Erectile Dysfunction
Also know as impotence or E.D. (thanks Bob Dole!), is a situation where a man is consistently unable to attain and/or maintain penile erection of sufficient rigidity to allow sexual intercourse.
What causes it?
Erectile dysfunction can be caused by both physical causes as well by psychiatric causes. Most cases involve at least some degree of physical cause.
The process of obtaining and maintaining an erection is a somewhat complex one and I won’t attempt to go too deeply into details of it here. In a nutshell, it is a hydraulic system. Under appropriate mental and/or physical stimulation, there is an increase in arterial blood flow to the penis. Concurrent with this, there is relaxation of smooth muscles in the penis which allow the spongy cavernous tissues in the penis to become filled and engorged with this blood while at the same time there is constriction other smooth and skeletal muscles which causes increased resistance in the veins that normally drain blood from the penis. The net effect is that the penis becomes filled with blood that increases in pressure and causes rigidity. Think of a water balloon. When it is empty, it is soft and small. If you fill it with water, it begins to grow in size and becomes firm. The penis basically works in similar fashion.
So, physical or organic causes of erectile dysfunction can involve anything that interferes with the normal function of nerves supplying the penis, including both sensory nerves that are involved with physical stimulation as well as nerves that control the muscles mentioned above. Also, anything that disrupts the normal arterial supply to the penis, the normal spongy cavernous tissues in the penis, or the normal venous system that drains blood from the penis can lead to erectile dysfunction.
Psychiatric causes typically involve situations of stress and/or anxiety, including what has been called “Performance Anxiety.” Basically the situation here is that there is nothing physically wrong with the equipment, but rather mental stress, anxiety, lack of libido, etc is preventing normal physical arousal.
Typically one of the first things a doctor will ask a patient with a complaint of erectile dysfunction is whether or not he ever has normal erections. The doctor may ask “Are you able to maintain a normal erection and ejaculation when you are alone, such as when you masturbate?” or “Do you have normal erections when you sleep or do you ever wake up with erections in the morning?”
These questions are designed to help differentiate organic physical causes from psychiatric causes. Essentially, if a man is able to successfully masturbate or if he has normal erections when he sleeps, it suggests that all the “plumbing” is working properly and that the source of the problem is mental rather than physical.
Nocturnal erections can be formally tested by placing a device on the penis at bedtime that measures the frequency and rigidity of erections.
A simple home test that was once used to further help make this differentiation was the “Stamp test.” This was done back in the days when you could still by postage stamps in rolls. These were stamps that came in rolls of 50 or 100 and were joined be a perforated edge. They had dried glue on the back that had to be moistened to make them stick to an envelope. I don’t think you can still buy these stamps anywhere as the post office now sells self-adhesive stamps with a peel-off backing. I may be wrong about this however since I haven’t bought any stamps in a long time.
Anyway, with the stamp test a man would basically take a short length of stamps, moisten the back, and wrap it around the shaft of his penis when he went to bed at night. When he woke up in the morning, if he found that the perforations between the stamps were torn, then that suggested that he’d had an erection while asleep which caused the diameter of the penis to grow large enough to tear the stamps apart.
Again, if the stamps were torn apart, then this suggested that the problem was mostly mental, rather than something physically wrong with the penis or its blood vessels or nerves.
In addition to physical damage to the above mentioned systems as a cause, erectile dysfunction can also be seen as a side effect of certain medications. Particularly, blood pressure medications are frequent culprits. A few common ones include methyldopa, clonidine, and reserpine. Also, use of alcohol, tobacco and recreational drugs can frequently be associated with erectile dysfunction.
Medical conditions that tend to be associated with erectile dysfunction would include things such as high cholesterol or triglycerides, high blood pressure, diabetes, neurologic disease, prostate disease, other hormonal diseases such as testosterone deficiency, thyroid or adrenal disease, kidney disease, arteriosclerosis (hardening of the arteries), and history of trauma or surgery in the pelvic area or prostate.
Finally, it is important to distinguish erectile dysfunction from loss of libido or sexual desire. Typically, erectile dysfunction becomes a problem because the patient has a desire for sexual intercourse but is unable to have normal function. That said, the two conditions can become intertwined leading to some confusion.
