Penile Erectile Dysfunction:
Causes and Treatments

If you have the problem of penile erectile dysfunction you should know that a recent study estimated that 30 million men suffer from various degrees of erectile dysfunction (ED) ranging from mild to severe. It is clearly an age-related phenomenon since the prevalence of erectile dysfunction increases significantly with age.

Here are a few numbers and facts that might be illuminating to you. By the time men reach the age of 40, 5% of them are completely impotent, never achieving an erection rigid enough for penetration. Approximately 15% of men have significant problems achieving or maintaining an erection.

In 90% of cases involving men older than 35, the causes are physical in nature. In men younger than 35, the causes are usually psychological in nature. But the important thing to know is that even in the cases of those patients for whom the psychological issues are the primary factor, medical intervention can often help solve the problem.

Learn about Stendra, a new FDA approved treatment for erectile dysfunction.

On This Page


CAUSES OF PENILE ERECTILE DYSFUNCTION
If you have erectile dysfunction or male impotence there are four main causes to look into. A description of each follows:

Vascular
Blood must be able to move into the penis and stay there to maintain an erection. Arteries are the vehicles that bring blood into the penis. Any process that damages the arteries and increases the likelihood of vascular disease would make a man more likely to have erectile dysfunction. A history of arterial disease (e.g. coronary artery, heart disease, strokes, or peripheral vascular disease) indicates that the penile arteries are also at risk. In fact, erectile dysfunction may often appear before any of these more severe manifestations of vessel disease. So, you can understand that smoking is one of the most common contributing causes to erectile dysfunction. Other causes include high blood pressure (especially if it is uncontrolled), heart disease, high cholesterol, and diabetes.

Neurological
A man must have an intact neurological system in order for an erection to occur. Patients with multiple sclerosis or those who have had damage to their peripheral nerves from diabetes may also suffer from erectile dysfunction.

Hormonal
Significantly low testosterone and thyroid hormones or a very high prolactin may cause problems with erections.

Psychological
This can be an initial problem or a secondary problem. In some cases men may not achieve an erection primarily because of psychological issues. However, many men have a significant psychological response (or secondary reaction) to what is initially a primary physical problem. Once a man loses confidence in his erections, his attitude and interest level may change and diminish. At that point, he may develop increasing difficulty achieving and maintaining an erection.


PENILE ERECTILE DYSFUNCTION TREATMENT OPTIONS
How do you go about getting help? Well, if you're a patient with a straightforward case of erectile dysfunction (for example, a 65-year-old diabetic who wants rapid treatment for sexual impotence), a general urologist is often a good starting point. The doctor should take a thorough history and perform a basic evaluation. This will include a focused physical exam, measurement of penile sensation, and a basic check of hormones. Available options should be explained thoroughly. Most often, the first course of action will be to provide an oral medication. The side effects of any medication should be explained and a prescription written. There should also be follow-up exams on a regular basis. If the oral medications do not work well or cause unpleasant side effects, there are a number of other effective erectile dysfunction therapy options available.

Oral Medications
Oral medications include Viagra, Levitra, Cialis, and Stendra.

These medications should be taken approximately 60 minutes prior to engaging in sexual activity. Viagra and Levitra are effective for approximately four hours. Cialis is effective for 36 hours. Viagra is less effective if it is taken within hours of having eaten fatty foods, so those types of food should be avoided when taking Viagra. Ideally, Viagra should be taken on an empty stomach. Stendra is a pill that patients take on an as-needed basis 30 minutes before sexual activity. You should be aware that none of these drugs will affect desire in any way. They will merely make a penis respond more quickly and remain firmer when it is stimulated and aroused.

The maximum dosage is 20 mg of Levitra or Cialis and 100 mg of Viagra. This should not be exceeded in any 24-hour period. Even if a lesser dosage is used, it should only be used once in a 24-hour period.

Although all three of these medications work slightly differently, they basically function the same way. They block an enzyme that normally prevents erections from occurring. When a man is sexually aroused, nitric oxide is released, which causes a cascade of biochemical reactions: the blood vessels and tissues of the penis relax and dilate, allowing blood to rush in and an erection to occur. These oral medications block the enzyme PDE5, which reverses this cascade.

