are normal. Every man experiences erectile dysfunction from time to time. Nevertheless, if the problem is persistent, men should seek professional help, particularly since erectile dysfunction is usually treatable and may also be a symptom of an underlying health problem. It is important to treat any medical condition that may be causing erectile dysfunction.
Drug therapy with PDE5 inhibitors is the main treatment for erectile dysfunction. Sildenafil (Viagra), vardenafil (Levitra, Staxyn), tadalafil (Cialis), and avanafil (Stendra) are the PDE5 inhibitor drugs approved for treating erectile dysfunction. In general, if a man is a candidate for PDE5 inhibitor therapy and is satisfied with the results, no further treatment is necessary.
PDE5 inhibitors are not safe or effective for all men. Men who cannot or choose not to take the drugs may have other options, including:
Ultimately, how successful the medical treatment is and how well it is accepted depends, in large part, on the man's expectations and how he and his partner both adapt to the procedure.
Psychotherapies. Some form of psychological, behavioral, or sexual therapy may be recommended for certain patients.
Lifestyle Changes. No matter what the treatment, a healthy lifestyle is important for restoring and maintaining erectile function. This includes a heart-healthy diet, regular exercise, and engaging in activities that help reduce stress.
PDE5 inhibitor drugs are generally the first choice of treatment for erectile dysfunction. They are:
All of these drugs are known as phosphodiesterase-5 (PDE5) inhibitors and are approved for treatment of erectile dysfunction. By blocking the PDE-5 enzyme, these drugs help the smooth muscles of the arteries in the penis to widen and increase blood flow.
PDE5 inhibitor drugs come in pill form and are taken by mouth. Vardenafil is available as a standard pill (Levitra) or as a quickly dissolving tablet (Staxyn).
These drugs all work equally well. A doctor usually selects one of the brands based on the patient’s individual preference, ease of use, and cost of medication.
PDE5 inhibitors are a good choice for men of any age who are in good health and who do not have conditions that prevent taking them.
However, PDE5 inhibitors are not suitable for everyone. Men who take nitrate drugs for angina cannot take PDE5 inhibitors. The PDE5 inhibitors are less effective in men with diabetes and in men who have been treated for prostate cancer. Men who take certain alpha-blockers for high blood pressure or benign prostatic hyperplasia (BPH) should take PDE5 inhibitors with extra care if at all. [Tadalafil (Cialis) is approved to treat symptoms of enlarged prostate in men who have both BPH and erectile dysfunction.]
Men with the following conditions should not take PDE5 inhibitors:
PDE5 inhibitors work only when the man experiences some sexual arousal. The pill should be taken about 1 hour before sexual intercourse. It generally starts to work within 10 - 30 minutes. The effects of these drugs may last for several hours, and tadalafil may last for up to 36 hours.
Do not take more than one pill a day. Sildenafil should be taken on an empty stomach. Vardenafil, tadalafil, and avanafil may be taken with or without food.
Success rates increase with the number of attempts, so don't be discouraged if the drug does not work at first.
PDE5 inhibitors are also sometimes used in combination with testosterone replacement therapy for men with hypogonadism (low testosterone levels). Some research indicates that the addition of testosterone provides little benefit.
Common side effects of PDE inhibitors include flushing, upset stomach, headache, nasal congestion, back pain, and dizziness.
Effects on the Heart. There have been reports of fatal heart attacks in a small percentage of men taking PDE5 inhibitors. These medications can cause sudden and dangerous drops in blood pressure when the drug is taken with nitrate drugs, which are used for angina. Common nitrate drugs include nitroglycerine, isosorbide mononitrate, isosorbide dinitrate, erythatyl tetranitrate, pentaerythritol tetranitrate, and sodium nitroprusside. No one taking nitrates, including related substances such as amyl nitrate ("poppers"), should take sildenafil, vardenafil, tadalafil, or avanafil.
Intercourse itself involves an increase in physical exertion and a very small risk of heart attack for patients with heart disease or heart disease risk factors. If you have heart disease or have recently had a heart attack, talk with your doctor about whether you can safely have sex.
Visual Effects. In rare cases, men who take these drugs develop vision problems that include seeing a blue haze, temporary increased brightness, and even temporary vision loss in a few cases. The effect is usually temporary, lasting a few minutes to several hours. Men at risk for eye problems who take PDE5 inhibitors should have regular eye examinations with an ophthalmologist. Men should also see an eye doctor if visual problems last more than a few hours.
