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Erectile Dysfunction (ED)

Problems getting and maintaining an erection can be caused by psychological issues, medical conditions, or medication you’re taking.
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Last updated August 6, 2021

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What is erectile dysfunction?

Erectile dysfunction (ED), also known as impotence, is a very common condition. It occurs when an erection doesn’t last long, is too weak, or doesn’t happen at all. ED affects approximately 40% of men at age 40 and nearly 70% of men at age 70, according to the Cleveland Clinic. It can happen to men of all ages but becomes more common as men age.

Many men who have ED feel embarrassed and don’t want to talk about it. But it’s very important to tell your doctor if you have ED because it can be caused by conditions that should be treated, including psychological issues and medical conditions such as heart disease and diabetes.

Doctors treat the condition all the time, so don’t feel ashamed to report it. There are many effective treatments for ED, including medication, psychotherapy, and surgery.

Pro Tip

ED is not just a result of aging—and neither should it just be accepted. Your providers will appreciate you being honest and open in talking about this problem. We will not judge you and are happy to help. —Dr. Jason Chandrapal

Common causes of erectile dysfunction

There are three main categories of causes of ED:

  • Medical (such as heart problems)
  • Pharmacologic (meaning ED is caused by medications or other treatments)
  • Psychological (such as depression or anxiety)

Getting the right diagnosis is important because it determines the best treatment and whether you need any other testing. Nearly 90% of cases of ED are caused by medical or pharmacologic problems, while the rest are due to psychological issues.

Medical

Heart disease

When you have heart disease, it can also affect smaller blood vessels in your body, like the ones that supply blood to the penis. These blood vessels become narrowed and can lead to problems getting an erection. If you’re middle-aged and experiencing ED, your doctor may test you for heart problems, since ED may be the first sign of a heart condition.

Other signs of heart disease

Diabetes

Diabetes, like heart disease, can narrow small blood vessels in the penis and cause ED. It can also injure the nerves in the penis, which play an essential role in getting an erection. You may be tested for diabetes if you have ED, especially if you’re middle-aged and have other symptoms.

Other signs of diabetes

Testosterone deficiency

ED and low libido (decreased sex drive) can be signs of testosterone deficiency, a condition that becomes more common as you age. Besides the age-related decline in testosterone, low levels of the hormone can be caused by infection, trauma, or medications such as chemotherapy drugs, opioids, and corticosteroids. It’s also linked to certain medical conditions, like anemia and obesity.

Testosterone deficiency is diagnosed with blood tests. If you have testosterone deficiency, you can be treated with testosterone replacement therapy.

Other signs of testosterone deficiency

Post-surgery

If you’ve had pelvic surgery, such as treatment or removal of your prostate, or radiation, there’s a chance you could develop ED because the nerves that connect to the penis may be affected during the procedure.

Pro Tip

Important questions to ask your doctor: Could ED be a sign of something more, like early heart problems? What is the next step if this treatment doesn’t or stops working? —Dr. Chandrapal

Psychological

When ED is caused by a psychological issue, you’ll still be able to have an erection when you wake up in the morning or when you masturbate. This isn’t the case in other causes of ED, where you may never experience an erection.

Depression

When you have depression, you may lose interest in sex, which can make you unable to have an erection even if you try. In addition, ED can be a side effect of some medications for depression.

Other signs of depression

  • Feeling tired all the time
  • Not finding pleasure in activities
  • Inability to concentrate
  • Thoughts of hurting or killing yourself

Performance anxiety

Performance anxiety is when you can’t get an erection because you’re nervous about poor performance during sex. You can also experience performance anxiety if you’re worried that you won’t get an erection.

Pharmacologic (caused by drugs or medicine)

Alcohol

Alcohol is the substance that most commonly weakens erections. Drinking less can improve your chance of getting an erection.

Stimulant drugs (cocaine, crack, ecstasy, amphetamines, methamphetamine)

These drugs inhibit the nerves that allow you to have an erection. Combining them with alcohol makes your chance of getting an erection even lower.

Antidepressants

Antidepressants, especially those in the SSRI (selective serotonin reuptake inhibitor) category, can reduce libido and increase your chance of experiencing ED. The problem is completely reversible if you stop taking the medication.

Hair regrowth treatment

Medicines like finasteride (Propecia) and dutasteride (Avodart), which are often used to treat baldness in men, can inhibit a hormone called DHT (dihydrotestosterone). This leads to ED in about 1% to 2% of men who use these medications. The longer you take them, the greater your chance of developing ED.

Natural ways to improve ED

ED can sometimes be improved by making lifestyle changes like these:

Quitting smoking. Smoking can affect the blood vessels in your body, including the ones that supply blood for erections. Many smokers see an improvement in their ED when they quit the habit. If you haven’t been able to give up smoking on your own, ask your doctor about over-the-counter and prescription medications that may help.

