What are erection problems?
Erection * problems can be a difficult topic to discuss, but if you have problems getting or keeping an erection, you have good reasons to talk with a doctor: Erection problems not only interfere with your sex life, they can be a sign of other health problems.
Erection problems can be a sign of blocked blood vessels or nerve damage from diabetes. If you don’t see your doctor, these problems will go untreated and can harm your body.
Your doctor can offer several ED treatments. For many men, the answer is as simple as taking a pill. Other men have to try two or three options before they find a treatment that works for them. Don’t give up if the first treatment doesn’t work. Finding the right treatment can take time.
*See Pronunciation Guide for tips on how to say the words in bold type.
What causes an erection?
Hormones, blood vessels, nerves, and muscles must all work together to cause an erection. Your brain starts an erection by sending nerve signals to the penis when it senses sexual stimulation. Touch may cause this arousal. Other triggers may be things you see or hear, or sexual thoughts or dreams.
The nerve signals cause the muscles in the penis to relax and let blood flow into the spongy tissue in the penis. Blood collects in this tissue like water filling a sponge. The penis becomes larger and firmer, like an inflated balloon. The veins then get shut off to keep blood from flowing out.
After climax or after the sexual arousal has passed, the veins open back up and blood flows back into the body.
What causes erectile dysfunction?
Many different conditions can lead to ED. Many of the causes are health problems that affect the heart and blood vessels and need to be treated to help prevent more serious problems.
- high blood pressure
- high cholesterol
Unhealthy lifestyle habits can also contribute to ED. Anything that’s bad for your heart is also bad for your sexual health.
- alcohol and drug abuse
- lack of exercise
Nerve damage from many causes can interfere with the signals that start an erection.
- spinal cord injury
- treatments for prostate cancer, including radiation and prostate removal
- multiple sclerosis and other nerve diseases
Some prescription drugs such as some antidepressants or high blood pressure medicines can cause ED. Your doctor may be able to change your drug treatment. Never stop taking a prescribed drug without talking with your doctor.
A small number of ED cases result from a reduced level of the male hormone testosterone.
Doctors used to believe that most cases of ED resulted from mental or emotional problems. We now know that most ED has a physical cause. But depression and worry or anxiety can still cause ED. And ED from physical causes can lead to depression and worry, making ED worse.
A person should not assume ED is part of the normal process of aging. Another cause most likely exists.
What will happen in the doctor's office?
Talking about ED can be difficult. When you meet with your doctor, you might use a phrase like “I’ve been having problems in the bedroom” or “I’ve been having erection problems.” Remember that a healthy sex life is part of a healthy life. Don’t feel embarrassed about seeking help. ED is a medical problem, and your doctor treats medical problems every day.
If talking with your doctor doesn’t put you at ease, ask for a referral to another doctor. Your doctor may send you to a urologist—a doctor who specializes in sexual and urologic problems.
Your partner may want to come with you to see the doctor. Many doctors say ED is easier to treat when both partners are involved.
To find the cause of your ED, your doctor will take a complete medical history and do a physical exam.
Your doctor will ask general questions about your health, as well as specific questions about your erection problems and your relationship with your partner. Bring a list of all the medicines you take, or bring them with you to show to your doctor. Tell your doctor about any surgery you have had.
Your doctor will ask about habits like alcohol use, smoking, and exercise.
Your doctor might ask you questions like
- How do you rate your confidence that you can get and keep an erection?
- When you have erections with sexual stimulation, how often are your erections hard enough for penetration?
- During sexual intercourse, how often are you able to maintain your erection after penetration?
- When you attempt sexual intercourse, how often is it satisfactory for you?
- How would you rate your level of sexual desire?
- How often are you able to reach climax and ejaculate?
- Do you have an erection when you wake up in the morning?
The answers to these questions will help your doctor understand the problem.
A physical exam can help your doctor find the cause of your ED. As part of the exam, the doctor will examine your testes and penis, take your blood pressure, and check your reflexes. A blood sample will be taken to test for diabetes, cholesterol level, and other conditions that may be associated with ED.
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 available testosterone in the blood can yield information about problems with the endocrine system and may explain why a patient has decreased sexual desire.
Monitoring erections that occur during sleep—nocturnal erections—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 a psychological cause. Tests for nocturnal erections are not completely reliable, however. Scientists have not standardized such tests and have not determined when they should be conducted for best results.
