It is estimated that 30 million men in the United States suffer from sexual dysfunction. Erectile Dysfunction is defined as a lack of penile rigidity adequate for penetration. Many of these men are not aware of the many options that are available for the treatment of this problem. For a large majority of men who experience sexual dysfunction, the cause is physical rather than psychological. A number of diseases such as high blood pressure, diabetes or even old age may alter sexual function. For example, half of all men with diabetes experience some degree of sexual dysfunction during their lifetime. In the past, many men were not given effective treatment options. Now we are able to pinpoint the cause of erection problems and can successfully treat 90% to 95% of them.
How an Erection Happens
For an erection to occur, a series of events must take place. The first event in this chain is psychosexual stimulation. This is promoted by the male sex drive, also known as libido. The mind then sends impulses down the nerve pathways to the penis. These nerve impulses relax the smooth muscles of the arteries which supply the penis with blood. This muscle relaxation leads to engorgement and erection of the penis. After orgasm, the blood is returned into the general circulation and the penis returns to a soft (flaccid) state. Even a minor disturbance in any of these steps such as decreased blood supply, disturbances of nerve mechanisms or psychosexual problems may lead to erection problems.
Causes of Erectile Dysfunction
As men age there is a natural slowing down of many bodily functions. From a sexual viewpoint, this may occur as decreased firmness of erections, shorter lasting erections or a longer “recovery time” in between erections. These changes may be caused by a decreased production of testosterone, decreased blood flow or other diseases. Most commonly, the sexual changes associated with old age are due to a combination of factors.
Decreased Blood Flow
A decrease in the blood flow to the penis will affect the quality of erections. The erections will be weak and/or maybe short lasting. Decreased blood flow can be caused by arteriosclerosis (clogged arteries), high blood pressure or pelvic trauma. Men who have clogged arteries in their heart often have the same problem with the arteries that supply blood to the penis.
Diabetes can interfere with erections. Half of all men with diabetes experience some degree of erectile dysfunction. Diabetes can affect the sending and receiving of nerve impulses. This condition is called peripheral neuropathy and may also affect the hands and feet of diabetics. Without good nerve function, erections are more difficult to achieve. Diabetes may affect the blood flow to the penis. Men with diabetes often experience decreases quality or number of erections. Healthy blood vessels are needed for the engorgement of penile tissue that leads to an erection.
High Blood Pressure
Hypertension can affect erections either by changes it causes to the blood vessels, or by the medications used for treatment. Hypertension causes the arteries to lose their elasticity, and therefore they cannot accommodate the onrush of blood needed for the erection. Hypertension may affect the veins, allowing the blood that rushes into the penis to exit just as quickly. The effects of hypertension on erectile function are cumulative over time and may occur even before a man knows he has hypertension.
Pelvic Surgery (Prostate, Bladder, Rectal)
When surgery is performed in the pelvic area, subtle impact to the nerves and or blood vessels may occur. Even with “nerve sparing” procedures, the nerves may be temporarily or permanently altered. With extensive pelvic surgery the amount and type of tissue removed may lead to impotence.
Spinal Cord Injury, Multiple Sclerosis and Other Nervous System Disorders
An injury to the spinal cord disrupts the nerve pathways necessary for an erection. Sometimes men with a spinal cord injury may get reflex erections. However, these are unpredictable and usually very short lasting. Multiple sclerosis interferes with the nerve impulses in the body. Generalized weakness and immobility also adversely affect the ability to achieve and maintain an adequate erection. Any other disorder which interferes with the nervous system can make good quality erections difficult or impossible.
The hormones play an important part in sexual function. They are responsible for the sex drive (also called libido). Hormonal imbalances such as low testosterone or high prolactin can disrupt the libido. The use of Testosterone (Hormone replacement therapy) is an option for somemen who have testosterone deficiency. This is often known as secondary hypogonadism. Blood tests, usually performed in the morning hours, are used to make the diagnosis. Patients typically complain of decreased sex drive, fatigue, sexual dysfunction, and overall decreased sense of well-being.
Depression and Psychological Problems
Depression may lead to erectile dysfunction by a loss of sex drive, or by the medications used for treatment. Problems with premature ejaculation and the anxiety associated with it may lead to erectile problems. If stress, anxiety or depression is the cause of your erectile dysfunction, your doctor may suggest that you, or you and your partner, visit a psychologist or counselor with experience in treating sexual problems (sex therapist). Even if it is caused by something physical, erectile dysfunction can create stress and relationship tension. Counseling can help, especially when your partner participates.
