Complete Overview of Erectile Dysfunction

Erectile Dysfunction

What is erectile dysfunction?
Erectile dysfunction, or impotence, is the inability to achieve and sustain an erection suitable for sexual intercourse. The condition is not considered normal at any age. Premature ejaculation, infertility, or low sex drive are not the same as erectile dysfunction, though one or more of these conditions may be associated with it.

How serious a problem is erectile dysfunction?
It is estimated that erectile dysfunction affects about 1 in 10 adult males on a long-term basis. A much more common problem that affects most men at some point is the occasional failure to achieve an erection. Occasional failure can occur for a variety of reasons, such as from drinking too much alcohol or from extreme fatigue. Failure to achieve an erection less than 20 percent of the time is not unusual and treatment is rarely needed. Failure more than 50 percent of the time generally signifies there is a psychological or physical problem (or combination of both) that requires treatment.

How is erectile dysfunction detected?
An erection is possible when three conditions are met:

* The nerves to the penis must be functioning properly
* The circulation to the penis must be adequate
* There must be a stimulus from the brain (or spinal cord for a reflex erection)

If there is something interfering with some or all of these conditions, a full erection will be prevented. Treatment is directed towards correcting these problems.

What is the treatment for erectile dysfunction?


* Sex therapy
* Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil) -- these are oral medications to help achieve an erection
* MUSE (Medication for Urethral Stimulation of Erection) Urethral suppository
* Caverject (Penile injection of alprostadil)
* VED (Vacuum Erection Device) -- these are suction devices with rubber constriction bands


* Penile implant (semi-rigid or inflatable)
* Penile revascularization

Erectile Dysfunction: Fact or Fiction

Erectile dysfunction (ED) is a normal part of getting older.
Fiction: It is not normal for a man to lose erectile function completely as a result of aging. Generally, other factors may be involved. These may include vascular disease, diabetes, hypertension, and personal habits such as cigarette smoking.

Prescription drugs can be associated with ED.
Fact: There are more than 200 prescription drugs that may be associated with ED.

A man can get an erection whenever he wants.
Fiction: This may be true of teenage boys; however, erections do not occur as often as a man gets older. Hormones in a manís body and other life changes may affect a manís level of arousal. It may take longer for a man to achieve an erection and may require more direct stimulation and foreplay.

ED is sometimes a psychological issue.
Fact: Psychological factors are responsible for 10 to 20 percent of ED cases. However, most men with ED have an underlying physical condition such as diabetes, heart disease, high blood pressure, or have had prostate cancer surgery.

Tight underwear can cause ED.
Fiction: Causes of ED can be physical and/or psychological, but tight underwear is not among the causes of ED.

Tobacco use, alcohol, or illegal drug use may bring about ED.
Fact: These substances can damage blood vessels and/or restrict blood flow to the penis, causing ED.

Most men never experience ED.
Fiction: Most men experience ED at one time or another. Studies suggest that as many as 52 percent of men between the ages of 40 and 70 may have erectile difficulties.

It is advisable to seek treatment for recurring ED.
Fact: A man should seek medical advice and treatment if ED occurs more than 50 percent of the time.

ED can result from the occasional riding of a bicycle.
Fiction: Bicycle riding, in moderation, does not affect erectile functioning. Men should take breaks when cycling long distances, however. A bike and seat that fit ergonomically with a manís body can relieve discomfort associated with bicycling.

Impotence is not just the problem of the man with ED.
Fact: Both partners can suffer if impotence goes untreated. Failure to communicate and denial of the problem can lead to depression, anxiety, and lack of self-esteem for both partners.

Erectile Dysfunction: Overview

Erectile dysfunction, commonly referred to as ED, is the inability to achieve and sustain an erection suitable for sexual intercourse. This condition is not considered normal at any age and is different from other problems that interfere with sexual intercourse, such as lack of sexual desire and problems with ejaculation and orgasm.

How common is ED?
It is estimated that about 1 in 10 adult males suffer from ED on a long-term basis.

A much more common problem that affects the majority of men at some point in their life is the occasional failure to achieve an erection. This problem can occur for a variety of reasons, such as from drinking too much alcohol or from being extremely tired.

Failure to achieve an erection less than 20% of the time is not unusual and treatment is rarely needed. Failure to achieve an erection more than 50% of the time, however, generally indicates there is a problem requiring treatment.

Is erectile dysfunction a normal part of aging?
No. ED doesn't have to be a part of getting older. While it is true that older men may need more stimulation (such as stroking and touching) to achieve an erection, they should still be able to get an erection and enjoy sex.

What causes ED?
In order to achieve an erection three conditions must occur:

* The nerves to the penis must be functioning properly.
* The blood circulation to the penis must be adequate.
* There must be a stimulus from the brain.

If there is something interfering with any or all of these conditions, a full erection will be prevented.

Common causes of ED include diseases that affect blood flow, such as atherosclerosis (hardening of the arteries); nerve diseases; psychological factors, such as stress, depression and performance anxiety; and injury to the penis. Chronic illness, certain medications and a condition called Peyronieís disease (scar tissue in the penis) can also cause ED.

