Erectile dysfunction, or ED, is the most common sex problem that men report to their doctor. It affects as many as 30 million men. Erectile dysfunction (impotence) is the inability to get and keep an erection firm enough for sex.
Having erection trouble from time to time isn’t necessarily a cause for concern. If erectile dysfunction is an ongoing issue, however, it can cause stress, affect your self-confidence and contribute to relationship problems. Problems getting or keeping an erection can also be a sign of an underlying health condition that needs treatment and a risk factor for heart disease.
Though it’s not rare for a man to have some problems with erections from time to time, ED that is progressive or happens routinely with sex is not normal, and it should be treated.
ED can happen:
- Most often when blood flow in the penis is limited or nerves are harmed
- With stress or emotional reasons
- As an early warning of a more serious illness, like: atherosclerosis (hardening or blocked arteries), heart disease, high blood pressure or high blood sugar from Diabetes
Finding the cause(s) of your ED will help treat the problem and help with your overall well-being. As a rule, what’s good for your heart health is good for your sex health.
Symptoms of ED
Erectile dysfunction symptoms might include persistent:
- Trouble getting an erection
- Trouble keeping an erection
- Reduced sexual desire
Causes of ED
Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles and blood vessels. Erectile dysfunction can result from a problem with any of these. Likewise, stress and mental health concerns can cause or worsen erectile dysfunction.
Sometimes a combination of physical and psychological issues causes erectile dysfunction. For instance, a minor physical condition that slows your sexual response might cause anxiety about maintaining an erection. The resulting anxiety can lead to or worsen erectile dysfunction.
Physical causes of erectile dysfunction
In many cases, erectile dysfunction is caused by something physical. Common causes include:
- Heart disease
- Clogged blood vessels (atherosclerosis)
- High cholesterol
- High blood pressure
- Metabolic syndrome — a condition involving increased blood pressure, high insulin levels, body fat around the waist and high cholesterol
- Parkinson’s disease
- Multiple sclerosis
- Certain prescription medications
- Tobacco use
- Peyronie’s disease — development of scar tissue inside the penis
- Alcoholism and other forms of substance abuse
- Sleep disorders
- Treatments for prostate cancer or enlarged prostate
- Surgeries or injuries that affect the pelvic area or spinal cord
- Low testosterone
Psychological causes of erectile dysfunction
The brain plays a key role in triggering the series of physical events that cause an erection, starting with feelings of sexual excitement. A number of things can interfere with sexual feelings and cause or worsen erectile dysfunction. These include:
- Depression, anxiety or other mental health conditions
- Relationship problems due to stress, poor communication or other concerns
How Erections Work
During sexual arousal, nerves release chemicals that increase blood flow into the penis. Blood flows into two erection chambers in the penis, made of spongy muscle tissue (the corpus cavernosum). The corpus cavernosum chambers are not hollow.
During erection, the spongy tissues relax and trap blood. The blood pressure in the chambers makes the penis firm, causing an erection. When a man has an orgasm, a second set of nerve signals reach the penis and cause the muscular tissues in the penis to contract and 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. Men may notice that the size of the penis varies with warmth, cold or worry; this is normal and reflects the balance of blood coming into and leaving the penis.
The penis is the male sexual organ.
The shaft is the longest part of it. The head or glans is at the end of the shaft. The opening at the tip of the head, where urine and semen come out, is called the meatus.
Inside, two cylinder-shaped chambers called the corpora cavernosa run the length of the penis. They have a maze of blood vessels, tissue, and open pockets.
The urethra, the tube that urine and semen flow through, runs along the underside of them, in the spongy tissue of the corpus spongiosum.
Two main arteries (one in each of the corpora cavernosa) and several veins move blood in and out. Nerves relay messages to and from other parts of your body.
What Is Ejaculation?
When you’re aroused, tubes called the vas deferens squeeze sperm from the testes toward the back of the urethra. The seminal vesicles also release fluid there.
The urethra senses the sperm and fluid mixture. Then, at the height of sexual excitement, it sends signals to your spinal cord, which in turn sends signals to the muscles at the base of your penis. These contract powerfully and quickly, every 0.8 seconds. This forces the semen out of the penis as you climax.
