What is Erectile Dysfunction?
Erectile dysfunction (ED) is a condition where a man has trouble getting or maintaining an erection firm enough for intercourse. You may have heard ED called impotence in the past, but that term isn’t used as often as it used to be.
It’s not unusual to have occasional ED. It can be caused by many temporary, everyday factors like stress, being very tired, relationship problems, or drinking too much alcohol. For about one in ten men, however, ED becomes a long-term problem.
When ED happens frequently or gets progressively worse, there may be an underlying problem that needs treatment. Sometimes, treating the underlying problem also stops ED from happening. Some cases of ED may need to be treated with medication or other ED treatments.
Some common causes of ED include:
- Blood flow problems
- Emotional issues or stress
- Nerve damage
- Other health problems like heart disease or diabetes
ED can cause embarrassment, stress on relationships, and problems with self-confidence, but it doesn’t have to. Many cases can be treated successfully.
How do Erections Work?
A penis is ordinarily soft and responds to temperature or stress by growing or shrinking as blood flow fluctuates.
An erection is initiated when a thought or sensory input (touch, visual, smell, or sound) triggers the brain to relax the blood vessels in the penis. Blood flows into two parallel chambers of spongy muscle tissue in the penis and is trapped there. The blood pressure in the chambers causes an erection. The scientific term for the two chambers is corpus cavernosa.
During an orgasm, nerve signals tell the muscle tissue to contract, releasing the blood and softening the erection. The blood returns to circulation, and the penis returns to pre-erection size.
Symptoms of Erectile Dysfunction
Each case is different, but symptoms of ED might include:
- Difficulty getting an erection more than 50% of attempts
- Difficulty maintaining an erection firm enough to have sex more than 50% of attempts
- Decreased sexual desire
- Low self-esteem
- Stress on the man and/or his relationship
Many people think that ED is an unavoidable part of aging, but it doesn’t have to be. Occasional ED is normal, but ED that happens often or causes problems with your relationships isn’t. ED can also be a symptom of a serious medical condition like cardiovascular disease.
If you have ED, it’s important to talk to your doctor about your health. If it’s caused by a health condition, seeking treatment could not only improve the ED – it could be life-saving.
What Causes Erectile Dysfunction?
An erection is a carefully coordinated process between the brain, nerves, blood vessels, hormones, muscles, and state of mind. A problem at any point in the process can interfere with a man’s ability to achieve or maintain an erection. There are many physical and non-physical factors that may contribute to ED, including:
- Blood flow problems – conditions like heart disease and hardened arteries can reduce blood flow in and out of the penis.
- Cancer treatment – surgical or radiation treatments for bladder, colorectal, or prostate cancer can affect how the penis functions.
- Drugs – cocaine, methadone, opiates, amphetamines, marijuana, barbiturates, nicotine, and alcohol can all cause ED.
- Injury – trauma to the spine, pelvic area, or penis can affect functionality.
- Medications – some common medications used to treat health conditions cause ED as a side effect. This includes:
- Parkinson’s disease medications
- Diuretics (water pills)
- Nerve problems – damaged nerves or problems with nerve signals can stop the physical process of developing an erection.
- Psychological conditions – conditions like anxiety, depression, or stress can keep the mind from doing its part to trigger an erection.
- Physical problems – health issues like metabolic syndrome, obesity, sleep disorders, multiple sclerosis, and many more
- Sedentary lifestyle – lack of exercise and movement can lead to ED or problems that cause ED, like heart disease and obesity.
How Do Doctors Diagnose Erectile Dysfunction?
Diagnosis begins with your health history, a physical exam, and a discussion about your symptoms, medications, health history, and sexual history to narrow down a cause.
Some of the questions might feel embarrassing or too personal, but it’s essential to answer them honestly to give your doctor all the information necessary to figure out what’s causing your ED. Finding the cause is the first step in treating it. Remember that nothing you say will seem shocking or unusual to your doctor – they’ve seen and heard it all.