Can ED be prevented?
For people who are at risk of developing ED due to personal behavior, steps may be taken to prevent its occurrence. However, other causes of ED may not be preventable.

urologist or a psychologist.

What should I do if I am having problems achieving/maintaining an erection?
If you suspect you may have erectile dysfunction, see your doctor. He or she can perform a variety of tests to identify what is causing your problem and refer you to a specialist if needed. Once the cause is pinpointed, there are several treatments to consider.

How is erectile dysfunction treated?
There are many different ways ED can be treated. Treatments include oral medications, sex therapy, penile injections and surgery. Each type of treatment has its own advantages and disadvantages. Talk to your doctor to determine the best treatment for you.
Does insurance cover ED treatment?
Insurance coverage of ED depends upon the type of treatment prescribed. If there is a documented medical condition that is shown to be causing ED, insurance will usually cover at least some of it. Sex therapy and medications that have not yet been approved by the FDA are generally not covered. Medicaid does not cover vacuum constriction devices or penile implants. Talk to your insurance provider to determine whether the treatment you are considering will be covered.

Preventing Erectile Dysfunction

For people who are at risk of developing ED, taking active steps to prevent its occurrence will not only help you maintain erectile function, but also will help you lead a healthier life overall. Some steps you can take to prevent ED:

* Stop smoking to decrease your risk of developing atherosclerosis (narrowing of the arteries)
* Exercise regularly
* Maintain a healthy weight
* Take prescribed medications as directed
* Avoid excessive use (more than three drinks a day) of alcohol
* Avoid the use of illegal drugs
* If you have a chronic illness such as diabetes or kidney disease, follow your doctorís guidelines to keep these conditions in control

Implantable Penile Prosthesis

A penile prosthesis is another treatment option for men with erectile dysfunction. The simplest type of prosthesis consists of a pair of malleable rods surgically implanted within the erection chambers of the penis. Today, many men choose a hydraulic, inflatable prosthesis that allows a man to have an erection whenever he chooses.

A penile implant is usually used when there is a clear medical cause for ED and when the problem is unlikely to resolve or improve naturally or with other medical treatments. Sometimes a penile prosthesis is implanted during surgery to reconstruct the penis when scarring has caused erections to curve.

How does the penile prosthesis work?
The inflatable penile prosthesis consists of two cylinders--a reservoir and a pump--that are placed surgically in the body. The two cylinders are inserted in the penis and connected by tubing to a separate reservoir of fluid. The reservoir is implanted under the groin muscles. A pump is also connected to the system and sits under the loose skin of the scrotal sac, between the testicles.

To inflate the prosthesis, the man presses on the pump. This does not involve putting pressure on the testicles. The pump transfers fluid from the reservoir to the cylinders in the penis, inflating them. Pressing on a deflation valve at the base of the pump returns the fluid to the reservoir, deflating the penis.

What is sex like with the prosthesis?
When the penis is inflated, the prosthesis makes the penis stiff and thick, similar to a natural erection. Most men rate the erection as shorter than their normal erection, however, newer models have cylinders that may increase the length, thickness and stiffness of the penis.

A penile prosthesis does not change sensation on the skin of the penis or a manís ability to reach orgasm. Ejaculation is not affected. Once a penile prosthesis is put in, however, it may destroy the natural erection reflex. Men usually cannot get an erection without inflating the implant. If the implant is removed, the man may never again have natural erections.

Do the implants work?
About 90%-95% of inflatable prosthesis surgeries are successful, meaning the implants produce erections suitable for intercourse. Satisfaction rates with the prosthesis are very high, and typically 80%-90% of men are satisfied with the results and say they would choose the surgery again.

Is the implant safe?
No surgery is totally free of possible complications. Complications associated with penile implants include:

* Uncontrolled bleeding after the surgery; this condition may require an additional surgery
* Infection
* Scar tissue formation
* Erosion
* Mechanical failure

Is the prosthesis noticeable?
While men who have had the prosthesis surgery can see the small surgical scar where the bottom of the penis meets the scrotal sac, other people probably will be unable to tell that a man had an inflatable penile prosthesis. Most men would not be embarrassed in a locker room or public restroom, for example.

Depression and Erectile Dysfunction

In some men, depression can accompany the condition of erectile dysfunction (ED). It is common for men with ED to feel angry, frustrated, sad, or unsure of themselves. Men may feel less "manly" because of ED. Such feelings may lead to a lack of self-esteem and eventually to depression.

What is depression?
Depression is an illness marked by persistent sadness, feelings of hopelessness, and a pessimistic outlook.

The most common symptoms of depression include:

* low self-esteem
* loss of interest in formerly pleasurable activities
* fatigue
* changes in appetite
* sleep disturbances
* apathy

Depression affects the way one feels about oneself and the way one thinks about things. People who are depressed cannot simply "pull themselves together" and get better. Depression is not a sign of personal weakness.

Without treatment, symptoms of depression can last indefinitely. Appropriate treatment, however, can help most people who suffer from depression.

