Impotence (Erectile Dysfunction)

What Is It?

Impotence means that a man's penis doesn't get hard enough to have sexual intercourse. The man cannot get or maintain an erection. The medical term is erectile dysfunction. This condition affects approximately 30 million men in the United States. Erectile dysfunction is not the same as premature ejaculation, which is ejaculating within one minute after initiation of intercourse.

Erectile dysfunction, also called impotence, means that a man's penis doesn't get hard enough to have intercourse. The man cannot get or maintain an erection. This condition affects approximately 30 million men in the United States. Erectile dysfunction is not the same as premature ejaculation, the inability to ejaculate (retarded ejaculation) or infertility.)

The major causes of erectile dysfunction include:

* Vascular (blood vessel) disease — Erections happen when blood collects in the shaft of the penis. Vascular disease can limit the amount of blood flowing to the penis or the amount staying in the penis. Both can result in problems with erections. Blood vessels can be damaged by hardening of the arteries (atherosclerosis) or trauma. Vascular disease is believed to be the most common medical cause of impotence.
* Nerve damage (neuropathy) — Nerves must be working normally for a man to get and keep an erection. Nerves can be damaged by diabetes, multiple sclerosis, prostate surgery or damage to the spinal cord.
* Psychological factors — Psychological issues such as depression, anxiety, guilt or fear can sometimes cause sexual problems. At one time, these factors were thought to be the major cause of impotence. Doctors now know that physical factors cause impotence in most men with the problem. However, embarrassment or "performance anxiety" can make a physical problem worse. Impotence caused only by psychological causes is found most commonly in young men.
* Medications — Many medications cause problems with sexual function, including drugs for high blood pressure,depression, heart disease and prostate cancer.
* Hormonal problems — Abnormal levels of certain hormones, such as testosterone, thyroid hormone and a pituitary hormone known as prolactin, can interfere with erections and sex drive (libido). This is an uncommon cause of impotence.

Erectile Dysfunction: Psychological Causes

Psychological factors are responsible for about 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. However, the most common psychological causes of ED include:

* Stress: Stress can be job-related, money-related, or the result of marital 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 (thus a feeling of inadequacy) 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 couple's relationship.

All men at one time or another will experience ED. Only if the problem becomes persistent -- occurs more than 50% of the time, or becomes a source of distress for you or your partner 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.

Reviewed by the doctors at the Glickman Urological Institute at The Cleveland Clinic.

Symptoms

A man with impotence has either a problem getting an erection or difficulty maintaining one. This usually interferes with sexual activity.

Impotence can happen suddenly or gradually. Some men slowly lose the firmness of their erections or how long the erections last. In other men, especially those whose impotence is largely caused by psychological factors, the problem may occur unpredictably and can improve at any time. Despite their difficulties with erections, men with impotence may continue to have normal orgasm and ejaculation without a full erection.

Diagnosis

Your doctor will ask you about your medical history to learn if any medical conditions might be causing the erectile dysfunction, including vascular, neurological and hormonal disorders. Because vascular disorders affect the entire body, many men who have erectile dysfunction because of vascular disease also have a history of heart disease, stroke or poor circulation in their legs. Neurological problems can contribute to erectile dysfunction in men with a history of diabetes and spinal cord injury. They also can cause symptoms in other parts of the body, such as numbness or weakness in legs. In men with abnormal hormone levels, a reduced sex drive often accompanies erectile dysfunction. Your doctor also will review the medications you take, including over-the-counter products and herbal remedies.

Your doctor will ask about your sex life. This sometimes is called a psychosexual history. It includes questions about the quality of your sexual relationships.

Your doctor will examine you, including your penis and testes, to look for evidence of underlying medical problems. Your blood may be tested for blood sugar (to check for diabetes), cholesterol and levels of certain hormones.

Occasionally, a doctor may order additional tests, such as a nocturnal penile tumescence study. This is a way to assess how often you get erections while you sleep. A Doppler ultrasound of the blood vessels in the penis is another test that occasionally will show a cause for poor erections.

Although your doctor may not be able to give you a specific reason why you have developed erectile dysfunction, many of the treatments work well no matter what caused the problem, so extensive testing may not be necessary.

Expected Duration

How long your erectile dysfunction lasts depends upon what causes it and how quickly your treatment starts to work. The important thing to remember is that erectile dysfunction is treatable in all age groups.
Prevention

Little is known about how to prevent erectile dysfunction. However, avoiding cigarette smoking and maintaining normal blood pressure and cholesterol levels can help because smoking and high cholesterol can affect blood vessels. Men with diabetes should strive to keep blood sugar levels under control. Because certain medications have been associated with erectile dysfunction, ask your doctor about possible side effects before you start using any new prescription.