Your doctor may need to know about:
- Medications you take, including prescriptions, over-the-counter, herbal supplements, and recreational drugs.
- The symptoms of your ED, when they started, and the circumstances in which it occurs.
- Duration, frequency, and quality of your erections.
- The circumstances in which your erections are strongest or weakest.
- If you experience nighttime or morning erections.
- If you have any unusual symptoms like lumps, bumps, or a curve in the penis.
Emotional and mental health
He may also ask questions about your emotional health and relationships, like:
- How erectile dysfunction is affecting your life, relationships, and enjoyment of sex.
- Psychological problems like depression or anxiety.
- If there have been recent changes in your relationship quality or status.
- How satisfied you are with your sex life, and if that has changed recently.
- If you take any medications for your mental health.
- Are you under a significant amount of stress or have you experienced any recent upsetting events.
Your physical exam will include an overall look at your health as well as the health of your genitals. Your doctor may also focus on heart health because cardiovascular conditions can affect blood flow to the genital area. An exam may include:
- Blood pressure
- Heart rate and rhythm
- Exam of the penis and testicles
- Pulses at various locations on your body
- Rectal prostate exam, depending on your age and other risk factors
The results of your physical exam and answers from your health history may determine which tests your doctor will order. Tests that can help diagnose ED may include:
- Complete blood count (CBC) – to check for conditions like anemia
- Liver and kidney function tests – to check that both are functioning correctly
- Lipid profile – to measure cholesterol
- Fasting blood glucose or A1C – to check for diabetes
- Thyroid function test – the thyroid helps regulate sex hormones
- Hormone levels – Prolactin or testosterone are sex hormones
- Urinalysis – for information about sugar, protein, and testosterone levels
- Ultrasound (penile doppler) – to look for hardening of the arteries, blood flow problems, leaky veins, and scar tissue
- Bulbocavernosus reflex – to check penile nerve sensation
- Nocturnal penile tumescence (NPT) – to measure the number of erections while sleeping
- Penile biothesiometry – to evaluate nerve function and sensitivity
- Vascular stimulant injection – to cause an erection
- Pelvic imaging – arteriography, CT, or MRI, typically only if you have a history of cancer or trauma
Erectile Dysfunction Treatment
Because ED is often caused by blood-flow problems, taking care of your heart health is always important. Making heart-healthy diet and exercise choices can help prevent or improve ED.
When ED needs to be treated, your doctor may recommend one or more treatments. Most treatments are temporary, except for implants, and only used when you want to have sex. They provide a workaround for the symptoms of ED but don’t cure it. In many cases, treating an underlying health condition or making lifestyle changes will improve ED.
If one type of treatment doesn’t work for you, your doctor may adjust the treatment or move on to another type. Every man is different. It may be necessary to try several treatments before finding the right one or the right combination of treatments for you. It’s not unusual to need physical treatment and therapy.
There are many lifestyle factors that put a man at higher risk of developing ED. Making healthier lifestyle choices in areas that you can change might reduce your risk of developing ED and improve current symptoms. Lifestyle risk factors that can contribute to ED include:
- Drinking excessive amounts of alcohol
- Lack of exercise
- Poor diet
- Using illicit drugs
For overall better health, eat a healthy diet, exercise regularly, limit alcohol, and avoid street drugs and smoking.
Some medications prescribed for various medical conditions can affect your ability to get and maintain an erection. They can interfere with the nerves necessary to trigger an erection.
Some common medications that can cause erectile dysfunction are:
- Cancer treatments
- Drugs to lower blood pressure
If your doctor believes your current medications may be causing ED, you may be prescribed alternate medications. However, It’s important for your health and safety to continue to take your medications as prescribed until you’ve talked to your doctor.