Depression is not a "womanís disease"
Depression is found in men and women, even though men account for only one in 10 diagnosed cases of depression. Depression once was considered a "womanís disease" that was linked to hormones and premenstrual syndrome (PMS). This lingering stereotype of the disease may prevent some men from recognizing its symptoms and seeking appropriate treatment.

Depression in men may not be recognized
In American culture, expressing emotion is largely considered a feminine trait. Depression in males may go unrecognized because:

* Men tend to deny having problems because they are supposed to "be strong."
* Men who are depressed are more likely to talk about the physical symptoms of depression, such as feeling tired, rather than about actual emotions.
* Outward symptoms of male depression are not always understood. Men are less likely than women to show "typical" signs of depression, such as crying, sadness, or loss of interest in activities they used to enjoy.
* Men are more likely than women to keep their feelings hidden, but they may become more irritable and aggressive.

For these reasons, many menóas well their health care professionalsófail to recognize depression.

Diagnosing depression in men with ED
The diagnosis of depression begins with a physical exam and interview by a health care professional, who likely will ask about issues including family history and chemical dependency. There is no single test that can diagnose depression; however, there are certain patterns that health care professionals look for in order to make a proper diagnosis. These patterns may include overall sadness, irritability, and withdrawal from everyday activities.

Treating depression in men with ED
Treatment for depression may include antidepressant medications, psychotherapy (talk therapy), or a combination of both.

* Antidepressants: Many different drugs, including Prozac, Zoloft, Ellaville, and Wellbutrin, are used to treat depression. Note that some antidepressants can worsen ED. Health care providers can recommend antidepressants that are appropriate for men with ED.
* Talk therapy: During therapy, a person with depression talks to a licensed and trained mental health care professional who helps the person identify and work through issues related to depression. Types of talk therapy include couples therapy, individual therapy, and group therapy.

Help is available
Depression that accompanies ED is treatable. The first step in addressing your concerns about ED-related depression is to be honest with yourself, your partner, and your doctor. After depression has been brought out into the open, coping with it will be easier and less stressful.

Intimacy and Erectile Dysfunction

Dealing with erectile dysfunction can be difficult on a relationship. Sexual intercourse is one means of creating intimacy with your partner, but there are other ways. Non-sexual activities may include:

* Sharing feelings Ė Discussing your feelings with a partner may bring the two of you closer together. Talking and listening can help you and your partner understand one another. Open dialogue with your partner about each otherís needs and concerns helps to overcome barriers to a healthy relationship.
* Participating in common interests Ė Sharing common interests in hobbies, sporting activities, or volunteer activities can bring couples closer together.
* Making time to be alone together Ė Taking a bath together, sharing a candlelight dinner, taking a walk, or just holding each other in bed are a few suggestions for creating intimacy with your partner.

There are many additional ways of creating intimacy. Explore different activities that you and your partner can do together to bring you closer.

Sex Therapy

Sex therapy is a short-term form of counseling, generally involving 5 to 20 sessions with a sex therapist. A typical session may be one hour every week or every other week.

During the session, the counselor will give the patient "assignments" to do at home, such as:

* Reading books about sexuality
* Touching exercises that are designed to take away the pressure to perform during sex
* Practicing better sexual communication skills

Sex therapy may be useful for treating erectile dysfunction if a man is able to have a normal erection during sleep, the results of his physical examination and blood tests are normal and he is generally in good health. Sex therapy may also be helpful when erectile dysfunction is caused by stress, such as: work worries, financial worries, relationship conflicts, and poor sexual communication. In these cases, sex therapy may be the best treatment option.

Does sex therapy work?
Sex therapy is most effective when a manís sexual partner is willing to be part of the treatment. Studies have shown that for men with stress-related ED, having the partner involved in the therapy resolves the problem 50%-70% of the time. When the man must go through counseling alone, the results are somewhat lower.

Sex therapy is unlikely to work if a man drops out of treatment after only one or two sessions.

Sometimes several sessions of sexual counseling can be helpful to a man who is going to receive medical or surgical treatment for erectile dysfunction. A counselor can help guide a couple in agreeing on a treatment or help them improve their sexual communication and lovemaking skills. A single man may benefit from counseling on how to talk to his partner about penile injections or a vacuum constriction device, both treatments for ED.

Does health insurance cover sex therapy?
Some insurance plans cover sex therapy. Once you select a therapist, call her/him to ask about whether or not his or her services are covered by your insurance provider. If payment cannot be worked out through insurance, many therapists can adjust their fees. Sex therapy clinics tend to be less expensive than private therapists. The cost of sex therapy programs can vary depending on the nature of the problem and the response to treatment.

How do I find a sex therapist?
Call your local hospital or university medical center to see if they have a sex therapy clinic. Also, ask your doctor if he or she can recommend a therapist.

Erectile Dysfunction and Lifestyle Changes: Diet and Exercise

There are now a number of epidemiologic studies that suggest a link between erectile dysfunction (ED) and obesity, high cholesterol, hypertension, diabetes, and heart disease.