In a few cases, these drugs have been associated with partial vision loss. The vision loss is caused by non-arteritic anterior ischemic optic neuropathy (NAION), a condition that occurs from poor blood flow to optic nerves. However, erectile dysfunction is itself linked to the same vascular problems that cause NAION. Patients who suffer from diabetes, high blood pressure, and heart disease are at higher risk for erectile dysfunction as well as other vascular problems such as NAION. Although the risk of blindness appears small, men who experience a sudden loss of vision should immediately stop taking the drug and contact their doctors.
Hearing Loss. A small number of men have experienced sudden hearing loss in one ear, sometimes accompanied by ringing in the ears and dizziness. If you have this symptom, immediately contact your doctor.
Priapism. PDE5 inhibitors pose a very low risk for priapism in most men. (Priapism is sustained, painful, and unwanted erection.) Exceptions are young men with normal erectile function. Priapism is an emergency situation that requires prompt treatment to prevent permanent damage to the penis.
DrugInteractions. In addition to serious interactions with nitrates, PDE5 inhibitors may also interact with certain antibiotics, such as erythromycin, and acid blockers, such as cimetidine (Tagamet, generic). Patients should tell their doctor about any other medications they are taking.
Other Concerns. Some recent data indicate that men who take drug treatments for erectile dysfunction are at increased risk for contracting sexually transmitted diseases (STDs), including HIV. This risk is due to unsafe sexual practices, not the drugs themselves. Still, it is important for men of all ages to be aware of the risks of STDs and how to prevent them through safe sex interventions.
Alprostadil is derived from a natural substance, prostaglandin E1, which opens blood vessels. This medicine is an effective treatment for many men with ED. It can be administered by:
Candidates. Alprostadil is not an appropriate choice for men with:
Injected Alprostadil. Injected alprostadil (Caverject, Edex) uses a very small needle that the man inserts into the erectile tissue of his penis. Although this treatment is very effective, some men find the injections to be painful or uncomfortable.
The drug should not be injected more than 3 times a week or more than once within a 24-hour period.
Suppository Alprostadil. The MUSE system delivers alprostadil through the urethra using suppository pellets. It works in the following way:
The MUSE system should not be used more than twice a day and is not appropriate for men with abnormal penis anatomy.
Side Effects of Most Alprostadil Methods. Certain side effects are common to all methods of alprostadil administration, although they may differ in severity depending on how the drug is given:
Studies have been inconclusive as to whether testosterone replacement therapy is helpful for men with erectile dysfunction. Men with hypogonadism (clearly low testosterone levels) may benefit, but men who have ED and normal testosterone levels are not likely to benefit from testosterone therapy. Before considering testosterone therapy, men should be sure their hormone levels have been measured correctly and accurately.
Forms of testosterone therapy include:
Side effects may include acne, breast enlargement, headache, and emotional instability. Testosterone therapy may increase the risk for the following serious side effects:
Vacuum erection devices, also called vacuum constriction devices, are another option for men with erectile dysfunction. They are available without prescription and have a high success rate, but are cumbersome and may be difficult to use for some men. They typically work as follows:
Lack of spontaneity is this method's major drawback. There are few side effects.
Penile implants are an option for men who cannot take medication or haven’t been helped by less invasive treatments. In general, they work well in restoring sexual function, and men are usually satisfied with the results.
Two types of surgical implants are used for the treatment of erectile dysfunction:
Erectile tissue is permanently damaged when these devices are implanted, and these procedures are irreversible. Although uncommon, mechanical breakdown can occur, or the device can slip or bulge. In addition, a less than optimal quality of erection may result. Infection is a rare, but serious, complication.
In rare cases, penile vascular surgery may be considered as treatment for erectile dysfunction. Two types of operations are most commonly performed: revascularization (bypass) surgery, and venous ligation. Some insurance carriers consider these procedures experimental and will not pay for them.
According to the American Urologic Association, men who smoke or who have the following conditions are not candidates for penile vascular surgeries:
Revascularization. The revascularization procedure usually involves taking an artery from a leg and then surgically connecting it to the arteries at the back of the penis, bypassing the blockages and restoring blood flow. Penile arterial revascularization is appropriate only for young men (under age 45) who have blood vessel injury at the base of the pain that was caused by events such as blunt trauma or pelvic fracture.
