Erectile Dysfunction (ED)

During sexual arousal, nerve signals make blood flow into the penis. The penis contains two erection chambers (called the corpus cavernosum), made of spongy muscle tissue. During erection, these spongy tissues relax and trap blood. The blood pressure in the chambers makes the penis firm, causing an erection.

During orgasm, more nerve signals make the muscular tissues in the penis contract. The blood is released back into a man’s circulation and the erection comes down. When you are not sexually aroused, the penis is soft and limp.

Penis size can vary as blood enters and leaves the penis. Penis size can change with warmth, cold, or worry. These changes are normal.

More than 80% of men suffering from ED can trace its origin to a physical problem or disorder. In some cases, erectile dysfunction can be considered an early warning system for heart attack and stroke. Physical causes include the following:

• Not enough blood flows into the penis. Many health issues can reduce this blood flow, including diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic disease. Between 35% and 50% of men with diabetes experience ED.
• The penis cannot trap blood during an erection. If blood does not stay in the penis, a man cannot keep an erection. This is called venous leak, and is the most common cause of ED.
• Nerve signals from the brain or spinal cord do not reach the penis, as a result of certain diseases, injury, or surgery in the pelvic area. In addition, diabetes can cause small vessel disease or nerve damage to the penis.
• Surgery and/or radiation for cancers in the lower abdomen or pelvis can cause ED. Treating prostate cancer, colorectal cancer, or bladder cancer often leaves men with ED, due to injury to nerves and arteries near the penis.
• Drugs used to treat other health problems can interfere with erections.
• Obstructive sleep apnea can lead to ED due to restricted oxygen flow to the penis.
• Smoking can reduce blood flow to the penis, leading to ED.

Emotional causes include the following:

• Depression
• Anxiety
• Relationship conflicts
• Stress at home or at work
• Stress from social, cultural, or religious conflicts
• Low self-esteem
• Worry about sex performance, or loss of interest in sex

Men at higher risk for ED may have:

• High blood sugar (diabetes)
• High blood pressure
• High cholesterol
• Cardiovascular disease

They may also be:

• Over age 50
• Smokers
• Drug/Alcohol users
• Obese
• Sedentary (lacking exercise)

1. Medical History. Tell your health care provider about your symptoms, how long you’ve had them, and how they affect your everyday living. Tell your provider about any stressors in your life. Your health care provider may also ask you the following questions:

About your physical health:

• What prescription drugs, over-the-counter drugs or supplements do you take?
• Do you use recreational drugs?
• Do you smoke?
• How much alcohol do you drink?
• Have you had surgery or radiation therapy in the pelvic area?
• Do you have any urinary problems?
• Do you have other health problems (treated or untreated)?

About your emotional health:

• Are you often under a lot of stress, or has something recently upset you?
• Do you have any anxiety, depression, or other mental health issues?
• Are you taking any drugs for your mental health?
• How satisfied are you with your sex life? Have there been any changes lately?
• How is your relationship with your partner? Have there been any changes lately?

About your ED symptoms:

• How long have you had these symptoms? Did they start slowly or all at once?
• Do you wake up in the morning or during the night with an erection?
• If you do have erections, how firm are they? Is penetration difficult?
• Do your erections change at different times, like when going in a partner, during stimulation by mouth, or with masturbation?
• Do you have problems with sex drive or arousal?
• Do you have problems with ejaculation or orgasm (climax)?
• How is this problem changing the way you enjoy sex?
• Do you have painful with erections, feel a lump or bump in the penis or have penile curvature? (These are signs of Peyronie’s Disease, which can be treated but calls for an expert in urology to assess and manage.)

2. Physical Exam. A health provider will examine your genitals (penis and testicles). Depending on your age and risk factors, the exam may also focus on your heart, peripheral pulses, and blood pressure. A rectal exam to check the prostate may also be performed.

3. Blood and Urine Tests. Sample of your blood and your urine may be taken to test for health problems that cause ED. In some cases, blood tests may include those for testosterone and other male hormones, and for blood sugar (diabetes).

4. Questionnaires. These are used to rate your ability to begin and maintain erections, gauge your satisfaction with sex, and help identify any problems with orgasm.

5. Imaging tests. Ultrasonography (penile Doppler) analyzes blood flow. Where there is a history of trauma or cancer, pelvic X-rays like arteriography, MRI, or CT scanning may check for conditions underlying ED.

6. Vascular stimulant. This is injected into the penis to cause an erection.

7. Nocturnal penile tumescence (NPT). This overnight test checks for erections during sleep.

8. Biothesiometry. This test uses electromagnetic vibration to test nerve function.

1. Lifestyle changes. ED can indicate problems in heart and vascular health, so you may be advised to change eating habits, stop smoking and drinking, stop using recreational drugs, or increase workouts. ED can also stem from emotional problems, so you may be advised to seek treatment for depression or anxiety and for dealing with relationship conflicts and stress.

2. Oral drug therapy (PDE5 inhibitors). These can include medications like Viagra, Cialis, Levitra, or Stendra. These drugs help blood flow into the penis, but do not work as well for cancer and diabetes patients.

3. Testosterone therapy. If a blood test shows low testosterone, this can be combined with PDE5 inhibitors.

4. Intracavernosal injection (ICI) therapy. The drug Alprostadil, which is injected into the side of penis with a very fine needle, causes blood vessels and muscles in the penis to relax and dilate. This facilitates blood flow. Alprostadil may also be combined with other drugs. Injections are self-administered, following instruction.

5. Intraurethral (IU) therapy. A tiny medicated pellet of Alprostadil is placed in the urethra, the tube that carries urine out of the body. No injections are needed, but this therapy may be less effective than ICI.

6. Vacuum erection device. A plastic tube slips over the penis, and a pump creates a low-pressure vacuum around the erectile tissue, causing an erection. An elastic ring is then placed onto the base of the penis, which holds the blood in the penis and keeps it hard.

7. Penile implants. Also called penile prostheses, this is the main surgical treatment of ED. The implants stiffen the penis, allowing for normal sex. There are two types of penile implants. One is semi-rigid, bendable, and made of silicone. The other is inflatable, connected via tubing to a pump placed inside the scrotum. The surgery usually begins with a small cut, made either above the penis (where it joins the belly) or under (where it joins the scrotum). No tissue is removed and blood loss is typically small. Anesthesia is usually used during the procedure. A patient will either go home on the same day or spend one night in the hospital.

8. Penile vascular surgery. Also called microvascular arterial bypass surgery, this is similar to a cardiac bypass, but is in the penis. It is used to treat some younger men with a history of severe pelvic trauma. This surgery is not recommended for older men with hardened arteries.

9. eWave® therapy. This non-invasive treatment uses low-frequency sound waves to stimulate erectile tissue and increase blood flow to the penis. The waves also help new blood vessels form. (Not FDA approved.)

Many major medical insurance carriers cover most treatments for ED.