Please note that all of these drugs are contraindicated for men who are:

  • Currently using nitrates or have Retinitis Pigmentosis

Other men who may not take the available oral medications are those with a predisposition to potentially hazardous cardiovascular events. These conditions include:

  • Unstable angina
  • Congestive heart failure
  • Taking multiple antihypertensive drugs
  • MI, heart attack, CVA (stroke), or life threatening arrhythmia within the last six months.
  • Hypotension, decreased blood pressure (BP <90/50) or hypertension, increased blood pressure (BP>170/110)
  • Patients on alpha blocks for high blood pressure or prostrate problems should not take Levitra or Cialis

If you fall into the above categories you should see an erectile dysfunction specialist since there are very effective alternatives available for treating impotence.

Other reasons you may want to consider seeing a specialist include:

  • If there has been a sudden onset of erectile dysfunction
  • You are under 50 years old
  • You have Peyronie's Disease

You may even want to start the process with a specialist even if you don't fit these criteria since a specialist is able to take the time to evaluate, understand, and get to know a patient. It would be a good idea to fully understand the physical aspects of your problem as well as the psychological issues and ramifications. Finally, you may find the atmosphere in a specialist's office to be more personal and private.

Other Options
What if you can't take one of the available oral medications or if the medications aren't working the way you'd like? You can try other effective alternatives for treating impotence.

Oral medications work for 70% of men. For many of these men, it is truly a wonder drug, giving them excellent, predictable, and long-lasting penile erections. Oral medications have revolutionized the treatment of erectile dysfunction. They have brought the issue into the open and have given many men hope.

However, for 30% of patients, the oral medications fail. For these men, the oral medication does not work well, does not work at all, or is not recommended from a medical point of view. These men are often more unhappy than before they sought treatment since they are convinced that they are alone and that there is no help for them.

But if you fall into this group you should see an erectile dysfunction specialist, since there are other excellent options for the treatment of your erectile dysfunction. Physicians who specialize in impotence are the most comfortable and confident at presenting, teaching, and performing alternate treatments.

One of the options available for the treatment of erectile dysfunction is the self-injection of medication into the penis. This often sounds scary to the patient and not particularly appealing. However, in reality, the technique does not involve a traditional syringe and does not hurt. Often, once a patient understands the reality of his treatment, he is willing to consider this highly popular and effective treatment technique.

It works like this. The medication goes into the penis with a device that's similar to the ones used by diabetics. A disposable syringe is placed on the injector, the device is placed against the side of the penis, and you press a button. A spring pushes a very thin needle into the penis and, at the same time, pushes the medication into the penis.

Most men would tell you that the "injection" doesn't hurt. They describe it as either painless or as if they have been flicked with a rubber band. The injection is extremely quick and uses a very fine needle (usually a 29 or 30 gauge). And since the side of the penis doesn't have many pain receptors, there is little sensation.

The three most common medications used for injections are papaverine, phentolamine, and prostaglandin E1. All three act by relaxing the smooth muscles and causing the arteries to dilate. This activates the trapping mechanism. Prostaglandin E1 received FDA approval in 1996 for erectile dysfunction treatment. It is currently marketed and available in prescription plans under two brand names, Caverject Impulse and Edex.

The different medications have different characteristics. The papaverine and phentolamine come in a liquid, do not need to be refrigerated, and have the least discomfort associated with them. Prostglandin E1 is a powder that is mixed with a fluid prior to use (this is due to the fact that it is stable as a powder at room temperature, but not as a liquid). Prostaglandin E1 can cause some ache. Although it is not medically concerning, it can be uncomfortable. However, in most cases, the discomfort is short-lived. Discomfort is experienced by approximately 20% of patients and is most common in patients who have neurological erectile dysfunction such as diabetes or post-radical prostatectomy.

You might want to know about possible complications from the injections. They are the development of scar tissue and the possibility of a prolonged erection, but those risks are significantly minimized when you are seeing a physician who is very experienced with this treatment option and the appropriate dosing levels. The risk of scarring is greatly reduced if the penis is compressed for five minutes after the injection and the site of the injection is varied.