Venous Ligation. Venous ligation is performed when the penis is unable to store a sufficient amount of blood to maintain an erection. This operation ties off or removes veins that are causing an excessive amount of blood to drain from the erection chambers. Long-term success rates for this procedure are less than 50 percent.
Arterial Stents. Doctors are investigating the use of drug-coated stents (similar to those used in angioplasty for heart blockages) for treating ED in patients who have not been helped by drug therapy. The stents are tiny, expandable metal mesh tubes that are implanted in an artery that provides blood flow to the penis. Preliminary studies have been promising, but only men with specific types of blood flow blockages caused by atherosclerosis are candidates for this procedure. These stents are currently only being studied in clinical trials. They have not yet been approved for ED treatment.
Because many cases of erectile dysfunction are due to reduced blood flow from blocked arteries, it is important to maintain the same healthy lifestyle habits used to prevent heart disease.
Diet. Everyone should eat a diet rich in fresh fruits and vegetables, whole grains, and fiber and low in saturated fats and sodium. Because erectile dysfunction may be related to circulation problems, diets that benefit the heart are especially important.
Foods that some people claim to have qualities that enhance sexual drive include chilies, chocolate, scallops, oysters, olives, and anchovies. No evidence exists for these claims.
Weight Control. Being overweight can contribute to erectile dysfunction. Try to achieve and maintain a healthy weight.
Exercise. Regular exercise is helpful for weight control, stress reduction, and a healthy heart.
Alcohol and Smoking. Men who drink alcohol should do so in moderation. Quitting smoking is essential.
Staying sexually active may help prevent erectile dysfunction. Frequent erections stimulate blood flow to the penis.
If medications are causing ED, discuss with your doctor whether to change to a different medication or reduce the dosage.
Even if erectile dysfunction is caused by a physical problem, interpersonal, supportive, or behavioral therapy are often helpful for patients and their partners.
Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Patients should always check with their doctors before using any herbal remedies or dietary supplements.
There is no evidence that any herbal product, vitamin, or dietary supplement can improve erections or sexual performance in men or women. Despite this, many herbs and dietary supplements are marketed as aphrodisiacs. Aphrodisiacs are substances that are claimed to increase sexual drive, performance, or desire. There are several special concerns for people taking alternative remedies for erectile dysfunction.
Yohimbe. Yohimbe is derived from the bark of a West African tree. Side effects include nausea, insomnia, nervousness, and dizziness. Large doses of yohimbe can increase blood pressure and heart rate and may cause kidney failure.
Viramax is a commercial product that contains yohimbine, the active chemical ingredient of yohimbe, and three other herbs: catuaba, muira puama, and maca. It has not been proven to be either effective or safe, and interactions with medications are unknown
Gamma-Butyrolactone (GBL). GBL is found in products marketed for improving sexual function (such as Verve and Jolt). This substance can convert to a chemical that can cause toxic and life-threatening effects, including seizures and even coma.
Gingko Biloba. Although the risks for gingko biloba appear to be low, there is an increased risk for bleeding at high doses and interaction with vitamin E, anti-clotting medications, and aspirin and other NSAIDs. Large doses can cause convulsions. Commercial gingko preparations have also been reported to contain colchicine, a substance that can be harmful in people with kidney or liver problems.
L-arginine (also called arginine). Arginine may cause gastrointestinal problems. It can also lower blood pressure and change levels of certain chemicals and electrolytes in the body. It may increase the risk for bleeding. Some people have an allergic reaction to it, which in some cases may be severe. It may worsen asthma.
Dehydroepiandrosterone (DHEA). DHEA is a supplement related to certain male and female hormones. Studies show inconclusive results in its treatment for erectile dysfunction. DHEA may interact dangerously with other medications.
Spanish Fly. Spanish fly, or cantharides, which is made from dried beetles, is the most widely-touted aphrodisiac but can be particularly harmful. It irritates the urinary and genital tract and can cause infection, scarring, and burning of the mouth and throat. In some cases, it can be life threatening. No one should try any aphrodisiac without consulting a doctor.
Other Dietary Supplements Marketed for Erectile Dysfunction. There are numerous products marketed as "all-natural" dietary supplements and promoted as treatments for erectile dysfunction and sexual enhancement. The FDA has not approved any of these products. In recent years, the FDA has banned from the market many of these dietary supplements and warns that they contain the same or similar chemical ingredients used in PDE5 inhibitor prescription drugs.
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Review Date: 9/17/2013
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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