Erectile Dysfuntion

ERECTILE
DYSFUNCTION

 
Overview
Prevalence
Anatomy
Physiology
Causes
Treatment

OVERVIEW

Erectile dysfunction (ED) is the inability of a man to achieve or maintain an erection sufficient for his sexual needs or the needs of his partner. Most men experience this at some point in their lives, usually by age 40, and are not psychologically affected by it.

Some men, however, experience chronic, complete erectile dysfunction (impotence), and others, partial or brief erections. Frequent erectile dysfunction can cause emotional and relationship problems, and often leads to diminished self-esteem. Erectile dysfunction has many causes, most of which are treatable, and is not an inevitable consequence of aging.

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PREVALENCE

The term "erectile dysfunction" can mean the inability to achieve erection, an inconsistent ability to do so, or the ability to achieve only brief erections. These various definitions make estimating the incidence of erectile dysfunction difficult. According to the National Institutes of Health in 2002, an estimated 15 million to 30 million men in the United States experience chronic erectile dysfunction.

According to the National Ambulatory Medical Care Survey (NAMCS), approximately 22 out of every 1000 men in the United States sought medical attention for ED in 1999.

Incidence of the disorder increases with age. Chronic ED affects about 5% of men in their 40s and 15–25% of men by the age of 65. Transient ED and inadequate erection affect as many as 50% of men between the ages of 40 and 70.

Diseases (e.g., diabetes, kidney disease, alcoholism, atherosclerosis) account for as many as 70% of chronic ED cases and psychological factors (e.g., stress, anxiety, depression) may account for 10–20% of cases. Between 35 and 50% of men with diabetes experience ED.

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ANATOMY OF
THE PENIS

The internal structure of the penis consists of two cylinder-shaped vascular tissue bodies (corpora cavernosa) that run throughout the penis; the urethra (tube for expelling urine and ejaculate); erectile tissue surrounding the urethra; two main arteries; and several veins and nerves. The longest part of the penis is the shaft, at the end of which is the head, or glans penis. The opening at the tip of the glans, which allows for urination and ejaculation, is the meatus.

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PHYSIOLOGY
OF AN ERECTION

The physiological process of erection begins in the brain and involves the nervous and vascular systems. Neurotransmitters in the brain (e.g., epinephrine, acetylcholine, nitric oxide) are some of the chemicals that initiate it. Physical or psychological stimulation (arousal) causes nerves to send messages to the vascular system, which results in significant blood flow to the penis. Two arteries in the penis supply blood to erectile tissue and the corpora cavernosa, which become engorged and expand as a result of increased blood flow and pressure.

Because blood must stay in the penis to maintain rigidity, erectile tissue is enclosed by fibrous elastic sheathes (tunicae) that cinch to prevent blood from leaving the penis during erection. When stimulation ends, or following ejaculation, pressure in the penis decreases, blood is released, and the penis resumes its normal shape.

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CAUSES

There are many underlying physical and psychological causes of erectile dysfunction. Reduced blood flow to the penis and nerve damage are the most common physical causes. Underlying consitions associated with erectile dysfunction include the following:

  • Vascular disease
  • Diabetes
  • Drugs
  • Hormone disorders
  • Neurologic conditions
  • Pelvic trauma, surgery, radiation therapy
  • Peyronie's disease
  • Venous leak
  • Psychological conditions

Vascular Disease
Arteriosclerosis, the hardening and narrowing of the arteries, causes a reduction in blood flow throughout the body and can lead to impotence. It is associated with age and accounts for 50% to 60% of impotence in men over 60.

Risk factors for arteriosclerosis include:

  • Diabetes mellitus
  • High blood pressure
  • High cholesterol

Smoking, which can lead to any of the above risk factors, is perhaps the most significant risk factor for impotence related to arteriosclerosis.

Diabetes Mellitus
Chronic high levels of blood sugar associated with diabetes mellitus often damage small blood vessels and nerves throughout the body, which can impair nerve impulses and blood flow necessary for erection. About 60% of men with diabetes experience impotence.

Drugs
Over 200 commonly prescribed drugs are known to cause or contribute to impotence, including drugs for high blood pressure, heart medications, antidepressants, tranquilizers, and sedatives. A number of over-the-counter medications also can lead to impotence. Long-term use of alcohol and illicit drugs may affect the vascular and nervous systems and are associated with erectile dysfunction.

Hormone Disorders
Hormone disorders account for fewer than 5% of cases of impotence. Testosterone deficiency, which occurs rarely, can result in a loss of libido (sexual desire) and loss of erection. Among other conditions, an excess of the hormone prolactin, caused by pituitary gland tumor, reduces levels of testosterone. Hormone imbalances can also result from kidney or liver disease. Back to Top

Neurologic Conditions
Spinal cord and brain injuries (e.g., paraplegia, stroke) can cause impotence when they interrupt the transfer of nerve impulses from the brain to the penis. Other nerve disorders, such as multiple sclerosis, Parkinson's disease, and Alzheimer's disease, may also result in impotence.

