• Erectile dysfunction (ED), also known as impotence, is the persistent inability to have an erection that is hard enough for penetration and or a hard erection that lasts long enough to complete satisfying sexual activity.
• ED may have a significant effect on the sex life of a man and his partner.
• Symptoms of erectile dysfunction include lack of an erection hard enough for penetration and or lasting long enough for completion of sexual activity.
• ED may occur with or without other sexual dysfunction, including decreased libido (decreased interest in sexual activity), orgasmic dysfunction (troubles achieving an orgasm/climax), and ejaculatory dysfunction (problems with the fluid released during sex, including lack of ejaculation (anejaculation), small volume ejaculate, ejaculation that occurs too quickly [premature ejaculation], ejaculate that goes back into the bladder [retrograde ejaculation] and pain with ejaculation).
• Erectile dysfunction is common, and the risk of developing ED increases with age. Experts have estimated that erectile dysfunction affects 30 million men in the United States.
• The causes of erectile dysfunction include aging, high blood pressure, diabetes mellitus, cigarette smoking, atherosclerosis (hardening of the arteries), depression, nerve or spinal cord damage, medication side effects, alcoholism or other substance (drug) abuse, pelvic surgery including radical prostatectomy, pelvic radiation, penile/perineal/pelvic trauma such as pelvic fracture, Peyronie’s disease (a disorder that causes curvature of the penis and sometimes painful erections), and low testosterone levels.
• Erectile dysfunction is treatable in all age groups.
• Treatments include psychotherapy, adopting a healthy lifestyle, oral phosphodiesterase type V (PDE5) inhibitors (Viagra, Levitra, Cialis, Stendra, and Staxyn), intraurethral prostaglandin E1 (MUSE), intracavernosal injections (prostaglandin E1, Caverject, Edex, Bimix and Trimix), vacuum devices, penile prosthesis and vascular surgery, and (in some cases) changes in medications when appropriate.
• Discuss over-the-counter products and or supplements with a doctor before using them.
Erectile dysfunction (ED, impotence) varies in severity; some cannot have an erection at all, whereas other men sometimes have troubles getting a hard erection, and others get a hard erection, but it only lasts for a short period. Approximately 50% of men over the age of 40 have trouble with erectile dysfunction.
While erectile dysfunction can occur at any age, the risk of developing erectile dysfunction increases with age. According to the Massachusetts Male Aging Study, erectile dysfunction was 52% in men 40-70 years of age. The prevalence of complete erectile dysfunction increases from 5% at 40 years of age to 15% among men 70 years of age and older.
Erections are neurovascular events, meaning that nerves and blood vessels (arteries and veins) are involved in the process of an erection. All must work properly to develop a hard erection that lasts long enough. Erection begins with sexual stimulation. Sexual stimulation can be tactile (for example, by a partner touching the penis or masturbation) or mental (for example, by having sexual fantasies, viewing porn). Sexual stimulation or sexual arousal causes the nerves going to the penis to release a chemical, nitric oxide. Nitric oxide increases the production of another chemical, cyclic GMP (cGMP), in the muscle of the corpora cavernosa. The cGMP causes the muscles of the corpora cavernosa to relax, allowing more blood to flow into the penis. The incoming blood fills the corpora cavernosa, making the penis expand.
The ability to achieve and sustain erections requires the following:
1. A healthy nervous system that conducts nerve impulses in the brain, spinal column, and penis
2. Healthy arteries in and near the corpora cavernosa that when stimulated can bring increased blood flow into the penis
3. Healthy muscles and fibrous tissues within the corpora cavernosa can distend allowing the penis to fill with blood
4. Adequate levels of nitric oxide in the penis
5. Normal-functioning tunica albuginea that allows for compression of the veins
6. Appropriate psychosocial interactions
Erectile dysfunction can occur if a man doesn’t meet one or more of these requirements. The following are causes of erectile dysfunction, and many men have more than one potential cause:
• Aging: There are two reasons why older men are more likely to experience erectile dysfunction than younger men. First, older men are more likely to develop diseases (such as heart attacks, angina, cardiovascular disease, strokes, diabetes mellitus, and high blood pressure) associated with erectile dysfunction. Second, the aging process alone can cause erectile dysfunction in some men by causing muscle and tissue changes within the penis.