The following recommendations may play a role in the prevention of ED or improvement (if the problem is already present):

* Eat a healthful diet. A diet that limits saturated fat intake and includes several portions of fruits, vegetables, and whole grains can benefit men with ED.
* Reduce cholesterol. High cholesterol can harden, narrow, or block the arteries (atherosclerosis) leading to the penis. Men can lower cholesterol through diet, exercise, and medication.
* Maintain a healthy weight. As noted above, overweight men are more likely to have ED.
* Exercise regularly. Regular exercise may reduce the risk of ED. Choose exercises that you enjoy and will make a regular part of your day. In addition to reducing the risk of ED, exercise also can help you manage stress. Check with your doctor before starting any exercise program.

Lifestyle Factors and Erectile Dysfunction

Men can take active steps to prevent erectile dysfunction (ED) or to improve erectile function. These steps also can help men lead healthier lifestyles overall. Men can:

Stop smoking. Non-smokers have a lower risk of developing atherosclerosis (hardening of the arteries). Quitting smoking can help some men partly or fully restore erectile function.

Maintain a healthy weight. According to The American Urological Association (AUA), overweight men are more likely to have ED.

Exercise regularly. Regular exercise can reduce the risk of ED, according to the AUA.

Control diabetes. Diabetes can harm arteries and nerve endings supplying the penis. Diet, exercise, and medical therapy can help men avoid diabetes-related ED.

Reduce cholesterol. High cholesterol can damage the linings of blood vessels throughout the body, including those in the penis. Cholesterol also can harden, narrow, or block the arteries leading to the penis. Men can lower cholesterol through diet, exercise, and medication.

Avoid excessive use of alcohol. Excessive drinking can inhibit erectile functioning and can affect production of the male hormone testosterone, affecting sex drive and erections. More than 80 percent of chronic alcoholics have chronic ED.

Avoid the use of illegal drugs. Marijuana, cocaine, and other illegal drugs can cause impotence.

Reduce stress and anxiety. Stress and anxiety are leading causes of temporary ED. Less stress can mean improved erectile functioning.

Living With Erectile Dysfunction

Erectile dysfunction takes more than a physical toll. The emotional impact that the condition can have on a man and his partner can be just as difficult. It is common for men with ED to feel anger, frustration, sadness, or a lack of confidence. However, the condition can be treated.

The first step in addressing your concerns about ED is to be honest with yourself, your partner and your doctor concerning the problem. Once ED has been brought out into the open, coping with it as you go through treatment will be easier and less stressful. Communication is essential to successful diagnosis and treatment, as well as to helping your partner understand any feelings you may have.

While you are being treated for ED, it is important to be patient with your progress and to keep in mind that everybody is different. A treatment that might work for one person may not work for another. It is also important to know that the treatment you choose may not work the first time and/or may not work every time. For some couples, sex therapy may be beneficial in helping the partners to support each other and maintain intimacy while coping with ED. It may also help to learn more about othersí experiences with ED. Contact your doctor about local support groups in your area.

Treating Erectile Dysfunction: Lifestyle Changes

One way to improve erectile dysfunction is to make some simple lifestyle changes. For some men, adopting a healthier lifestyle by quitting smoking, exercising regularly, and/or reducing stress may be all that is needed to find relief. For those who require more intensive treatment, adopting these lifestyle changes in addition to other treatments can further help.

Quit smoking
Quitting smoking can be very difficult and there is no single best way that works for all people. The following are some approaches to try that might help you kick the habit:

* Pick a quitting date one to three weeks in the future. Prepare for the date by cutting down on smoking, staying away from your favorite places to smoke, and making a plan for how you will deal with stressful events without smoking.
* On your quitting date, get rid of all cigarettes, keep busy, and stay in smoke-free places.
* The nicotine patch, nicotine gum, or other medication that may be prescribed to help you quit can be helpful but they will not take away your cravings to smoke. Talk to your doctor to see if you should try these techniques.
* Make a clean break. Do not allow yourself to smoke "now and then." An addiction to nicotine can be reactivated anytime, even years after quitting.
* Take it one moment, one hour, one day at time. Cravings to smoke are usually short-lived and will go away whether or not you have a cigarette.

Get help with quitting if you need it. Choose a comprehensive smoking cessation program that does not rely on a single technique (such as hypnosis). Your doctor can point you in the right direction.

Exercise regularly
Regular exercise can improve your health in many ways. Along with improving erectile function, exercise can:

* Strengthen the heart
* Improve the flow of oxygen in the blood
* Build energy levels
* Lower blood pressure
* Improve muscle tone and strength
* Strengthen and build bones
* Help reduce body fat
* Help reduce stress, tension, anxiety and depression
* Boost self-image and self-esteem
* Improve sleep
* Make you feel more relaxed and rested
* Make you look fit and healthy

To get the most benefit, you should exercise at least 20 to 30 minutes, three times a week. Current studies suggest that four or five times a week is best. If you are a beginner, exercise for 20 minutes and build up to 30 minutes.