A psychosocial examination, using an interview and a questionnaire, can reveal psychological factors. A man’s sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.
How is erectile dysfunction treated?
Most doctors suggest that treatments proceed from least to most invasive. Making a few healthy lifestyle changes may solve the problem. Quitting smoking, reducing alcohol consumption, losing excess weight, and increasing physical activity may help some men regain sexual function.
Cutting back on or replacing medicines that could be causing ED is considered next. For example, if a patient thinks a particular blood pressure medicine is causing problems with erection, he should tell his doctor and ask whether he 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.
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 during treatment for ED from physical causes.
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 U.S. Food and Drug Administration (FDA) approved sildenafil (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.
The recommended dose for Viagra is 50 milligrams (mg), and the doctor 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 doctor may adjust this dose to 20 mg if 10 mg is insufficient. Lower doses of 5 mg and 2.5 mg are available for patients who take other medicines or have conditions that may decrease the body’s ability to use the drug. The 5 mg and 2.5 mg doses of Cialis are FDA-approved for daily use.
None of these PDE inhibitors should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin pills for heart problems should not use any of the three drugs because the combination can cause a sudden drop in blood pressure. Also, men should tell their doctor if they take any drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure. The doctor may need to adjust the ED prescription. Taking a PDE inhibitor and an alpha-blocker within 4 hours of each other can cause a sudden drop in blood pressure. A small number of men have experienced vision or hearing loss after taking a PDE inhibitor. Men who experience vision or hearing loss should seek prompt medical attention.
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 belief that an improvement will occur.
While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. 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 widen blood vessels. The injectable form of alprostadil is marketed as Caverject. These drugs may create unwanted side effects, however, including scarring of the penis and persistent erection, known as priapism. Nitroglycerin ointment, a muscle relaxant, can sometimes enhance an erection when rubbed on the penis.
A system for inserting a pellet of alprostadil into the urethra uses a prefilled applicator to deliver the pellet about an inch into the urethra. The pellet form of alprostadil is marketed as MUSE. 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; a warm 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.
Mechanical vacuum devices cause an erection by creating a partial vacuum, which draws blood into the corpora cavernosa, engorging and expanding the penis. 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 ring, which is moved from the end of the cylinder to the base of the penis as the cylinder is removed. The elastic ring maintains the erection during intercourse by preventing blood from flowing back into the body (see Figure 2). The elastic ring can remain in place up to 30 minutes. The ring should be removed after that time to restore normal circulation and to avoid skin irritation.
Couples may find that using a vacuum device requires some practice or adjustment. An erection achieved with a vacuum device may not feel like an erection achieved naturally. The penis may feel cold or numb and have a purple color. Bruising on the shaft of the penis may occur, but the bruises are usually painless and disappear in a few days. Ejaculation may be weakened because the elastic ring blocks some of the semen from traveling through the urethra, but the pleasure of orgasm is usually not affected.
Surgery usually has one of three goals:
- to implant a device that can cause the penis to become erect
- to reconstruct arteries to increase blood flow 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.
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. The pump causes fluid to flow from a reservoir residing in the lower pelvis to two cylinders residing in the penis. Inflatable implants can expand the length and width of the penis to some degree. They also leave the penis in a more natural state than malleable implants do when not inflated.
Once a man has either a malleable or inflatable implant, he must use the device to have an erection. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have decreased in recent years because of technological advances.
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 groin or fracture of the pelvis. The procedure is usually unsuccessful 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, called ligation, can reduce the leakage of blood that diminishes the rigidity of the penis during an erection. However, experts have raised questions about the long-term effectiveness of this procedure, and it is rarely done.
Points to Remember
- Erection problems may be a sign of health problems.
- A doctor can help you overcome erection problems.
- Smoking, being overweight, drinking too much alcohol, and avoiding exercise can contribute to erection problems.
- Most cases of erectile dysfunction (ED) have a physical cause, but counseling can help couples build a stronger relationship.
- Many men can take a pill to treat ED. These men should still treat the health conditions that caused ED.
- Taking a pill doesn’t work for all men.
- Men who take medicines called nitrates should not take a pill to treat ED.
- Additional treatment options for ED include injections, urethral inserts, a vacuum device, and a surgical implant.