But erectile dysfunction (ED) affects up to 30 million American men, many of whom don’t understand how or why it happens.
What you should know about ED
1. Most men with ED don’t actually have ED. Older men are more likely to suffer from erectile dissatisfaction than erectile dysfunction. This means that getting and keeping an erection has become more difficult and is more frustrating than it once was, but it’s not impossible.
2. Penises are fragile. Yes, you can break your penis. It’s not like a broken bone, though — instead, the blood vessels within the penis burst, causing painful swelling. According to the UK’s National Health Service, one-third of penile fracture cases are attributed to sexual intercourse where the partner is on top.
3. Erections happen early. Like in the womb, early. Male fetuses can experience erections in the womb.
4. Medications for ED don’t always work. Drugs designed to help men with ED regain a healthy sex life only work in about two-thirds of cases. Also, Psychology Today reports that some men need increasingly larger doses, which come with increasingly intense side effects.
6. The average erection is 5.6 inches long. A 2013 study attempted to settle penis size once and for all. The findings: The average erect penis is just shy of 5.6 inches. The data came directly from study participants, who self-measured, so there is the question of how many exaggerated.
7. The world’s largest erection is 13.5 inches. Jonah Falcon is said to have the world’s largest penis that, when erect, is well over 1 foot long. When flaccid, it measures 9.5 inches.
8. ED can signal a serious health problem. Sometimes, sexual problems are a sign of bigger issues. According to the Mayo Clinic, ED can be caused by heart disease, diabetes, Parkinson’s disease, multiple sclerosis, high cholesterol, and more.
9. Erections aren’t required for orgasm. Yes, men who can’t achieve erections may still have orgasms.
10. Lifestyle choices can make you more prone to ED. Alcoholism, drug use, being overweight, smoking, certain medications, and even “prolonged bicycling” can lead to ED, according to the Mayo Clinic.
11. Men have between three to five erections per night. Every night while you’re sleeping, your penis is hard at work. The average man experiences up to five erections while they sleep, each lasting about 30 minutes.
12. ED stress can make matters worse. ED can cause psychological stress, and psychological stress can cause ED. When men are frustrated by their inability to perform, it can make it even more difficult to overcome ED. Talking with a doctor or sex therapist may help.
Physical Causes of ED
ED happens when:
- There is not enough blood flows into the penis
Many health issues can reduce blood flow into the penis, such as hardened arteries, heart disease, high blood sugar (Diabetes) and smoking.
- The penis cannot trap blood during an erection
If blood does not stay in the penis, a man cannot keep an erection. This issue can happen at any age.
- Nerve signals from the brain or spinal cord do not reach the penis
Certain diseases, injury or surgery in the pelvic area can harm nerves to the penis.
- Diabetes can cause small vessel disease or nerve damage to the penis
- Cancer treatments near the pelvis can affect the penis’ functionality
Surgery and or radiation for cancers in the lower abdomen or pelvis can cause ED. Treating prostate, colon-rectal or bladder cancer often leaves men with ED. Cancer survivors should see a Urologist for sexual health concerns.
- Drugs used to treat other health problems can negatively impact erections
Patients should talk about drug side effects with their primary care doctors.
Emotional Causes of ED
Normal sex needs the mind and body working together. Emotional or relationship problems can cause or worsen ED. Some emotional issues that can cause ED are:
- Relationship conflicts
- Stress at home or work
- Stress from social, cultural or religious conflicts
- Worry about sex performance
The Treatment of ED
Non-invasive treatments are often tried first. Most of the best-known treatments for ED work well and are safe. Still, it helps to ask your health care provider about side effects that could result from each option:
- Oral drugs or pills known as phosphodiesterase type-5 inhibitors are most often prescribed in the U.S. for ED (Viagra, Cialis, Levitra, Stendra)
- Testosterone Therapy (when low testosterone is detected in blood testing)
- Penile Injections (ICI, intracavernosal Alprostadil)
- Intraurethral medication (IU, Alprostadil)
- Vacuum Erection Devices
- Penile Implants
- Surgery to bypass penile artery damage for some younger men with a history of severe pelvic trauma. Penile vascular surgery is not recommended for older men with hardened arteries.
