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What is erectile dysfunction? The answer is simple: An inability to consistently attain and maintain an erection satisfactory for sexual intercourse. It’s also called impotence, as the condition was known until the term erectile dysfunction, or ED, was coined in 1992.
But the answer to erectile dysfunction isn’t the same for everyone. Some men have only minor problems with sexual function and are troubled by them very little. For others, ED is a source of significant bother, affecting their relationships and their psyche.
Regardless, erectile dysfunction can be a warning sign of potential problems elsewhere in the body, so men who experience the condition should consider it as a call to improve their overall health. If lifestyle changes aren’t enough to prevent or reverse ED, an array of treatments may help.
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So, What Is Erectile Dysfunction, Really?
Erections occur when a stimulus triggers endothelial cells in the penis to release nitric oxide, which activates an enzyme known as cyclic guanosine monophosphate (cyclic GMP). Cyclic GMP then causes the smooth muscle of the penis to relax, allowing blood to fill the two erectile chambers and produce an erection.
This entire process requires a coordinated effort on the part of the brain, the nervous system, blood vessels, and hormones. A problem with one or more of these components can result in ED. Research suggests that about 40 percent of 40-year-olds experience some degree of ED, and the prevalence rises by about 10 percent per decade until age 70.
In the majority of men with ED, the cause is physical, often a neurovascular condition, according to Thomas Jaffe, MD, Director of Male Reproductive Medicine and Surgery at the University of Pittsburgh Medical Center’s Department of Urology.
“Neurovascular disease develops from cardiovascular disease and diabetes, as examples,” he explains. “The ‘neuro’ in neurovascular refers to an inability of the endothelial cells to release nitric oxide, which is essentially a smooth muscle relaxer. The ‘vascular’ in neurovascular results in poor blood flow.”
So, medical problems that cause dysfunction of the nerves and blood vessels of the penis can lead to ED. Among these conditions are cardiovascular disease and its risk factors—including diabetes, hyperlipidemia (cholesterol abnormalities), hypertension, obesity, and smoking—as well as other conditions, such as sleep disorders, Parkinson’s disease, and multiple sclerosis.
Alcohol or substance abuse, a long list of medications, treatments for benign and cancerous prostate diseases, and certain pelvic and spinal surgeries may cause ED, as well.
ED: IN SOME CASES, IT MAY BE LINKED TO HEART HEALTH
Erectile dysfunction is more than a blow to a man’s ego. It’s also been labeled as a portal into men’s cardiovascular health. Since ED has a strong vascular component, it’s no surprise that it may be a harbinger of heart disease. In fact, experts estimate that ED may precede heart disease by up to four years because the smaller arteries of the penis are affected before the larger coronary arteries.
“There is a significant relationship between the two,” Dr. Jaffe says. “ED is thought of as an indicator of impending cardiovascular disease. In addition, the worse the ED, the worse the cardiovascular disease.”
So, if you have ED and haven’t undergone a cardiac risk assessment, talk to your doctor about your cardiovascular health. Work with your healthcare team to optimize your blood pressure, cholesterol, blood sugar, weight, and other risk factors that contribute to both ED and cardiovascular disease. And, if you smoke, ask your doctor about nicotine replacement products, medications, counseling, and other cessation strategies.
ED on Your Mind
Just as physical problems contribute to ED, so too do emotional and psychological ones. In fact, you may be physiologically normal, but mental health conditions such as depression, anxiety, and emotional stress can interfere with your ability to produce an erection and function sexually. Relationship disturbances also may contribute to ED.
Additionally, if you’ve been bothered by ED, you may develop anxiety about being unable to achieve an erection, and this performance anxiety can perpetuate your ED.
“There is a significant psychological component to normal erectile function,” Dr. Jaffe says. “If all your physiology is normal but psychologically you convince yourself you cannot have an erection, you will not.”
What Is Erectile Dysfuntion? Treatments Can Help
Since the “little blue pill” we know as sildenafil (brand name Viagra) gained regulatory approval in 1998, medications, along with lifestyle changes, have been a mainstay of ED management. Since then, other medications have joined sildenafil in the class of drugs known as phosphodiesterase-5 (PDE-5) inhibitors: vardenafil (Levitra) and tadalafil (Cialis), both approved in 2003; and avanafil (Stendra), approved in 2012. These drugs block the action of an enzyme, (PDE-5) that ends erections.
Although effective, the medications don’t work in all men with ED, Dr. Jaffe notes: “PDE-5s require the release of nitric oxide from nerves in the penis as a result of stimulation. Basically, if you are reasonably healthy—meaning you have good blood vessels that keep the nerves that release nitric oxide healthy—a PDE-5 will work. But in patients with bad vascular disease or diabetes… there is a low probability of success.”
3 ED Medication Alternatives
If you don’t benefit from PDE-5s, consider these additions or alternatives to the medications:
- Vacuum constriction devices: In this treatment, a pump draws blood into the shaft of the penis to create an erection, and a constriction ring placed at the base of the penis maintains the erection. Pros: Can be effective even if you have penile nerve damage. Cons: “They do not lend themselves to spontaneity, and in addition, they often given an adequate erection for intercourse, not necessarily a rigid one,” Dr. Jaffe says. “This is because you’re drawing blood into a closed system, so it is harder to get significant blood flow into the penis and to trap that blood. A PDE-5 can help by allowing some relaxation of the smooth muscle so that more blood can be brought in by the vacuum.”
- Injection therapy: Single-agent or multi-agent medications injected directly into the penis. Pros: The injections can produce and maintain erections, usually in about 20 minutes; often a good treatment for men with diabetes who fail PDE-5 treatment. Cons: Pain from the injections; limited use (only three times a week, Dr. Jaffe says); and, in rare cases, may create scar tissue that results in Peyronie’s disease, an abnormal curvature of the penis. Also carries a risk of priapism (a prolonged erection that requires medical attention), “which is marginal if a patient is given appropriate instruction on how to use the injections,” Dr. Jaffe notes.
- Implanted penile prostheses (IPP): Generally reserved for ED patients who fail conservative therapies, IPPs feature a small pump placed in the scrotum that, when squeezed, releases saline that fills and expands two cylinders lining the penis to create an erection. Pros: Allows for spontaneity; no restrictions on number of times used. Cons: “The length of erection with an IPP is a patient’s stretched flaccid length,” Dr. Jaffe says. “If flaccid length is poor, implant erection length will be poor. Finally, if a patient doesn’t like the implant, although it can be removed, no other therapy will work.”
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