Penile injections were developed approximately 30 years ago and were the second method developed for the treatment of erectile dysfunction. The first treatment method was surgical and involved the insertion of a penile implant.

Our experience with injectable medication tells us that many men are successfully treated this way. Their erections are often much stronger and more reliable than those from the oral medications. In some ways, the injection is a more spontaneous solution for treating impotence since it can be used right before a sexual encounter. With foreplay and the medication, the individual gets a good, strong erection. On top of that is this news: some studies suggest that men who use the injections on a regular basis have a high likelihood of seeing improvements in their spontaneous erections.


EVALUATING AND DIAGNOSING PENILE ERECTILE DYSFUNCTION
Your first appointment should last between 45 and 60 minutes. It should include:

History
The physician will take a thorough medical history in order to place your erectile dysfunction within a medical context. He will also take a full sexual history. This may include questions such as:

  • How long have you had the erectile dysfunction?
  • What happens when you try to have intercourse?
  • Do you have decreased rigidity?
  • Do you have difficulty maintaining your erection?
  • At what point do you lose your erection?
  • Do you wake up at any point with an erection?
  • How rigid are the nocturnal erections?
  • What is your sexual interest level (libido) like?
  • Does your penis have a curve, bend, or twist in it when it is rigid?
  • Is your ejaculation normal?
  • Is it early (premature) or delayed?
  • What is the status of your relationship?
  • How is the relationship going?
  • How is your erectile dysfunction affecting the relationship?

Information
Your physician will explain to you how erections work (in terms
that you will understand). He will explain why yours may not be working.

Physical Examination
Your physician will perform a focused physical examination on your penis and testes. In general, you should have a regular (general) physical examination either before or after your appointment.

Evaluation
Your physician will usually measure the threshold for perceiving vibration of your penis (biothesiometry). Depending on your situation, he may perform specialized testing to assess the function of your penis. This may include:

  • An ultrasound to measure the blood flow through the penis.
  • A Rigi-scan to measure the quantity and quality of your nighttime erections.
  • A blood test to measure your hormone levels.

Once your physician has completed your evaluation, he will review impotence treatment options with you. He will consider these options in light of the history, physical, and specialized testing that has been performed.


FINDING A DOCTOR FOR PENILE ERECTILE DYSFUNCTION
As you might realize, all urologists are not impotence specialists. Urologists are physicians whose training has included specialization in the surgical and medical treatment of the "genitourinary system." This includes kidneys, bladder, ureter (the tubes that connect the bladder and the kidneys), prostate, penis, and testes.

The conditions that urologists treat include cancer (kidney, bladder, prostate, testicular, and penile), stones (kidney, ureter and bladder), urination problems (incontinence, benign prostatic hypertrophy, and stricture), trauma, and infection. One of the many conditions is impotence. It is usually one of the last topics listed in a urology textbook and is given little emphasis in urology residency programs.

Because of the broad spectrum of areas covered under urology, many urologists specialize in a particular area of expertise. A general urologist must keep abreast of major advances in a multitude of fields, and it isn't realistic for him/her to truly specialize in more than one or two areas.
Each year, a small number of urology residents elect to further specialize in the area of erectile dysfunction. These physicians undergo an additional one to two years of training under the most prominent physicians in the field. They are in the best position to perform a thorough evaluation of an impotence patient. They can also structure their scheduling to accommodate the needs of their patients with erectile issues.


HERBAL ALTERNATIVES FOR TREATING PENILE ED

For many years, Yohimbe, which is found in Rubaceae and related trees, was considered an impotence remedy. The efficacy of Yohimbe has been debated for a number of years. Many studies have concluded that it is no better than a placebo. Others have concluded that it does improve erections, though modestly. It is still occasionally used for men with very modest erectile dysfunction, especially when a lack of desire and psychological factors are major issues.

A multitude of multivitamins or herbal supplements are marketed for erectile dysfunction. At the moment, there are no reliable studies that prove the efficacy of any of these medications. The supplement combinations are not regulated by the FDA, and there are those that may be not only ineffective, but also harmful. Some include hormones, which remain controversial when used by patients with normal hormone levels.

Herbal supplements must be viewed with a fair amount of caution and skepticism until there is evidence that they are safe and effective.


