Erectile dysfunction (ED) is the inability to maintain an erection to completion of intercourse. ED is not a normal part of aging. It may, in fact, be an indication that there is something else going on with your health.
Sexual dysfunction has often been seen as a byproduct of aging, but that outlook is changing as we define what aging really means. There are people in their 80s who are sexually active and, conversely, there are people of all ages who have erectile dysfunction. Renowned researchers of human sexual response, Masters and Johnson, have stated that the ability to have sex well into old age essentially depends on not stopping.
What's "average" for older men? Keeping in mind that everyone ages differently:
- Arousal may take longer
- Erection may be less full
- The time it takes to reach orgasm may increase
- Orgasms may be less intense
- Recovery (the time needed before another erection can be achieved) after orgasm may take longer.
Bottom line, ED is not an inevitable consequence of aging. In fact, medical professionals who study aging have found that many of the common changes we used to believe were unavoidable, including ED, have turned out to be the result of disease.
Causes of Erectile Dysfunction
What causes ED? The process of erection is complex and involves the vascular system, the nervous system, the endocrine system and an individual's emotions. Medical experts estimate that 70 percent of ED cases can be traced to a physical cause and another 20 percent to stress, anxiety and depression, leaving 10 percent not clearly identified.
Physical causes of and risk factors for ED are related to basic health, meaning that if you have other health problems, your likelihood of having ED is greater. Conditions that lead to reduced blood flow to the penis, inability of the penis to retain blood during erection and reduced ability of the nerves to send or receive the proper signals are the most common physical causes.
Common conditions include:
- Cardiovascular disorders, such as high blood pressure, blocked arteries, and high cholesterol levels
- Insulin resistance
- Use of some prescription drugs, such as certain blood pressure and cardiovascular medications, tranquilizers and antidepressants
- Hormone disorders, such as thyroid disease and hypogonadism
- Pelvic trauma, surgery, radiation therapy
- Neurological disease, including Parkinson's, Alzheimer's, and multiple sclerosis
- Spinal cord injuries
- Enlarged prostate
- Disorders of the penis itself, such as Peyronie's disease
- Lifestyle choices that lead to those physical disorders may affect erectile function as well, including:
* Excessive caffeine
* Cigarette smoking
* Alcohol and drug abuse
* Lack of exercise
Psychological causes and risk factors, including almost any form of stress, worry and anxiety, can be causes of erectile dysfunction. Though psychological causes of ED are a much smaller percentage of the total, they are equally important and very treatable.
Consequences of ED
Physical causes of ED can be early warning signs of more general and potentially dangerous conditions.
- ED may diminish a man's willingness to be intimate and affectionate with his partner, damaging their relationship and hurting the person he most cares about.
- ED can affect more than your sex life. It can create mental stress that affects your self-confidence and the way you approach the world.
No one needs to passively accept the loss of sexual function because they think it's normal. With the help of your primary care physician or urologist, you can deal with the causes of ED with lifestyle changes, medical treatment for underlying disorders, ED-specific treatment and/or counseling.
How Psychological Problems Can Lead to ED
Erectile dysfunction can be a symptom of an underlying problem in the physiological chain. With your doctor, you have to figure out where the problem is occurring. The process of erection is complex and involves the vascular system, the nervous system, the endocrine system and an individual's emotions.
When a man is sexually aroused, the brain sends messages along the nerves to the vascular system. The messages tell the vascular system to increase the amount of blood flowing into the penis. Inside the penis are two chambers filled with spongy erectile tissue. This tissue fills with blood causing the penis to expand. At the same time, fibrous elastic sheathes around the erectile tissue tighten, so the blood can't leave the penis and the erection continues. After ejaculation or when sexual stimulation ends, the sheathes loosen, the blood leaves the penis, and the penis returns to its non-erect state. A problem with any one of these functions can result in ED.
In any case, your doctor will want to do a thorough exam, which may include some or all of the following:
- Medical history, including your general physical and emotional state, your lifestyle and questions about any prescribed or illicit drugs you're currently taking that might cause ED
- Sexual history
* How often do you have relations with your partner?
* How important is sex to you and your partner?
* Do you have difficulty obtaining and/or maintaining an erection?
* How long have you been unable to obtain and/or sustain an erection?
- Physical exam
* Are testicles normal in size?
* Does the prostate appear to be enlarged?
* Are hair patterns normal? (to evaluate potential problems with testosterone levels)
* Is the thyroid enlarged?
* Is blood pressure elevated?
* Does the body mass index suggest the risk of diabetes?
* Is there sensation in all extremities?
- Laboratory tests, such as routine blood and urine tests that can check your level of male hormones, cholesterol, blood sugar, and liver, kidney and thyroid function.
- Cardiac work-up including and EKG and echocardiogram. ED can be the first indicator of coronary artery and valve disease.
- Erectile function tests to evaluate blood flow into and out of the penis and measure the blood pressure in it (normally and during erection) and evaluate the sensitivity and nerve function of the penis. Among the most common are:
* Ultrasound to evaluate blood flow, venous leak, signs of arteriosclerosis and scarring or calcification of erectile tissue.