Pelvic Trauma, Surgery, Radiation Therapy
Trauma to the pelvic region or spinal cord can damage veins and nerves needed for erection. Surgery of the colon, prostate, bladder, or rectum may damage the nerves and blood vessels involved in erection. Prostate and bladder cancer surgery often require removing tissue and nerves surrounding a tumor, which increases the risk for impotence.

New nerve-sparing techniques aimed at lowering the incidence of impotence to 40% to 60% are now being developed and used in these surgeries. Temporary impotence is also associated with these procedures, even those in which nerve-sparing techniques were used. It can take as long as 6 to 18 months for full erections to return.

Radical cystectomy (for bladder cancer) and prostatectomy (for prostate cancer) require cutting or removing nerves that control penile blood flow. These nerves do not control sensation in the penis and are not responsible for orgasms; only erection is affected by these procedures.

Radiation therapy for prostate or bladder cancer also can permanently damage these nerves.

Peyronie's Disease
Peyronie's disease is a rare inflammatory condition that causes scarring of erectile tissue. Scarring produces curvature of the penis that can interfere with sexual function and cause painful erections.

Venous Leak
If the veins in the penis cannot prevent blood from leaving the penis during erection, erection cannot be maintained. Venous leak can be a result of injury, disease, or damage to the veins in the penis.

Psychological Conditions
Depression, guilt, worry, stress, and anxiety all contribute to loss of libido and erectile dysfunction. If a man experiences loss of erection, he may worry that it will happen again. This can produce anxiety associated with performance and may lead to chronic problems during sex. If the cycle is inescapable, it can result in impotence. Psychological factors in impotence are often secondary to physical causes, and they magnify their significance.

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TREATMENT

Sex Therapy

A significant number of men develop impotence from psychological causes that can be overcome. When a physiological cause is treated, subsequent self-esteem problems may continue to impair normal function and performance. Qualified therapists (e.g., sex counselors, psychotherapists) work with couples to reduce tension, improve sexual communication, and create realistic expectations for sex, all of which can improve erectile function.

Psychological therapy may be effective in conjunction with medical or surgical treatment. Sex therapists emphasize the need for men and their partners to be motivated and willing to adapt to psychological and behavioral modifications, including those that result from medical or surgical treatment.

Medical Treatment

Oral Medication
Oral medications used to treat erectile dysfunction include selective enzyme inhibitors (e.g., sildenafil [Viagra®], vardenafil HCl [Levitra®], tadalafil [Cialis®]) and yohimbine (Yohimbine®, Yocon®).

Selective enzyme inhibitors are available by prescription and may be taken up to once a day to treat ED. They improve partial erections by inhibiting the enzyme that facilitates their reduction and increase levels of cyclic guanosine monophosphate (cGMP, a chemical factor in metabolism), which causes the smooth muscles of the penis to relax, enabling blood to flow into the corpora cavernosa.

Patients taking nitrate drugs (used to treat chest pain) and those taking alpha-blockers (used to treat high blood pressure and benign prostatic hyperplasia should not take selective enzyme inhibitors.

Men who have had a heart attack or stroke within the past 6 months and those with certain medical conditions (e.g., uncontrolled high blood pressure, severe low blood pressure or liver disease, unstable angina) that make sexual activity inadvisable should not take Cialis®. Dosages of the drug should be limited in patients with kidney or liver disorders.

Viagra® is absorbed and processed rapidly by the body and is usually taken 30 minutes to 1 hour before intercourse. Results vary depending on the cause of erectile dysfunction, but studies have shown that Viagra is effective in 75% of cases. It helps men with erectile dysfunction associated with diabetes mellitus (57%), spinal cord injuries (83%), and radical prostatectomy (43%).

In clinical studies, Levitra® has been shown to work quickly, provide consistent results, and improve sexual function in most men the first time they take the drug. It also has shown to be effective in men of all ages, in patients with diabetes mellitus, and in men who have undergone radical prostatectomy.

Cialis® has been shown in clinical trials to stay in the body longer than the other selective enzyme inhibitors. It promotes erection within 30 minutes and enhances the ability to achieve erection for up to 36 hours.

Common side effects of selective enzyme inhibitors include headache, reddening of the face and neck (flushing), indigestion, and nasal congestion. Cialis® may cause muscle aches and back pain, which usually resolve on their own within 48 hours.

Yohimbine improves erections for a small percentage of men. It stimulates the parasympathetic nervous system, which is linked to erection, and may increase libido. It is necessary to take the medication for 6 to 8 weeks before determining whether it will work or not.

Yohimbine has a stimulatory effect and side effects include elevated heart rate and blood pressure, mild dizziness, nervousness, and irritability. Yohimbine's effects have not been studied thoroughly, but some studies suggest that 10% to 20% of men respond to treatment with the drug.