• Diabetes mellitus: Erectile dysfunction tends to develop 10 to 15 years earlier in diabetic men than among nondiabetic men. The increased risk of erectile dysfunction among men with diabetes mellitus may be due to the earlier onset and greater severity of atherosclerosis (hardening of the arteries), which narrows the arteries and reduces the delivery of blood to the penis. Atherosclerosis can affect the arteries in the penis and the arteries in the pelvis that supply the penile arteries. Diabetes mellitus also causes erectile dysfunction by damaging nerves that go to the penis, much like the effect of diabetes on nerves in other areas of the body (diabetic neuropathy). Diabetes can also affect the muscles in the penis, leading to troubles with erections. Smoking cigarettes, obesity, poor control of blood glucose levels, and having diabetes mellitus for a long time further increase the risk of erectile dysfunction in people with diabetes.
• Hypertension (high blood pressure): Men with high blood pressure have an increased risk of developing erectile dysfunction. Hypertension can cause problems with erections related to atherosclerosis or low levels of nitric oxide production from the arteries in the penis. Medications to treat hypertension may cause erectile dysfunction.
• Cardiovascular diseases: The most common cause of cardiovascular diseases in the United States is atherosclerosis, the narrowing, and hardening of arteries that reduces blood flow. Atherosclerosis (a type of vascular disease) typically affects arteries throughout the body; hypertension, high blood cholesterol levels, cigarette smoking, and diabetes mellitus aggravate atherosclerosis. Hardening of the arteries to the penis and pelvic organs, atherosclerosis, causes insufficient blood flow into the penis. There is a close correlation between the severity of atherosclerosis in the coronary arteries and erectile dysfunction. For example, men with more severe coronary artery atherosclerosis (hardening of the arteries in the heart) also tend to have more erectile dysfunction than men with mild or no coronary artery atherosclerosis. Some doctors suggest that men with new onset erectile dysfunction undergo evaluation for silent coronary artery diseases (advanced coronary artery atherosclerosis that has not yet caused angina or heart attacks).
• Metabolic syndrome is associated with multiple risk factors for erectile dysfunction, including diabetes, abnormal lipid profile, hypertension, and obesity.
• Cigarette smoking: Cigarette smoking aggravates atherosclerosis and can cause vasospasm (spasms of the arteries), thereby increasing the risk of erectile dysfunction.
• Nerve or spinal cord damage: Damage to the spinal cord and nerves in the pelvis can cause erectile dysfunction. Nerve damage can be due to disease, trauma, or surgical procedures. Examples include injury to the spinal cord from automobile accidents, injury to the pelvic nerves from prostate surgery for cancer (prostatectomy), and some surgeries for colorectal cancer, radiation to the prostate, surgery for benign prostatic enlargement, multiple sclerosis (a neurological disease with the potential to cause widespread damage to nerves), and long-term diabetes mellitus.
• BPH: Benign enlargement of the prostate is associated with erectile dysfunction.
• Trauma: Trauma to the pelvis, including pelvic fracture, may cause erectile dysfunction, and an untreated penile fracture may result in erectile dysfunction.
• Substance abuse: Marijuana, heroin, cocaine, methamphetamines, crystal meth, and narcotic and alcohol abuse contribute to erectile dysfunction. Alcoholism, in addition to causing nerve damage, can lead to atrophy (shrinking) of the testicles and lower testosterone levels.
• Low testosterone levels: Testosterone (the primary sex hormone in men) is necessary for sex drive (libido) and is essential to maintain nitric oxide levels in the penis. Therefore, men with hypogonadism (low testosterone with symptoms) can have a low sex drive and erectile dysfunction.
• Medications: Many conventional medicines produce erectile dysfunction as a side effect. Medications that can cause erectile dysfunction include many used to treat high blood pressure, antihistamines, antidepressants, tranquilizers, and appetite suppressants.
• Recreational drugs: Recreational drugs, including alcohol, amphetamines, barbiturates, marijuana, nicotine, heroin, and cocaine, are associated with erectile dysfunction.
• Depression and anxiety: Psychological factors may be responsible for erectile dysfunction. These factors include stress, anxiety, guilt, depression, widower syndrome, low self-esteem, posttraumatic stress disorder, and fear of sexual failure (performance anxiety). It is also worth noting that many medications used for the treatment of depression and other psychiatric disorders may cause erectile dysfunction or ejaculatory problems.
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