If you believe one or more of your medications is causing ED, talk to your doctor before you stop taking them. Suddenly stopping can have uncomfortable or even dangerous effects. Additionally, depending on the medical reason you are taking them, you may leave a dangerous medical condition untreated. Your doctor can help you find a different medication or will recommend a schedule to safely stop taking the medicine.
Medications called phosphodiesterase-5 (PDE5) inhibitors work by helping increase the blood flow to the penis. You may have heard of these medications in radio or TV ads.
FDA-approved PDE5 inhibitors are:
- Viagra® (sildenafil)
- Levitra® (vardenafil)
- Cialis® (tadalafil)
- Stendra® (avanafil)
When blood flow problems are the cause of ED, these medications typically have a success rate of about 70%.
Erectile dysfunction pills can’t be taken with nitrates, which are prescribed for some heart problems, because nitrates widen blood vessels. Taking ED medications with nitrates can cause your blood pressure to suddenly become dangerously low. You should always talk to your doctor before trying one of these medications.
ED medications may cause side effects like congestion, flushing, headaches, indigestion, muscle aches, and temporary vision changes. Side effects are typically mild and don’t last long. Viagra can cause an unusual side effect of temporarily giving your vision a blue-green tint.
Low levels of testosterone (Low T or hypogonadism) can cause ED. Testosterone replacement therapy may help with erections alone or in combination with other medications.
Hormone replacement therapy for Low T can be given in multiple forms:
- Topical gels that are applied to the skin of the thighs, arms, or abdomen.
- Pellets that are implanted under the skin release testosterone slowly over 4-6 months.
- Injections that are given regularly at home or in a doctor’s office.
Counseling or Therapy
Counseling or sex therapy can help in many cases of ED. Psychological stress or conditions can be both a cause of and a side effect of ED. Therapy can help either way.
A sex therapist can help you and your partner deal with the emotional causes and effects of ED together.
Penile injections are also called intracavernosal injections (ICI). In ICI, you self-inject a medication called alprostadil into your penis to cause an erection. It can also be combined with other medicines. It works by relaxing the blood vessels to allow blood into the penis.
The thought of injecting your penis might be alarming, but the needle is tiny, and you will be taught how to inject yourself safely, how much medication to inject, and how to change your dose if needed. The success rate of self-injection for ED is nearly 85%. It is often the next step after trying oral medications.
Injection therapy typically triggers an erection that lasts 20-30 minutes but can sometimes last too long after orgasm. An erection that lasts more than an hour can be reversed in your doctor’s office. Ejections that last longer than two to four hours can cause permanent damage and untreatable ED. If you have a prolonged erection, go to the emergency room for treatment or you may risk permanently losing the ability to have an erection.
Intraurethral (IU) medication
An intraurethral treatment uses the same medication as penile injections, alprostadil, but in the form of a small pellet that you insert into the urethra. It has the benefit of not requiring a needle but is not as effective as an injection.
Like an alprostadil injection, a pellet can cause a prolonged erection that may need medical attention. A common side effect of intraurethral alprostadil is a burning feeling in the penis.
A vacuum device has a tube that seals over your penis and a pump that removes air from the tube, causing a vacuum. The vacuum forces blood into your penis, causing an erection lasting up to 30 minutes. Putting a ring around the base of the penis keeps the blood in place when you remove the vacuum tube. Vacuum devices are also called penis pumps. They have a success rate of about 75%.
Surgery is typically only an option when all other options have failed. There are two types of surgery for ED.
Penile revascularization surgery
In cases of severe pelvic trauma where blood vessels have been damaged, penile revascularization surgery can return blood flow to the penis using a process that is similar to cardiac bypass surgery. Essentially, a donor artery from the patient’s own body is transplanted to take over for damaged blood vessels. This type of surgery may be a good option for younger men but isn’t recommended for men whose erectile dysfunction is caused by hardened arteries.