Cigarette Smoking, Excessive Use of Alcohol, Drug Abuse
Habits such as smoking, heavy alcohol uses and recreational drug abuse may inhibit erectile function. The effects may be temporary or permanent. Temporary erectile dysfunction may occur as a result of indigestion of large amounts of alcohol. Permanent effects may occur from the effects of smoking on the blood vessels or alcohol on the nerves. Substances added to recreational drugs may damage both the vessels and nerves.
Oral medications available to treat ED include: Sildenafil (Viagra), Tadalafil (Cialis), and Vardenafil (Levitra). All three medications work in much the same way. Chemically known as phosphodiesterase inhibitors, these drugs enhance the effects of nitric oxide, a chemical that relaxes muscles in the penis. This increases the amount of blood flow and allows a natural sequence to occur — an erection in response to sexual stimulation. They don't automatically produce an erection. Instead they allow an erection to occur after physical and psychological stimulation. Many men experience improvement in erectile function after taking these medications regardless of the cause of their impotence.
Although these medications can help many people, not all men can or should take them to treat erectile dysfunction.
You should not take these medications if:
You take nitrate drugs for angina, such as nitroglycerin (Nitro-Bid, others), isosorbide mononitrate (Imdur) and isosorbide dinitrate (Isordil)
You take a blood-thinning (anticoagulant) medication
You take certain types of alpha blockers for enlarged prostate (benign prostatic hyperplasia) or high blood pressure
Prostaglandin E (alprostadil)
Two treatments involve using a drug called alprostadil. Alprostadil is a synthetic version of the hormone prostaglandin E. The hormone helps relax muscle tissue in the penis, which enhances the blood flow needed for an erection. There are two ways to use alprostadil:
Needle-injection therapy. With this method, you use a fine needle to inject alprostadil (Caverject, Edex, or the "Quad mix" formulation utilized at Tri-County Urologists, P.C., into the base or side of your penis. This generally produces an erection in five to 20 minutes that lasts about an hour. Because the injection goes directly into the spongy cylinders that fill with blood, alprostadil is an effective treatment for many men. And because the needle used is so fine, pain from the injection site is usually minor. Other side effects may include bleeding from the injection, prolonged erection and formation of fibrous tissue at the injection site.
Self-administered intraurethral therapy (Muse). This treatment involves using a disposable applicator to insert a tiny alprostadil suppository, about half the size of a grain of rice, into the tip of your penis. The suppository, placed about two inches into your urethra, is absorbed by erectile tissue in your penis, increasing the blood flow that causes an erection. Although needles aren't involved, you may still find this method painful or uncomfortable. Side effects may include pain, minor bleeding in the urethra, dizziness and formation of fibrous tissue.
Penile pumps (Vacuum Erection Devices)
This treatment involves the use of a hollow tube with a hand-powered or battery-powered pump. The tube is placed over the penis, and then the pump is used to suck out the air. This creates a vacuum that pulls blood into the penis. Once you achieve an adequate erection, you slip a tension ring around the base of your penis to maintain the erection. You then remove the vacuum device. The erection typically lasts long enough for a couple to have sex. You remove the tension ring after intercourse.
Vascular surgery (very very rare)
This treatment is usually reserved for men whose blood flow has been blocked by an injury to the penis or pelvic area. Surgery may also be used to correct erectile dysfunction caused by vascular blockages. The goal of this treatment is to correct a blockage of blood flow to the penis so that erections can occur naturally. But the long-term success of this surgery is unclear.
This treatment involves surgically placing a device into the two sides of the penis, allowing erection to occur as often and for as long as desired. The inflatable device allows you to control when and how long you have an erection, the semirigid rods keep the penis in a rigid state all the time. These implants consist of either an inflatable device or semirigid rods made from silicone or polyurethane. This treatment is usually not recommended until other methods have been considered or tried first. As with any surgery, there is a small risk of complications such as infection. This option, although surgical, has a patient satisfaction rate in the 90 percentile ranges. Most insurance plans do actually cover the cost of penile implants.
At the Michigan Center for Sexual Health, we focus not on the disease process, but on the patient as a whole. We provide a complete detailed evaluation and treatment plan. All advanced treatment options are available to our patients; both medical and surgical. Our Urologic physicians are dedicated to our patients' well-being, health, and improved quality of life.