Penile Erectile Dysfunction:
Causes and Treatments

If you have the problem of penile erectile dysfunction you should know that a recent study estimated that 30 million men suffer from various degrees of erectile dysfunction (ED) ranging from mild to severe. It is clearly an age-related phenomenon since the prevalence of erectile dysfunction increases significantly with age.

Here are a few numbers and facts that might be illuminating to you. By the time men reach the age of 40, 5% of them are completely impotent, never achieving an erection rigid enough for penetration. Approximately 15% of men have significant problems achieving or maintaining an erection.

In 90% of cases involving men older than 35, the causes are physical in nature. In men younger than 35, the causes are usually psychological in nature. But the important thing to know is that even in the cases of those patients for whom the psychological issues are the primary factor, medical intervention can often help solve the problem.

Learn about Stendra, a new FDA approved treatment for erectile dysfunction.

On This Page


CAUSES OF PENILE ERECTILE DYSFUNCTION
If you have erectile dysfunction or male impotence there are four main causes to look into. A description of each follows:

Vascular
Blood must be able to move into the penis and stay there to maintain an erection. Arteries are the vehicles that bring blood into the penis. Any process that damages the arteries and increases the likelihood of vascular disease would make a man more likely to have erectile dysfunction. A history of arterial disease (e.g. coronary artery, heart disease, strokes, or peripheral vascular disease) indicates that the penile arteries are also at risk. In fact, erectile dysfunction may often appear before any of these more severe manifestations of vessel disease. So, you can understand that smoking is one of the most common contributing causes to erectile dysfunction. Other causes include high blood pressure (especially if it is uncontrolled), heart disease, high cholesterol, and diabetes.

Neurological
A man must have an intact neurological system in order for an erection to occur. Patients with multiple sclerosis or those who have had damage to their peripheral nerves from diabetes may also suffer from erectile dysfunction.

Hormonal
Significantly low testosterone and thyroid hormones or a very high prolactin may cause problems with erections.

Psychological
This can be an initial problem or a secondary problem. In some cases men may not achieve an erection primarily because of psychological issues. However, many men have a significant psychological response (or secondary reaction) to what is initially a primary physical problem. Once a man loses confidence in his erections, his attitude and interest level may change and diminish. At that point, he may develop increasing difficulty achieving and maintaining an erection.


PENILE ERECTILE DYSFUNCTION TREATMENT OPTIONS
How do you go about getting help? Well, if you're a patient with a straightforward case of erectile dysfunction (for example, a 65-year-old diabetic who wants rapid treatment for sexual impotence), a general urologist is often a good starting point. The doctor should take a thorough history and perform a basic evaluation. This will include a focused physical exam, measurement of penile sensation, and a basic check of hormones. Available options should be explained thoroughly. Most often, the first course of action will be to provide an oral medication. The side effects of any medication should be explained and a prescription written. There should also be follow-up exams on a regular basis. If the oral medications do not work well or cause unpleasant side effects, there are a number of other effective erectile dysfunction therapy options available.

Oral Medications
Oral medications include Viagra, Levitra, Cialis, and Stendra.

These medications should be taken approximately 60 minutes prior to engaging in sexual activity. Viagra and Levitra are effective for approximately four hours. Cialis is effective for 36 hours. Viagra is less effective if it is taken within hours of having eaten fatty foods, so those types of food should be avoided when taking Viagra. Ideally, Viagra should be taken on an empty stomach. Stendra is a pill that patients take on an as-needed basis 30 minutes before sexual activity. You should be aware that none of these drugs will affect desire in any way. They will merely make a penis respond more quickly and remain firmer when it is stimulated and aroused.

The maximum dosage is 20 mg of Levitra or Cialis and 100 mg of Viagra. This should not be exceeded in any 24-hour period. Even if a lesser dosage is used, it should only be used once in a 24-hour period.

Although all three of these medications work slightly differently, they basically function the same way. They block an enzyme that normally prevents erections from occurring. When a man is sexually aroused, nitric oxide is released, which causes a cascade of biochemical reactions: the blood vessels and tissues of the penis relax and dilate, allowing blood to rush in and an erection to occur. These oral medications block the enzyme PDE5, which reverses this cascade.