* Penile nerve function to determine if there is sufficient nerve sensation in the penis.
* Nocturnal penile tumescence (NPT) tests to measure the number and strength of the erections you have during sleep.
* Vasoactive injection to measure pressure in penile blood vessels.
The importance of a proper diagnosis Some patients are unwilling to undergo a long evaluation and testing process to obtain a better understanding of their sexual problem. However, proper diagnosis is the key to beneficial treatment for two primary reasons: Self-treatment with over-the-counter or over-the-internet remedies is usually ineffective and can even be dangerous, and new, highly touted prescription medications for ED may or may not work, depending on the underlying cause of the problem. If a patient's health is optimized, the drugs may not be needed—or, if needed, they may be more effective.
Treatments for ED
If you are suffering from erectile dysfunction, there is help available. There are good treatments, but you have to make sure the treatment is appropriate for the problem. With more potential remedies on the market than ever, erectile dysfunction is a highly treatable problem in all age groups. However, before any ED-specific therapy is attempted, underlying causes should be diagnosed and treated.
Treatment for erectile dysfunction depends on its causes and its severity and include:
- Lifestyle modification. Since what makes us sick can also cause ED, what makes us well can also be a remedy for ED. Lifestyle modification can both prevent ED and improve sexual function. Five healthy behaviors characterize a healthy lifestyle—not smoking, eating a healthy diet, avoiding alcohol (or consuming it only in moderation), getting plenty of physical activity and controlling weight.
- Alternative medicine and natural remedies. Many alternative remedies are aggressively marketed for ED. However, very few have been studied, most are not regulated so their quality is not controlled, and some can actually be harmful. Be sure to talk to your doctor before using any alternative remedy. Alternative remedies that may work include:
- Dietary supplements. These may be helpful as part of an overall plan to maintain a healthy diet. Fish oil supplements can be beneficial to blood vessels overall.
- Herbal supplements. Most have been ineffective when tested in blind studies, but they may be useful for their placebo effect. However, a recent double-blind study appears to show evidence that ginseng is better than placebo and, in one small study, 78 pecent of men who had ED caused by impaired blood flow improved after taking ginkgo.
- Arginine.This amino acid may help increase circulation.
- Relaxation techniques. Relaxation is a requirement for successful sexual function.
- Vacuum devices. The vacuum device is an external penile pump. A plastic tube is placed over the penis and against the body to form a seal. The hand pump creates a vacuum in the tube that draws blood into the penis and creates an erection. A rubber ring is then snapped over the base of the penis to help maintain the erection. Downsides include lack of spontaneity, plus the resulting erection may be somewhat uncomfortable.
- Oral medication. The most popular prescription drugs for erectile dysfunction are selective enzyme inhibitors. They work in about two-third of patients by causing the smooth muscles of the penis to relax and allow blood to flow into the erectile tissue. Men with certain conditions shouldn't take selective enzyme inhibitors. Possible side effects include headache, flushing, indigestion, muscle aches and nasal congestion. Commonly prescribed selective enzyme inhibitors are:
* Sildenafil (brand name: Viagra®)
* Vardenafil HCl (brand name: Levitra®)
* Tadalafil (brand name: Cialis®)
Only a relatively small number of men have ED because of insufficient levels of sex hormones. However, for those who do, the problem is relatively easy to solve with hormone replacement medicines. Hormone replacement is not without its side effects. Please discuss possible side effects with your doctor.
- Suppositories. This treatment involves using an applicator to insert a tiny suppository into the tip of the penis to widen the penile blood vessels. Tests suggest this method can be more painful and less effective than injection therapy.
- Injection therapy. This therapy involves self-injection directly into the base or side of the penis to dilate blood vessels to produce an erection. The procedure is relatively painless, but possible potential side effects include bleeding from the injection, a burning sensation in the penis, dizziness, heart palpitations, flushing, scarring or fibrous tissue forming at the injection site, and prolonged erection.
- Surgery. There are several kinds of prosthetic devices that can be implanted in the penis. The two main types are (1) inflatable silicone or plastic tubes and (2) semi-rigid rods (made of metal covered by silicone or polyurethane). Implanting these devices is a surgical procedure requiring anesthesia and possibly an overnight in the hospital, with all the possible side effects of any surgery. This step is irreversible. For men whose ED is caused by blocked blood supply to the penis because of injury to the penis, pelvic area, or other vascular problems, vascular surgery of the penis may be the solution. These surgeries are not common and they're recommended only for men with very specific conditions.
- Psychotherapy. Individuals with ED caused by psychological issues will generally be referred to a mental health professional specializing in sex therapy. Issues can include:
* Lack of sexual knowledge
* Lack of communication between partners
* A poor relationship between partners
* Performance anxiety
* Life stresses
* Inhibition related to upbringing, religion, and social background
This article reprinted with permission from Second Opinion, a public television health program hosted by Dr. Peter Salgo and produced by WXXI (Rochester, NY), West 175 and the University of Rochester Medical Center.