When starting out, you should plan a routine that is easy to follow and stick with. As the program becomes more routine, you can vary your exercise times and activities. Here are some tips to get you started.

* Choose an activity you enjoy. Exercising should be fun, not a chore.
* Schedule regular exercise into your daily routine. Add a variety of exercises so that you do not get bored. Look into scheduled exercise classes at your local community center.
* Exercise does not have to put a strain on your wallet. Avoid buying expensive equipment or health club memberships unless you are certain you will use them regularly.
* Stick with it. If you exercise regularly, it will soon become part of your lifestyle.
* If you feel you need supervision or medical advice to begin an exercise program, ask your doctor to refer you to physical therapy. A physical therapist can evaluate your needs and start you on a safe and effective exercise program.

Reduce stress
Stress is common to everyone. Our bodies are designed to feel stress and react to it. It keeps us alert and ready to avoid danger. But it is not always possible to avoid or change events that may cause stress and it is easy to feel trapped and unable to cope. When stress persists, the body begins to break down and illnesses can occur. The key to coping with stress is identifying stressors in your life and learning ways to direct and reduce stress.

Learning an effective means of relaxation and using it regularly is a good first step. Allow yourself some "quiet time," even if it's just a few minutes. Examine and modify your thinking, particularly unrealistic expectations. Talking problems out with a friend or family member can help put things in proper perspective. Seeking professional assistance can help you gain a new perspective on how to manage some of the more difficult forms of stress. Other approaches to reducing stress include:

* Keep a positive attitude. Believe in yourself.
* Accept that there are events you cannot control.
* Be assertive instead of aggressive. "Assert" your feelings, opinions or beliefs instead of becoming angry, combative or passive.
* Learn to relax.
* Exercise regularly. Your body can fight stress better when it is fit.
* Eat well-balanced meals.
* Stop smoking.
* Consume moderate amounts of alcohol and caffeine.
* Set realistic goals and expectations.
* Get enough rest and sleep. Your body needs time to recover from stressful events.
* Don't rely on alcohol or drugs to reduce stress.
* Learn to use stress management techniques and coping mechanisms, such as deep breathing or guided imagery.

Treatment Options for Erectile Dysfunction

What is erectile dysfunction (ED)?
Erectile dysfunction is defined as the inability to attain and/or maintain an erection suitable for sexual activity.

What are the causes of ED?
Erectile dysfunction can be caused by a number of factors, including the following:

* Vascular disease ó Blood supply to the penis can become blocked or reduced as a result of vascular disease such as atherosclerosis (hardening of the arteries).
* Nerve disorders ó Nerves that send impulse to the penis can become damaged from stroke, diabetes, or other causes.
* Psychological states ó These includes stress, depression, and performance anxiety.
* Trauma ó An injury might contribute to ED.

Chronic illness, medications, and Peyronie's Disease (scar tissue in the penis) can also cause erectile dysfunction.

How is ED treated?
The first step to treating ED is finding the underlying cause, then the appropriate treatment can be given. If the problem continues after treatment, there are a number of non-surgical treatments that can help a man gain and maintain erections.

Non-surgical treatments

Oral corporeal pharmacotherapy
Sildenafil (Viagra) was the first oral medicine approved to treat ED. It is taken about one hour before sexual activity. Men who are on medicines that contain nitrates such as nitroglycerine, should not take Viagra. The combination of Viagra and nitrates can cause low blood pressure (hypotension). The most common side effects of Viagra are dyspepsia (indigestion), nasal congestion, flushing, headaches, and a transient visual disturbance. There have been no reports of priapism (prolonged, painful erection) with Viagra therapy. Other medicines used to treat ED include vardenafil (Levitra) and tadalafil (Cialis)

Vacuum constriction device
The vacuum constriction device is a cylinder that is placed over the penis. The air is pumped out of the cylinder, which draws blood into the penis and causes an erection. The erection is maintained by slipping a band off the base of the cylinder and onto the base of the penis. The band can stay in place up to 20 minutes. The vacuum device can be safely used to treat most causes of erectile failure. Lack of spontaneity and cumbersomeness of the device seem to be the biggest concerns of patients.

Intracavernosal injection therapy
This type of treatment is more commonly known as penile self-injection. Using a tiny needle and syringe, the man injects a small amount of medicine into the side of his penis. The medicine relaxes the blood vessels, allowing blood to flow into the penis. This treatment has been widely used and accepted since the early 1980s. The three most commonly used medicines are prostaglandin E1 (alprostadil) and papaverine, and phentolamine (Resitine).

Injection therapy is effective in treating a wide variety of erection problems caused by blood vessel, nerve, and psychological conditions. The most common adverse side effects are pain and penile scarring (fibrosis). Patients with cerebral vascular disease or severe cardiovascular diseases might not be able to tolerate the dizziness and high blood pressure occasionally encountered with injection therapy. A painful erection that lasts longer than two to three hours (priapism) can occur but can be lessened with proper dosing and by following the treatment guidelines.