Please note that all of these drugs are contraindicated for men who are:

  • Currently using nitrates or have Retinitis Pigmentosis

Other men who may not take the available oral medications are those with a predisposition to potentially hazardous cardiovascular events. These conditions include:

  • Unstable angina
  • Congestive heart failure
  • Taking multiple antihypertensive drugs
  • MI, heart attack, CVA (stroke), or life threatening arrhythmia within the last six months.
  • Hypotension, decreased blood pressure (BP <90/50) or hypertension, increased blood pressure (BP>170/110)
  • Patients on alpha blocks for high blood pressure or prostrate problems should not take Levitra or Cialis

If you fall into the above categories you should see an erectile dysfunction specialist since there are very effective alternatives available for treating impotence.

Other reasons you may want to consider seeing a specialist include:

  • If there has been a sudden onset of erectile dysfunction
  • You are under 50 years old
  • You have Peyronie's Disease

You may even want to start the process with a specialist even if you don't fit these criteria since a specialist is able to take the time to evaluate, understand, and get to know a patient. It would be a good idea to fully understand the physical aspects of your problem as well as the psychological issues and ramifications. Finally, you may find the atmosphere in a specialist's office to be more personal and private.

Other Options
What if you can't take one of the available oral medications or if the medications aren't working the way you'd like? You can try other effective alternatives for treating impotence.

Oral medications work for 70% of men. For many of these men, it is truly a wonder drug, giving them excellent, predictable, and long-lasting penile erections. Oral medications have revolutionized the treatment of erectile dysfunction. They have brought the issue into the open and have given many men hope.

However, for 30% of patients, the oral medications fail. For these men, the oral medication does not work well, does not work at all, or is not recommended from a medical point of view. These men are often more unhappy than before they sought treatment since they are convinced that they are alone and that there is no help for them.

But if you fall into this group you should see an erectile dysfunction specialist, since there are other excellent options for the treatment of your erectile dysfunction. Physicians who specialize in impotence are the most comfortable and confident at presenting, teaching, and performing alternate treatments.

One of the options available for the treatment of erectile dysfunction is the self-injection of medication into the penis. This often sounds scary to the patient and not particularly appealing. However, in reality, the technique does not involve a traditional syringe and does not hurt. Often, once a patient understands the reality of his treatment, he is willing to consider this highly popular and effective treatment technique.

It works like this. The medication goes into the penis with a device that's similar to the ones used by diabetics. A disposable syringe is placed on the injector, the device is placed against the side of the penis, and you press a button. A spring pushes a very thin needle into the penis and, at the same time, pushes the medication into the penis.

Most men would tell you that the "injection" doesn't hurt. They describe it as either painless or as if they have been flicked with a rubber band. The injection is extremely quick and uses a very fine needle (usually a 29 or 30 gauge). And since the side of the penis doesn't have many pain receptors, there is little sensation.

The three most common medications used for injections are papaverine, phentolamine, and prostaglandin E1. All three act by relaxing the smooth muscles and causing the arteries to dilate. This activates the trapping mechanism. Prostaglandin E1 received FDA approval in 1996 for erectile dysfunction treatment. It is currently marketed and available in prescription plans under two brand names, Caverject Impulse and Edex.

The different medications have different characteristics. The papaverine and phentolamine come in a liquid, do not need to be refrigerated, and have the least discomfort associated with them. Prostglandin E1 is a powder that is mixed with a fluid prior to use (this is due to the fact that it is stable as a powder at room temperature, but not as a liquid). Prostaglandin E1 can cause some ache. Although it is not medically concerning, it can be uncomfortable. However, in most cases, the discomfort is short-lived. Discomfort is experienced by approximately 20% of patients and is most common in patients who have neurological erectile dysfunction such as diabetes or post-radical prostatectomy.

You might want to know about possible complications from the injections. They are the development of scar tissue and the possibility of a prolonged erection, but those risks are significantly minimized when you are seeing a physician who is very experienced with this treatment option and the appropriate dosing levels. The risk of scarring is greatly reduced if the penis is compressed for five minutes after the injection and the site of the injection is varied.