Treatment

There are many effective treatments for impotence. The most popular is a class of drugs called phosphodiesterase type 5 (PDE5) inhibitors, which includes sildenafil citrate (Viagra), vardenafil (Levitra) and tadalafil (Cialis). These drugs, taken in pill form up to 60 minutes before sexual activity, work in approximately 70 percent of men. They are less effective in men with neurological causes of impotence such as nerve damage from prostate surgery, diabetes or spinal cord injury. PDE5 drugs can cause minor side effects such as flushing and headache, but they have been shown to be safe in most men, including those with heart disease. However, PDE5 drugs can interact with other medications and cause dangerously low blood pressure. They should never be taken with nitroglycerin or other nitrate medications commonly used to treat heart disease. Men with enlarged prostates who take alpha-blocker drugs such tamsulosin (Flomax) or doxazosin (Cardura) should probably avoid certain PDE5 drugs.

What Are the Differences Between Cialis, Levitra, and Viagra?

Cialis, Levitra, and Viagra work by a similar mechanism to cause erections. There are subtle differences in how long the drug works and how quickly it works. Levitra works a little longer than Viagra. They both take effect in about 30 minutes. With Levitra, the effects last for about 5 hours. With Viagra, the effects last approximately 4 hours.

Cialis works a bit faster (within about 15 minutes), and the effects last much longer -- up to 36 hours in some cases.
If One of These Drugs Isn't Effective for Erectile Dysfunction, Can I Try Another?

Yes, but because these drugs work the same way, it's unlikely that you'll have success with one if you've failed to achieve an adequate erection with another.

What Precautions Should I Take Before Taking One of These Drugs?

There are certain situations in which these drugs may not be safe to take. Before taking them, tell your doctor:

* If you are allergic to any drugs, including Viagra or other ED medications.
* About any prescription or nonprescription medications you are currently taking, including herbal and dietary supplements.
* If you are scheduled for surgery, including dental surgery.
* If you take nitroglycerin or a long-acting nitrate to treat chest pain. The combination of Cialis, Levitra or Viagra with these drugs can cause dangerously low blood pressure.
* If you take alpha-blockers for blood pressure or prostate problems. The combination of Cialis or Levitra with these drugs can also cause dangerously low blood pressure.

In addition, always follow the directions on your prescription label carefully and ask your doctor or pharmacist to explain any part that you do not understand. Take these drugs exactly as directed. Do not take more or less or take it more often than prescribed by your doctor. Do not take these drugs more than once a day.

Who Should Not Take Cialis, Levitra or Viagra?

If you have suffered from a heart attack, stroke or life threatening arrhythmia (irregular heart rate) within the last 6 months you should discuss other options with your doctor. It is also advised to avoid these drugs if you have uncontrolled high or low blood pressure or if you experience chest pain with sex.

What Are the Side Effects of Cialis, Levitra and Viagra?

Side effects are not common but they can occur. Side effects can include:

* Headache
* Upset stomach or ‘heartburn’
* Flushing (feeling warm)
* Nasal congestion
* Changes in vision (color, glare)
* Back pain (with Cialis)

Call your doctor if you experience severe forms of these symptoms or if they do not go away after 4-8 hours.

If these drugs don't work or cannot be used because of potential side effects, your doctor can recommend other therapies. The drug alprostadil (Caverject, Edex, Muse) causes blood vessels to widen. This can allow blood to flow more freely in the penis, leading to an erection. The drug can be injected with a tiny needle into your penis, or a small pellet (suppository) can be inserted into the opening of the penis. Suppositories like this are effective in approximately two-thirds of men. Injections are effective about 80 percent of the time.

Taking extra testosterone will not improve erectile dysfunction. For men who have abnormally low levels of the hormone, testosterone replacement may be helpful because it can enhance sexual desire.

Psychological therapy such as counseling, behavioral therapy or couples' therapy can be effective in men whose impotence is caused primarily by psychological factors.

Men who do not benefit from medical or psychological treatment often have success with mechanical or prosthetic devices. External products, known as vacuum erection devices, are safe and highly effective, but many men and their partners find them unappealing. Another option is a surgically placed penile implant. Only ten percent of men with impotence choose this option. Vascular (blood vessel) surgery sometimes is recommended for young, healthy men who develop impotence after trauma to the groin. Unfortunately, the long-term success rate of this surgery is not known.

When To Call A Professional

A man should speak to his doctor if he has trouble getting or keeping an erection over a period of three months or more. Because of embarrassment or shame, many men with erectile dysfunction don't talk to their doctors. They hope that the problem will go away on its own. However, this often is not the case. Although erectile dysfunction caused by psychological factors may get better on its own, treatment is needed if the problem is caused by a physical factor.
Prognosis

In general, the prognosis for men with erectile dysfunction is excellent. Although most cases of impotence have medical causes that cannot be cured, many treatment options will restore sexual function. In addition, there are several permanently curable forms of the disorder, including erectile dysfunction caused by psychological problems, hormonal disorders and traumatic injury to the penile arteries.