Transurethral pharmacotherapy
For this treatment, you place a suppository into the urinary tube (urethra) using a plastic applicator. The suppository contains the medicine alprostadil (MUSE), which is absorbed into the blood stream. MUSE relaxes the blood vessels, allowing blood to flow into the penis.

MUSE appears to be less effective than either injection or vacuum therapy. MUSE can be used to treat erectile dysfunction due to a wide variety of causes. Patients with urethral problems must use special care when using this treatment, since the suppository is placed directly into the urethra.

Sex therapy
Sex therapy can be very beneficial to most men when counseling is provided by a skilled sex therapist. Psychological causes might contribute to erectile failure even when there is a clear organic cause. Sex therapy also helps a man's partner accept and cope with the problem. A patient whose erectile failure has a clear psychological cause should receive sex counseling before any invasive treatments are pursued.

Medications That May Cause Erectile Dysfunction

Erectile dysfunction (ED) is a common side effect of a number of prescription drugs. While these medications may treat a disease or condition, in doing so they can affect a manís hormones, nerves or blood circulation, resulting in ED or increasing the risk of ED. If you experience ED and think that it may be a result of the medication you are using, DO NOT stop taking the medication. If the problem persists, contact your doctor and he or she may be able to prescribe a different medication. Common medications that may list ED as a potential side effect include:

* Diuretics
* Antihypertensives
* Antihistamines
* Antidepressants
* Parkinsons disease drugs
* Antiarrythmics
* Tranquilizers
* Muscle relaxants
* Non-steroidal anti-inflammatory drugs
* Histamine H2-receptor antagonists
* Hormones
* Chemotherapy medications
* Prostate cancer drugs
* Anti-seizure medications

Other substances or drugs that can cause or lead to ED include these recreational and frequently abused drugs:

* Alcohol
* Amphetamines
* Barbiturates
* Cocaine
* Marijuana
* Methadone
* Nicotine
* Opiates

Aside from the well-known complications that the use and abuse of these drugs can cause, ED is not often mentioned. However, use of these drugs is a risk factor for ED. These drugs not only affect and often times suppress the central nervous system, but can also cause serious damage to the blood vessels, leading to permanent ED.

Physical Causes of Erectile Dysfunction

The process of achieving an erection is complex, and problems may occur for a variety of reasons. These problems can be psychological, physical or a combination of the two.

Physical causes of ED are related to a breakdown or damage to the sequence of events that leads to an erection. This sequence involves nerve impulses in the brain, spine and penis as well as the subsequent response in the muscles, fibrous tissues, veins and arteries in and near the corpora cavernosa.

In some cases, the breakdown or damage in the sequence of events affects the arteries, muscles and surrounding tissues of the penis. This breakdown is most commonly the result of a disease. Diseases that commonly cause ED include:

* Diabetes: Diabetes can cause nerve and artery damage that can make achieving an erection difficult. Between 35% and 50% of men with diabetes experience ED.
* Kidney disease: Kidney disease can cause chemical changes that affect hormones, circulation, nerve function and energy level. These changes can lower libido (sex drive) or sexual ability. Drugs used to treat kidney disease may also cause ED.
* Neurological (nerve and brain) diseases: The nervous system plays a vital part in achieving and maintaining an erection. It is common for men with conditions such as stroke, multiple sclerosis (MS), Alzheimerís disease, Parkinsonís disease and spinal cord injuries to experience ED. This is due to an interruption in the transmission of nerve impulses between the brain and the penis.
* Vascular disease: Vascular diseases are those that affect the blood vessels. These diseases include atherosclerosis (hardening of the arteries), hypertension and high cholesterol. These diseases, which account for 70% of physical-related causes of ED, restrict blood flow to the heart, the brain and--in the case of ED-- to the penis. Atherosclerosis alone accounts for 50%-60% of ED cases in men over age 60.
* Prostate cancer: Prostate cancer doesnít cause ED on its own, but surgery to remove the cancer can lead to erectile problems.

The physical causes of ED are not only disease-related. There are many other potential causes, including:

* Surgery: Surgery performed to treat diseases such as prostate cancer and bladder cancer often require the removal of nerves and tissues around the affected area. Some of these surgeries result in only temporary problems (lasting 6-18 months), while others result in permanent damage to nerves and tissue.
* Injury: Injuries to the pelvis, bladder, spinal cord and penis that require surgery also commonly cause ED.
* Hormonal imbalances: Hormonal causes of ED account for only 5% of all cases of ED. Imbalances of hormones such as thyroid, prolactin and testosterone, can affect a manís response to sexual stimulation. These imbalances can be the result of a tumor on the pituitary gland, kidney disease or liver disease.
* Venous leak: If the veins in the penis cannot prevent blood from leaving the penis during an erection, an erection cannot be maintained. This is known as a venous leak, and can be a result of injury or disease.
* Tobacco, alcohol or drug use: All three of these substance can damage a personís blood vessels and/or restrict blood flow to the penis, causing ED. Smoking in particular plays a large role in causing ED in people with arteriosclerosis.
* Prescription drugs: There are over 200 types of prescription drugs that may cause ED.