Oral Drugs (PDE5 inhibitors)
Drugs known as PDE type-5 inhibitors increase penile blood flow. These are the only oral agents approved in the U.S. by the Food and Drug Administration for the treatment of ED.
- Viagra® (sildenafil citrate)
- Levitra® (vardenafil HCl)
- Cialis® (tadalafil)
- Stendra® (avanafil)
For best results, men with ED take these pills about an hour or two before having sex. The drugs require normal nerve function to the penis. PDE5 inhibitors improve on normal erectile responses helping blood flow into the penis. Use these drugs as directed. About 7 out of 10 men do well and have better erections. Response rates are lower for Diabetics and cancer patients.
If you are taking nitrates for your heart, you SHOULD NOT take any PDE5 inhibitors. Always speak with your health care provider before using a PDE5 inhibitor to learn how it might affect your health.
Most often, the side effects of PDE5 inhibitors are mild and often last just a short time. The most common side effects are:
- Stuffy nose
- Facial flushing
- Muscle aches
In rare cases, the drug Viagra ® can cause blue-green shading to vision that lasts for a short time. In rare cases, the drug Cialis® can cause or increase back pain or aching muscles in the back. In most cases, the side effects are linked to PDE5 inhibitor effects on other tissues in the body, meaning they are working to increase blood flow to your penis and at the same time impacting other vascular tissues in your body. These are not ‘allergic reactions’.
In those rare cases where a low sex drive and low blood levels of Testosterone are at fault for ED, Testosterone Therapy may fix normal erections or help when combined with ED drugs (PDE type 5 inhibitors).Vacuum Erection Device
A vacuum erection device is a plastic tube that slips over the penis, making a seal with the skin of the body. A pump at the other end of the tube makes a low-pressure vacuum around the erectile tissue, which results in an erection. An elastic ring is then slipped onto the base of the penis. This holds the blood in the penis (and keeps it hard) for up to 30 minutes. With proper training, 75 out of 100 men can get a working erection using a vacuum erection device.
Intracavernosal (ICI) and Urethra (IU) Therapies
If oral drugs don’t work, the drug Alprostadil is approved for use in men with ED. This drug comes in two forms, based on how it is to be used: intracavernosal injection (called “ICI”) or through the urethra (called “IU therapy”).
Alprostadil is injected into the side of penis with a very fine needle. It’s of great value to have the first shot in the doctor’s office before doing this on your own. Self-injection lessons should be given in your doctor’s office by an experienced professional. The success rate for getting an erection firm enough to have sex is as high as 85% with this treatment. Many men who do not respond to oral PDE5 inhibitors can be ‘rescued’ with ICI.
ICI Alprostadil may be used as a mixture with two other drugs to treat ED. This combination therapy called “bimix or trimix” is stronger than alprostadil alone and has become standard treatment for ED. Only the Alprostadil ingredient is FDA approved for ED. The amount of each drug used can be changed based on the severity of your ED, by an experienced health professional. You will be trained by your health professional on how to inject, how much to inject and how to safely raise the drug’s dosage if necessary.
ICI therapy often produces a reliable erection, which comes down after 20-30 minutes or with climax. Since the ICI erection is not regulated by your penile nerves, you should not be surprised if the erection lasts after orgasm. The most common side effect of ICI therapy is a prolonged erection. Prolonged erections (>1 hour) can be reversed by a second injection (antidote) in the office.
Men who have penile erections lasting longer than two to four hours should seek Emergency Room care. Priapism is a prolonged erection, lasting longer than four hours. It is very painful. Failure to undo priapism will lead to permanent penile damage and untreatable ED.
Intraurethral (IU) Therapy
For IU therapy, a tiny medicated pellet of the drug, Alprostadil, is placed in the urethra (the tube that carries urine out of your body). Using the drug this way means you don’t have to give yourself a shot, unfortunately it may not work as well as ICI. Like ICI therapy, IU Alprostadil should be tested in the office, before home usage.
The most common side effects of IU alprostadil are a burning feeling in the penis. If an erection lasts for over four hours, it will need medical attention to make it go down.
The main surgical treatment of ED involves insertion of a penile implant (also called penile prostheses). Because penile vascular surgery is not recommended for aging males who have failed oral PDE5 inhibitors, ICI or IU therapies, implants are the next step for these patients. Although placement of a penile implant is a surgery which carries risks, they have the highest rates of success and satisfaction among ED treatment options.
