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Erectile Dysfunction

What is Erectile Dysfunction?

Erectile dysfunction (ED) is trouble having an erection or not being able to keep an erection long enough to finish having sex. Another term for this problem is impotence.

It is normal for most men to have trouble having an erection sometimes when they are tired or nervous. When erectile dysfunction becomes a pattern or a long-lasting problem, it can deeply affect the emotional lives of men and their sex partners.

Erectile dysfunction affects older men more than younger men. Midlife and the later years bring changes in circulation that may affect the sex organs. Couples need to be more open and understanding with each other about sexual problems such as erectile dysfunction.

Fortunately, there are many effective treatments for erectile dysfunction.

How Does It Occur?

An erection happens when there is an increased blood flow into the penis. The penis becomes stiff when veins in the penis clamp down, trapping the blood. Nerves in the penis provide feelings of pleasure and help maintain the erection until ejaculation.

There are many possible physical and nonphysical causes of erectile dysfunction:

Possible nonphysical causes are:

  • anxiety, stress, or feelings of guilt
  • depression
  • eating or drinking too much, which diverts blood to the organs used for digestion
  • being very tired or having jet lag
  • fear of failure at intercourse
  • loss of interest in sex

Physical causes may be:

  • trouble with the blood flow to the penis
  • diabetes
  • high cholesterol
  • smoking
  • being overweight
  • diseases or injuries of the nervous system, such as paralysis of the lower body or multiple sclerosis
  • alcohol or drug abuse
  • low levels of male hormone (testosterone)
  • cardiovascular disease
  • side effects of medicines for heart disease, high blood pressure, epilepsy, or mental or emotional problems
  • problems after radical pelvic surgery for rectal or prostate cancer.

How Is It Diagnosed?

If erectile dysfunction lasts longer than 2 months or is a recurring problem, see your healthcare provider for a physical exam. The exam will include urine and blood sugar tests so that your provider can rule out diabetes. In addition, your provider may want to measure the level of testosterone, a male hormone in your blood. You may be referred to a doctor who specializes in erectile problems.

Your healthcare provider may want to test penile blood flow and pressure. Your provider may also want to measure the nighttime stiffness of the penis with a snap gauge test called nocturnal penile tumescence (NPT). For this test, a band is placed around the penis before you go to sleep. If you have an erection, the snap gauge will break.

If your healthcare provider has ruled out physical problems as a cause of erectile dysfunction, he or she may refer you and your partner to a psychotherapist or family counselor. Psychological problems causing erectile dysfunction are varied but most can be helped. Therapy often leads to improved function in other areas of life as well as in sexual function. Psychotherapists often like to work with both partners. Therapy, like other treatments, can be uncomfortable but worthwhile. If you have concerns about your referral, discuss them with your healthcare provider.

How Is It Treated?

If you have problems with blood flow or blood pressure to your penis, you may have several options. These treatments can help you have erections and increase your interest in being sexually active again.

Drug Treatment

Medicines called PDE-5 inhibitors are often used to treat erectile dysfunction. These medicines include Viagra, Levitra, and Cialis. After sexual stimulation, these medicines work by relaxing the blood vessels in the penis. More blood can enter the penis, which helps you get or keep an erection.

These pills should be taken on an empty stomach and followed by some sexual stimulation. They should not be used if you are taking nitrates for heart problems and chest pain. The combination of drugs could cause a dangerously low blood pressure. Erythromycin and some antifungal medicines can also interact with these pills. Men taking these other medicines may need a different dose to prevent side effects. PDE-5 inhibitors can cause side effects such as flushing, headache, and indigestion.

Other prescribed drugs can be self-injected into the penis when an erection is desired. A possible problem with these shots is priapism (painful erections that last more than 4 hours). This requires emergency treatment. Because of this risk, the shots must be used only with a healthcare provider's prescription. The penis will usually become erect in 10 to 15 minutes after having a shot. Erections resulting from these shots usually last as long as an hour.

If a man's level of testosterone is low, he may be prescribed hormone treatment. Testosterone is available in the form of patches or gels that are used on the skin or as monthly or bimonthly shots that can be given in the arm.

External Mechanical Devices

There are mechanical devices that trap blood in the penis to cause an erection. They come with a vacuum chamber, a pump, connecting tubing, and elastic bands. The system requires time and dedication on the part of the couple to become comfortable with it. There are a number of such devices on the market. They may be covered by Medicare when the problem is related to blood flow and the device is prescribed by a healthcare provider.

You insert the soft penis into the vacuum chamber tube connected to a pump by a piece of tubing. You then apply suction by using the small hand pump. Suction pulls blood into the penis, producing an erection. The blood is held in the penis by placing a tight band, similar to a rubber band, around the base of the erect penis. You should not keep the band in place longer than 30 minutes or fall asleep with it on.

Advantages of these devices include:

  • You can avoid the potential side effects of medicines prescribed for ED.
  • They may help to reestablish penile blood flow while the penis is becoming erect.


Men who are not helped with the treatments described above may have severe defects of the penile arteries or veins. They may choose surgery to correct the defects.

Surgery may also be used to place a mechanical device or Implant inside the body. These devices are used only when:

  • There is nerve and blood vessel damage.
  • There has been no improvement with ED medicine, mechanical devices used outside the body, hormonal replacement therapy, or medical treatment of the cause.

Treatment involves inserting a mechanical device or prosthesis into the area where the blood normally collects to stiffen the penis.

Although the overall success rate of these penile devices or prostheses is greater than 95%, many healthcare providers urge couples to consider simpler, less expensive choices before surgery.

Your healthcare provider will discuss the pros and cons of each type of device and help couples select one that is likely to work best for them. Semirigid implants use rods to give firmness to the penis. Inflatable implants have cylinders that can be inflated or deflated at will. Penile implants do not change a man's sensation or ejaculation.

Advantages of a semi-rigid implant are:

  • It is less expensive than an inflatable implant.
  • It is simple to insert.
  • It can be inserted under local, spinal, or general anesthesia.
  • It is always ready for use once it is in place.
  • It can be inserted during a 1-day surgery. You do not need to stay overnight at the hospital.

Disadvantages of a semi-rigid implant are:

  • It is always at its full size.
  • A semirigid implant can be bent so it can be hidden and then brought into position when desired, but sometimes it may be hard to hide.

Advantages of an inflatable implant are:

  • It can be easily hidden. It uses a pump tucked in the scrotum above the testicles and a fluid reservoir behind the pubic bone. The hollow cylinders that replace the erectile tissues are connected to the reservoir and can be inflated or deflated at will. The penis returns to a resting state when the fluid is returned to the reservoir from the cylinders by reversing the flow with the pump.

Disadvantages of an inflatable implant are:

  • It is more expensive.
  • Inserting it requires a hospital stay of 24 to 48 hours.
  • Since it is more complex, there are more ways in which the device could stop working.

It usually takes about 4 to 6 weeks after surgery before you can start using an implant. Risks of implant surgery include:

  • infection
  • rejection of the implant by your body or damage to the inside of the penis.

If any of this happens, the device has to be removed.

Continue reading about erectile dysfunction in our Patient Education section

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