Relaxation techniques such as meditation and yoga. These practices can help treat some of the causes of ED, such as performance anxiety and depression. Even something as simple as deep breathing may be useful.

Exercise and weight loss. Regular exercise has been shown to improve erectile function in a variety of ways, such as by lowering your cholesterol levels and reducing excess weight. Kegel exercises, which strengthen the muscles of your pelvic floor, can also help you regain normal erectile function.

Being honest with your partner. ED can be hard on a relationship, so it’s important to talk about what you’re experiencing and why it may be happening. It’s also a good idea to reassure your partner that they aren’t to blame and discuss other ways to give each other pleasure while you’re being treated for ED.

Medical treatment options for ED

The first step in treating ED is to determine what caused it. If it’s something medical, then the best thing to do is to treat the illness. For example, if the cause is diabetes, then you should get treatment to improve your blood sugar levels. If a psychological issue is causing ED, seeing a mental health professional may improve your ability to get an erection.

There are also medicines that can help you have an erection. All of them are available only by prescription.

Note that no OTC medications, herbal remedies, or supplements that claim to treat ED have been approved by the FDA to be safe and effective. These products may not help you, and they may even be harmful. It’s always best to see your doctor if you have ED.

Sildenafil (Viagra) and similar drugs

Sildenafil (Viagra) is part of a group of drugs called PDE-5 inhibitors. Others include tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra). They are taken by mouth, and work by increasing the amount of blood to your penis, leading to a stronger and longer-lasting erection.

PDE-5 inhibitors don’t force you to have an erection; instead, they allow you to have one when you want to. If you have a psychological cause of your ED, these medicines may not be helpful.

The main risk of PDE-5 inhibitors is that they may cause an erection that lasts too long (4 to 6 hours or more) known as a priapism. If this happens, you’ll need urgent medical attention because if the erection lasts beyond 4 to 6 hours, it can cause permanent erectile damage. These medicines aren’t safe for certain people, so it’s important to ask your doctor if they’re appropriate for you.

Testosterone replacement therapy

If you’re diagnosed with testosterone deficiency, testosterone replacement therapy may be helpful. Testosterone can be given as a pill or injection or via a gel or patch applied to your skin. Your doctor will need to monitor you to make sure your testosterone level doesn’t get too high. Taking testosterone without a prescription is risky and not recommended.

Dr. Rx

Treatments generally occur in a stepwise fashion from least to most invasive. It may take some time to find the right treatment, but we will find the right one eventually. And don’t underestimate the power of improving your diet, exercise, and mindfulness in helping ED. You must take an active role in your treatments! —Dr. Chandrapal

Psychotherapy

If there is a psychological cause to your ED, then the best treatment is talk therapy. Talking to a mental health professional can help relieve performance anxiety and treat depression. If you have depression, combining talk therapy with medication can improve your libido and make it easier to get an erection.

Intracavernosal injections (ICI)

Intracavernosal injections (ICI) medications are prescribed when oral ED medications are not helping. They are PDE-5 inhibitors that are injected directly into the shaft of the penis. The medication should begin to work 5 to 10 minutes after injection and should last 10 to 30 minutes.

Before using at home, you will try it out in a doctor's office to learn how to do it and make sure you don’t have an allergic reaction to it. There are many medications within the ICI class including alprostadil, Bi-mix, and Tri-mix. ICI should not be used in people who are prone to priapism, significant penile angulation, or those with a penile implant.

Intraurethral tablets

Alprostadil (Muse) tablets are another option if oral PDE-5 inhibitors don’t work. It is directly inserted into your urethra (the tube you urinate from) and dissolves into the erectile tissue. You should take alprostadil 5 to 20 minutes before sex. The most common side effect is a burning or painful penis. Like PDE-5 inhibitors, alprostadil can cause an erection that lasts too long.

Penis pump

A penis pump is a suction device that can help you get an erection by increasing blood flow to your penis. But the effectiveness varies and the erection may not last long. They are available by prescription and over the counter, with both versions having similar effectiveness. The device may cause some penile pain.

Penile implant

If your ED doesn’t respond to other treatments, your doctor may recommend getting a penile implant. In this surgery, a reservoir pump is placed under the wall of your abdomen and inflatable cylinders are inserted into the shaft of your penis. When the pump is activated, fluid from the reservoir fills the cylinders and causes an erection. To get rid of the erection, deactivate the pump and the fluid from the cylinders return to the reservoir.

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Dr. Chandrapal is the current Interprofessional Advanced Clinical Simulation Fellow at the VA medical center in Durham, NC. Prior to his current position he was a urology resident at Duke University. Originally from Houston, TX he went to undergrad at the University of Texas in Austin, followed by a masters degree from the University of Texas Health Science Center in San Antonio, and medical schoo...
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