Psychological Causes of Erectile Dysfunction

Psychological factors are responsible for 10%-20% of all cases of ED. It is often a secondary reaction to an underlying physical cause. In some cases, the psychological effects of ED may stem from childhood abuse or sexual trauma. The most common psychological causes of ED include:

* Stress: Stress can be job-related, money-related or the result of relationship problems, among other factors.
* Anxiety: Once a man experiences ED, he may become overly worried that the problem will happen again. This can lead to "performance anxiety" or a fear of sexual failure and consistently cause ED.
* Guilt: A man may feel guilty that he is not satisfying his partner.
* Depression: A common cause of ED, depression affects a person physically and psychologically. Depression can cause ED even when a man is completely comfortable in sexual situations. Drugs used to treat depression may also cause ED.
* Low self-esteem: This can be due to prior episodes of ED or can be the result of other issues unrelated to sexual performance.
* Indifference: This may come as a result of age and a subsequent loss of interest in sex, be the result of medications or stem from problems in a coupleís relationship.

All men at one time or another will experience ED. Only if the problem becomes persistent (occurs more than 50% of the time) should you be concerned and consider seeking medical advice and treatment. For men whose erectile dysfunction is caused by psychological problems, therapy may be needed.

Diagnosing Erectile Dysfunction

Because there are a variety of causes for ED, there are several different tests your doctor may use to diagnose the condition and determine its cause. Only after the cause of ED is determined can it be effectively treated.

Before ordering any tests, your doctor will review your medical history and perform a thorough physical examination. The doctor will also "interview" you about your personal and sexual history. Some of these questions will be very personal and may feel intrusive. However, it is important that you answer these questions honestly. The questions asked may include:

* What medications or drugs are you currently using? This includes prescription drugs, over-the-counter drugs, herbals, dietary supplements and illegal drugs.
* Have you had any psychological problems such as stress, anxiety and depression?
* When did you first notice symptoms of ED?
* What are the frequency, quality and duration of any erections you have had?
* What are the specifics of the circumstances under which ED first occurred?
* Do/did you experience erections at night or during the morning?
* What sexual techniques do you use?
* Are there problems in your current relationship?

The doctor may also wish to interview your sexual partner since your partner may be able to offer in sight about the underlying causes.

After your physical examination and interview, your doctor may then order any one of the following tests to further diagnose your condition:

* Complete blood count (CBC): This is a set of blood tests that, among other things, can detect the presence of anemia. Anemia is caused by a low red blood cell count and can cause fatigue, which in turn can cause ED.
* Liver and kidney function tests: These blood tests may indicate whether ED may be due to your kidneys or liver functioning improperly.
* Lipid profile: This blood test measures the level of lipids (fats), like cholesterol. High levels may indicate atherosclerosis (hardening of the arteries), which can affect blood circulation in the penis.
* Thyroid function test: One of the thyroid hormonesí functions is to regulate the production of sex hormones, and a deficiency in these hormones may contribute to or cause ED.
* Blood hormone studies: Testasterone and/or proactin levels in the blood may be measured to see if abnormalities in either of these sex hormones are present.
* Urinalysis: Analysis of urine can provide a wealth of information, including information on protein, sugar and testosterone levels. Abnormal measurements of these substances can indicate diabetes, kidney disease or a testosterone deficiency, all which can cause ED.
* Duplex ultrasound: This is perhaps the best test for evaluating ED. An ultrasound uses high-frequency sound waves to take "pictures" of the body's tissues. For people with ED, an ultrasound may be used to evaluate blood flow and check for signs of a venous leak, artherosclerosis or tissue scarring. This test is performed both while the penis is erect (usually induced by an injection of a drug that stimulates erection) and also while it is soft.
* Bulbocavernosus reflex: This test evaluates nerve sensation in the penis. During the test, your doctor will squeeze the head of your penis, which should immediately cause your anus to contract. If nerve function is abnormal, there will be a delay in response time.
* Nocturnal penile tumescence (NPT): This test measures a manís erectile function while he is sleeping. Normally, a man will have five or six erections while asleep. A lack of these erections may indicate there is a problem with nerve function or circulation to the penis. The test uses two methods, the snap gauge method and the strain gauge method. The snap gauge method is performed by wrapping three plastic bands of varying strength around the penis. Erectile function is then measured based on which of the three bands breaks. The strain gauge method works by placing elastic bands around the tip and base of the penis. If the penis becomes erect during the night, the bands stretch, measuring the changes in penile circumference.
* Penile biothesiometry: This test involves the use of electromagnetic vibration to determine sensitivity and nerve function. A decreased sensitivity to these vibrations may indicate nerve damage.
* Vasoactive injection: During this test, an erection is produced by injecting special solutions that cause the blood vessels to dilate (enlarge) allowing blood to enter the penis.
* Dynamic infusion cavernosometry: This test is used for men with ED who have a venous leak. During this test, fluid is pumped into the penis at a predetermined rate. By measuring the rate at which fluid must be pumped to attain a rigid erection, doctors can determine the severity of the venous leak.
* Cavernosography: Used in conjunction with the dynamic infusion cavernosometry, this test involves injecting a dye into the penis. The penis is then X-rayed so that the venous leak can be seen.
* Arteriography: This test is given to people who are candidates for vascular reconstructive surgery. A dye is injected into the artery believed to be damaged and X-rays will be taken.