If a man experiences erectile dysfunction, this may lead to anxiety associated with sexual activity which in turn may lead to decreased sexual desire. Additionally, this very anxiety may lead to the aforementioned performance anxiety which may exacerbate the erectile dysfunction itself. As you can see, this can be a complicated issue.
Normally, a man should be able to obtain an erection with appropriate mental and/or physical stimulation and maintain it long enough to obtain penetration and ejaculation. After ejaculation, it is normal for the man to lose his erection and it is normal for there to be a refractory period of time after this during which he is unable to obtain another erection. The length of time from obtaining an erection to ejaculation varies from one man to another as does the refractory period after ejaculation. They may also vary considerably in the same man, particularly depending on age.
Oftentimes men are bombarded with all sorts of imagery in our society causing to think there is something wrong with them if they are unable to maintain an erection lasting for hours and have multiple episodes of ejaculation, etc. This can cause tremendous unwarranted anxiety.
That’s not to say that some men do not suffer from conditions such as premature ejaculation, but these have little to do with erectile dysfunction and are a subject for another article.
What treatments are available?
To a large extent this is dependent on the cause. If it is an anxiety, psychiatric type of situation, then addressing this with appropriate counseling and/or medications should be the primary focus.
If it appears that the erectile dysfunction is related to a medication the patient is taking, then alternate medications can be explored.
If the man has had a proper endocrinologic evaluation to find testosterone deficiency, then testosterone supplementation with injections or patches may offer relief. This may also improve libido related issues. It is important to exclude the presence of prostate cancer first however as testosterone supplementation may accelerate its growth and spread.
Other treatments that have become less common in recent years included vascular reconstructive surgeries in men with arterial disease, surgical insertion of various prosthetic devices into the penis, use of vacuum pumps and constrictive rubber bands on the penis to obtain and maintain erections, and injection of prostaglandins into the penis.
These have largely fallen out of favor since the advent of oral medications including Sildenafil (Viagra), Tadalafil (Cialis), and Vardenafil (Levitra). These are fairly new medications that all work basically the same way. They cause relaxation of the arterial smooth muscles in the penis as described above, leading to increased blood flow into the penis and its cavernous spongy tissues. I will likely add some more details on these medications in the disease index portion of this website in the near future.
What’s the prognosis?
The reality is that most men will experience some degree of erectile dysfunction at some point in their lives. It may be the temporary erectile dysfunction that a young man experiences when he is fatigued or has had too much to drink or perhaps experiences anxiety associated with inexperience or a new partner, or it may be a progressively worsening situation associated with worsening arterial or neurologic disease due to high blood pressure, high cholesterol, or diabetes for instance. In any case, there are effective treatments available for most men. Often the biggest obstacle to men receiving this treatment is simply embarrassment causing them to not seek help.
This is unfortunate. There is nothing for a man to be embarrassed about. Healthy sexual function is a normal part of life and men experiencing problems in this area should most definitely seek out help from their physician.
Most men that come to me with this problem are rather shy and embarrassed at first and seem to be very relieved when I don’t appear surprised or shocked, but instead react to them the same way I would for any other medical problem. It is not uncommon for them to make an appointment for some totally unrelated problem and then hit me with a “By the way Doc, while I’m here anyway…” sort of statement.
If you are a man experiencing erectile dysfunction, don’t be shy or embarrassed about it. Go see your doctor! Get some help with it.
What can be done to prevent erectile dysfunction?
Again, most men will experience erectile dysfunction at some point in their lives.
Staying in the best overall physical and mental health possible is your best bet to minimize risk of developing this. If you develop diabetes, high cholesterol/triglycerides, or high blood pressure, getting and keeping this under control should be your number one goal. Avoid excessive alcohol consumption. Avoid all use of tobacco and recreational drugs.
Ultimately however, as has already been stated, if you start to develop a problem with erectile dysfunction, go see your doctor right away.
Finally, one last word.
Obviously the bottom line with all of this is about sexual intercourse. I’m not here to be your morality police, but if you are going to engage in sexual activity, play it safe and use appropriate protection to avoid an unwanted pregnancy and/or sexually transmitted disease!