Ease of administration makes oral medication advantageous. Some drugs, however, are suitable for only a relatively small group of men, and in many cases, oral medications may by less effective than other treatments.

Self-Injection
Self-injection involves using a short needle to inject medication through the side of the penis directly into the corpus cavernosum, which produces an erection that lasts from 30 minutes to several hours. Prostaglandin (alprostadil, Caverject®, Edex®), and phentolamine (Regitine®) produce results similar to Viagra but are localized in the penis after injection. They cause vascular dilation and a relaxation of smooth muscle. Prostaglandin is the only substance currently approved for erectile dysfunction treatment. Phentolamine is a heart medication with similar effects used by some physicians to treat impotence.

These drugs have been shown to produce erections in 80% of men who inject them. Some men claim that they produce erections that feel natural and improve sex. The injections are relatively painless and create an erection that begins about 5 to 15 minutes after the injection. It is recommended that self-injection be performed no more than once every 4 to 7 days. Side effects include infection, bleeding, and bruising at the injection site, dizziness, heart palpitations, and flushing. There is a small risk for priapism (an erection that lasts for more than 6 hours and requires medical relief). Repeated injection may cause scarring of erectile tissue, which can further impair erection.

Urethral suppositories containing prostaglandin (aprostadil), like Muse® (Medicated Urethral System for Erections), may be an alternative to injection. Using a hand-held delivery device, a man inserts a prostaglandin pellet through the meatus (penis opening) into the urethra. Prostaglandin is absorbed through the urethral mucosa and into the surrounding erectile tissue. It is available with a prescription, is well tolerated, and may improve erections in 60% of men who use it.

In addition to the side effects associated with injecting aprostadil, pain in the penis and perineum (area between scrotum and rectum) may occur with suppository use.

Vacuum Devices
Vacuum devices work by manually creating an erection. The penis is inserted into a plastic tube, which is pressed against the body to form a seal. A hand pump attached to the tube is used to create a vacuum that draws blood into the penis, causing the penis to become engorged. After 1 to 3 minutes in the vacuum, an adequate erection is created. The penis is removed from the tube and a soft rubber O-ring is placed around the base of the penis to trap blood and maintain the erection until removed. The ring can be left in place for 25 to 30 minutes.

Vacuum devices work best in men who are able to achieve partial erections on their own. They are easy to use at home, require no other procedure, and typically improve erections regardless of the cause of impotence. Some men experience a numbing feeling after placing the O-ring. Since the penis is flaccid between the ring and the body, the erection may be somewhat floppy.

Surgical Treatment

Penile Implants

Penile implants involve surgical insertion of malleable or inflatable rods or tubes into the penis. A semi-rigid prosthesis is a silicon-covered flexible metal rod. Once inserted, it provides the rigidity necessary for intercourse and can be curved slightly for concealment. It requires the simplest surgical procedure of all the prostheses. Its main disadvantage is that concealment can be difficult with certain types of clothing.

An inflatable penile prosthesis consists of two soft silicone or bioflex (plastic) tubes inserted in the penis, a small reservoir implanted in the abdomen, and a small pump implanted in the scrotum. To produce an erection, a man pumps sterile liquid from the reservoir into the tubes by squeezing the pump in the scrotum. The tubes act as erectile tissue and expand to form an erection. When the erection is no longer desired, a valve allows the fluid to return to the reservoir. Inflatable prostheses are the most natural feeling of the penile implants and they allow for control of rigidity and size.

The surgical procedure to implant the inflatable prosthesis is slightly more complicated than for a semi-rigid implant. Also, because there are more mechanical parts, there is a higher risk for mechanical failure requiring repair or adjustment.

A self-contained inflatable prosthesis is similar but has fewer parts. It consists of a pair of inflatable tubes in the penis with a pump attached directly to the end of the implant. The reservoir is also located in the shaft of the penis. Its compact design allows for simpler implantation, but because it takes up more space in the penis, there is less room for expansion.

Types of Penile Implants

Vascular Reconstructive Surgery
A small percentage of men undergo vascular reconstructive surgery to improve blood flow to the penis. Revascularization involves bypassing blocked veins or arteries by transferring a vein from the leg and attaching it so that it creates a path to the penis that bypasses the area of blockage. Young men with only local arterial blockage are the best candidates for this procedure. It may restore function in 50% to 75% of men.

Venous ligation is performed to prevent venous leak. Problematic veins are bound (ligated) or removed, which allows an adequate amount of blood to remain in the penis. It may improve function in 40% to 50% of men, but some men may experience problems over the long term.

Vascular surgery for erectile dysfunction is rarely performed and is generally considered experimental. Risks include nerve damage and the creation of scar tissue, both of which are causes of impotence. Surgeons experienced with these procedures may be difficult to find.

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