Before you are given any of these tests, your doctor will explain what is involved. If you have any questions, do not hesitate to ask your doctor.

Testosterone Replacement Therapy

Testosterone is a hormone produced by the testicles and is responsible for the proper development of male sexual characteristics. Testosterone is also important for maintaining muscle bulk, adequate levels of red blood cells, bone growth, sense of well-being, and sexual function.

Inadequate testosterone production is not a common cause of erectile dysfunction (ED). When ED does occur with decreased testosterone production, testosterone replacement therapy may improve the ED.

What causes testosterone deficiency?
As a man ages, the amount of testosterone in his body gradually declines. This natural decline starts after age 30 and continues throughout life. The significance of this decline is controversial and poorly understood. Among the potential causes of testosterone deficiency are:

* injury or infection to the testicles
* chemotherapy or radiation treatment for cancer
* genetic abnormalities such as Klinefelterís Syndrome (extra x chromosome)
* hemochromatosis (too much iron in the body)
* dysfunction of the pituitary gland (a gland in the brain that produces many important hormones)
* medications, including hormone analogues used to treat prostate cancer and steroids
* chronic illness
* cirrhosis of the liver
* chronic renal (kidney) failure
* inflammatory disease such as sarcoidosis (a condition that causes inflammation of the lungs and other organs)
* stress
* alcoholism
* congenital conditions, Kallmanís Syndrome (low hormones, inability to smell and other abnormalities)

What are the symptoms of testosterone deficiency?
Symptoms of testosterone deficiency include the following:

* decreased sex drive
* decreased sense of well-being
* depressed mood
* difficulties with concentration and memory
* erectile dysfunction
What are the changes that occur in the body with testosterone deficiency? Changes that occur with testosterone deficiency include:
o a decrease in muscle mass, with an increase in body fat
o variable effects on cholesterol metabolism
o a decrease in hemoglobin and possibly mild anemia
o fragile bones (osteoporosis)
o a decrease in body hair

How do I find out if I have a testosterone deficiency?
The only accurate way to detect the condition is to have your doctor measure the amount of testosterone in your blood. It sometimes may take several measurements of testosterone to be sure if a patient has a deficiency, since levels of testosterone tend to fluctuate throughout the day. The highest levels of testosterone are generally in the morning. This is why doctors prefer, if possible, to obtain early morning levels of testosterone.

What options are available for testosterone replacement?
The options available for testosterone replacement are:

* intramuscular injections, generally every two or three weeks
* testosterone patches worn either on the body or on the scrotum (the sac that contains the testicles). These patches are used daily. The body patch application is rotated between the buttocks, arms, back or abdomen.
* testosterone gels that are applied daily to the shoulders, upper arms, or abdomen.
* mucoadhesive material applied above the teeth twice a day.

Each of these options provides adequate levels of hormone replacement. Each has side effects and advantages and disadvantages. Intramuscular injections produce wider swings in hormone concentration, with higher levels shortly after the injection and lower levels just before the next injection is due. They may also produce increases in blood cell count that are higher than normal.

The body patches may produce skin irritation in a significant number of men, requiring discontinuation of the patch. The gels require care in making sure that the hormone is not accidentally transferred to another person or partner. The mucoadhesive material placed above the teeth may cause difficulties with taste and with gum irritation.

There are currently no pills available in the United States that provide adequate levels of hormone replacement. In addition, oral medications may produce liver abnormalities and are to be avoided.

The choice of hormone replacement therapy is best made with a thorough discussion between a patient and his physician.

Who shouldnít take testosterone replacement therapy?
Testosterone replacement therapy may stimulate growth of the prostate. If early prostate cancer is present, testosterone may stimulate the cancerís growth. Therefore, men who have prostate cancer should not take testosterone replacement therapy. It is important for all men considering testosterone replacement therapy to undergo prostate screening before starting this therapy.

Although it is a rare condition, men who have breast cancer should not take testosterone replacement therapy.

What are the side effects of testosterone replacement therapy?
In general, hormone replacement therapy is safe. It is associated with some side effects, including:

* acne or oily skin
* mild fluid retention
* stimulation of prostate tissue, with perhaps some increased urination symptoms such as decreased stream or frequency
* breast enlargement
* worsening of sleep apnea (a sleep disorder that results in frequent night time awakenings and daytime sleepiness)
* decreased testicular size

Many of these side effects are not common.

Laboratory abnormalities that can occur with hormone replacement include:

* changes in cholesterol concentrations
* increase in red cell count
* decrease in sperm count, producing infertility (especially in younger men)

If you are taking hormone replacement therapy, regular follow-up appointments with your physician are important.

Excerts on this page Courtsey of "The Cleveland Clinic Foundation".