Penile injections were developed approximately 30 years ago and were the second method developed for the treatment of erectile dysfunction. The first treatment method was surgical and involved the insertion of a penile implant.

Our experience with injectable medication tells us that many men are successfully treated this way. Their erections are often much stronger and more reliable than those from the oral medications. In some ways, the injection is a more spontaneous solution for treating impotence since it can be used right before a sexual encounter. With foreplay and the medication, the individual gets a good, strong erection. On top of that is this news: some studies suggest that men who use the injections on a regular basis have a high likelihood of seeing improvements in their spontaneous erections.


EVALUATING AND DIAGNOSING PENILE ERECTILE DYSFUNCTION
Your first appointment should last between 45 and 60 minutes. It should include:

History
The physician will take a thorough medical history in order to place your erectile dysfunction within a medical context. He will also take a full sexual history. This may include questions such as:

  • How long have you had the erectile dysfunction?
  • What happens when you try to have intercourse?
  • Do you have decreased rigidity?
  • Do you have difficulty maintaining your erection?
  • At what point do you lose your erection?
  • Do you wake up at any point with an erection?
  • How rigid are the nocturnal erections?
  • What is your sexual interest level (libido) like?
  • Does your penis have a curve, bend, or twist in it when it is rigid?
  • Is your ejaculation normal?
  • Is it early (premature) or delayed?
  • What is the status of your relationship?
  • How is the relationship going?
  • How is your erectile dysfunction affecting the relationship?

Information
Your physician will explain to you how erections work (in terms
that you will understand). He will explain why yours may not be working.

Physical Examination
Your physician will perform a focused physical examination on your penis and testes. In general, you should have a regular (general) physical examination either before or after your appointment.

Evaluation
Your physician will usually measure the threshold for perceiving vibration of your penis (biothesiometry). Depending on your situation, he may perform specialized testing to assess the function of your penis. This may include:

  • An ultrasound to measure the blood flow through the penis.
  • A Rigi-scan to measure the quantity and quality of your nighttime erections.
  • A blood test to measure your hormone levels.

Once your physician has completed your evaluation, he will review impotence treatment options with you. He will consider these options in light of the history, physical, and specialized testing that has been performed.


FINDING A DOCTOR FOR PENILE ERECTILE DYSFUNCTION
As you might realize, all urologists are not impotence specialists. Urologists are physicians whose training has included specialization in the surgical and medical treatment of the "genitourinary system." This includes kidneys, bladder, ureter (the tubes that connect the bladder and the kidneys), prostate, penis, and testes.

The conditions that urologists treat include cancer (kidney, bladder, prostate, testicular, and penile), stones (kidney, ureter and bladder), urination problems (incontinence, benign prostatic hypertrophy, and stricture), trauma, and infection. One of the many conditions is impotence. It is usually one of the last topics listed in a urology textbook and is given little emphasis in urology residency programs.

Because of the broad spectrum of areas covered under urology, many urologists specialize in a particular area of expertise. A general urologist must keep abreast of major advances in a multitude of fields, and it isn't realistic for him/her to truly specialize in more than one or two areas.
Each year, a small number of urology residents elect to further specialize in the area of erectile dysfunction. These physicians undergo an additional one to two years of training under the most prominent physicians in the field. They are in the best position to perform a thorough evaluation of an impotence patient. They can also structure their scheduling to accommodate the needs of their patients with erectile issues.


HERBAL ALTERNATIVES FOR TREATING PENILE ED

For many years, Yohimbe, which is found in Rubaceae and related trees, was considered an impotence remedy. The efficacy of Yohimbe has been debated for a number of years. Many studies have concluded that it is no better than a placebo. Others have concluded that it does improve erections, though modestly. It is still occasionally used for men with very modest erectile dysfunction, especially when a lack of desire and psychological factors are major issues.

A multitude of multivitamins or herbal supplements are marketed for erectile dysfunction. At the moment, there are no reliable studies that prove the efficacy of any of these medications. The supplement combinations are not regulated by the FDA, and there are those that may be not only ineffective, but also harmful. Some include hormones, which remain controversial when used by patients with normal hormone levels.

Herbal supplements must be viewed with a fair amount of caution and skepticism until there is evidence that they are safe and effective.


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