Penile implants are devices that are placed fully inside your body. They make a stiff penis that lets you have normal sex. This is an excellent choice to improve uninterupted intimacy and makes relations more spontaneous.
There are two types of penile implants.
Semi rigid Implant (Bendable)
The simplest kind of implant is made from two easy-to-bend rods that are most often made of silicone. These silicone rods give the man’s penis the firmness needed for sexual penetration. The implant can be bent downward for peeing or upward for sex.
With an inflatable implant, fluid-filled cylinders are placed lengthwise in the penis. Tubing joins these cylinders to a pump placed inside the scrotum (between the testicles). When the pump is engaged, pressure in the cylinders inflate the penis and makes it stiff. Inflatable implants make a normal looking erection and are natural feeling for your partner. Your surgeon may suggest a lubricant for your partner. With the implant, men can control firmness and, sometimes, the size of the erection. Implants allows a couple to be spontaneously intimate. There is generally no change to a man’s feeling or orgasm.
5 natural ways to overcome erectile dysfunction
Erectile dysfunction (ED) can occur for many reasons. Sometimes it is as simple as the side effect of a particular medication. But for roughly 75% of men, the cause is more complex. ED may result from vascular disease, neurological disease, diabetes, or prostate-related treatments or surgeries.
Whether you currently suffer from ED or are hoping to sidestep this condition, try these tips to overcome ED for better health and a better sex life.
- Start walking. According to one Harvard study, just 30 minutes of walking a day was linked with a 41% drop in risk for ED. Other research suggests that moderate exercise can help restore sexual performance in obese middle-aged men with ED.
- Eat right. In the Massachusetts Male Aging Study, eating a diet rich in natural foods like fruit, vegetables, whole grains, and fish — with fewer red and processed meat and refined grains — decreased the likelihood of ED.
- Pay attention to your vascular health. High blood pressure, high blood sugar, high cholesterol, and high triglycerides can all damage arteries in the heart (causing heart attack), in the brain (causing stroke), and leading to the penis (causing ED). An expanding waistline also contributes. Check with your doctor to find out whether your vascular system — and thus your heart, brain, and penis — is in good shape or needs a tune-up through lifestyle changes and, if necessary, medications.
- Size matters, so get slim and stay slim. A trim waistline is one good defense — a man with a 42-inch waist is 50% more likely to have ED than one with a 32-inch waist. Losing weight can help fight erectile dysfunction, so getting to a healthy weight and staying there is another good strategy for avoiding or fixing ED. Obesity raises risks for vascular disease and diabetes, two major causes of ED. And excess fat interferes with several hormones that may be part of the problem as well.
- Move a muscle, but we’re not talking about your biceps. A strong pelvic floor enhances rigidity during erections and helps keep blood from leaving the penis by pressing on a key vein. In a British trial, three months of twice-daily sets of Kegel exercises (which strengthen these muscles), combined with biofeedback and advice on lifestyle changes — quitting smoking, losing weight, limiting alcohol — worked far better than just advice on lifestyle changes.
Diagnosis of ED
For many people, a physical exam and answering questions (medical history) are all that’s needed for a doctor to diagnose erectile dysfunction and recommend a treatment. If you have chronic health conditions or your doctor suspects that an underlying condition might be involved, you might need further tests or a consultation with a specialist.
Tests for underlying conditions might include:
- Physical exam. This might include careful examination of your penis and testicles and checking your nerves for sensation.
- Blood tests. A sample of your blood might be sent to a lab to check for signs of heart disease, diabetes, low testosterone levels and other health conditions.
- Urine tests (urinalysis). Like blood tests, urine tests are used to look for signs of diabetes and other underlying health conditions.
- Ultrasound. This test is usually performed by a specialist in an office. It involves using a wandlike device (transducer) held over the blood vessels that supply the penis. It creates a video image to let your doctor see if you have blood flow problems.This test is sometimes done in combination with an injection of medications into the penis to stimulate blood flow and produce an erection.
- Psychological exam. Your doctor might ask questions to screen for depression and other possible psychological causes of erectile dysfunction.