Penile implant surgery uses rods or cylinders to give the penis the firmness needed for an erection. This type of surgery is typically very successful. It can be a treatment option when nerve damage causes erectile dysfunction. Implants have the benefit of giving the man control of the erection, while still looking and feeling like a natural erection. Sometimes the man can even control the size and firmness of the erection. They allow more spontaneity than treatments that take time to take effect and typically do not change the sensation or orgasm.
- Semi-rigid implants are made from bendable rods, typically silicon, that can be bent upward for sex and downward for urination.
- Inflatable implants use fluid-filled cylinders and a pump that inflates or deflates the cylinders to create an erection. The pump is implanted in the scrotum. When an erection is desired, the pump is manually activated, which fills the cylinders with saline, mimicking blood flow. This creates an erection with a normal appearance. After intercourse, a release valve causes the saline to move back into its reservoir (which is implanted in the abdomen).
Like any surgery, there are risks with penile implants that your doctor will discuss with you ahead of time. If you experience an infection or mechanical malfunction after surgery, you may need further surgery. If an implant needs to be removed, other ED treatments might not work.
What to Expect with Penile Implant Surgery
Like any surgery, you must be free of infections and may need to stop certain medications a few days before the procedure. Surgery is done under anesthesia and typically only requires one small incision. The incision might be where the penis joins the abdomen or where it joins the scrotum. There is very little blood loss, and no tissue is removed. It may be a same-day procedure or may require an overnight stay.
After surgery, most men will need pain relief for the first week or two. You may experience pain, swelling, and bruising for several weeks and will need to limit physical activity for about a month.
Sex is usually possible about eight weeks after the procedure.
How can I tell what’s causing my ED?
It’s not possible to tell for sure without a medical assessment, but most men with ED have an underlying physical condition. Your health history may give you clues. If you have a chronic health condition like diabetes or heart disease, chances are good that it’s contributing to your ED.
Likewise, if you’re in the middle of a very stressful time in your life or have a history of a mental health disorder like depression or anxiety, that may also contribute. The only way to know for sure, and to find the right treatment, is to talk to your doctor.
Can worrying about sexual performance cause ED?
Yes. Your brain is where all erections start. Anxiety over ED can make it worse. Education and treatment can help you overcome performance anxiety.
Are there over-the-counter supplements that can help ED?
There are supplements on the market that claim to treat ED, but most haven’t been tested or proven safe. The FDA has recently published warnings about tainted or unapproved ED products. Many contain hidden drug ingredients or have unsafe doses. These are not FDA approved, not regulated, and not worth the risk to your health.
Are there clinical trials for ED?
There may be ongoing clinical trials for restorative or regenerative treatments, including extracorporeal shock wave therapy (ESWT), stem cell injections, and autologous platelet-rich plasma (APRP) injections. Talk to your doctor about your current treatment before starting a clinical trial.
Can I use more than one ED treatment at a time?
Yes. In fact, it’s common to prescribe more than one treatment. For your health and safety, it’s important that you talk to your doctor before trying any new treatment.
I think a medication is causing my ED. Can I stop taking it?
It’s possible your medication is causing your ED, but it’s important to talk to your doctor before stopping a medication or changing how you take it. Talk to your doctor about your concerns and ask if there is an alternate option for your treatment. If you must stay on the medication, there are treatments that can help your ED.
Does COVID cause erectile dysfunction?
One recent study indicated that COVID-19 may cause erectile dysfunction. The reasons are not clear at this time, but early evidence shows that men with COVID-19 are more likely to be diagnosed with ED. Further studies are needed to fully understand the impact COVID-19 has on ED.
Questions to ask your doctor
It can be difficult to know what questions to ask your doctor when you’re in the office. Your doctor will share a lot of information with you. Here are some questions you might ask:
- What is ED?
- What caused my ED?
- What tests can help diagnose the cause of my ED, and what are they looking for?
- Could my heart health be to blame? Can you check it for me?
- What can I do at home to help improve my symptoms?
- What treatments are available?
- What treatment do you think will help me?
- How will that treatment help, and what are the side effects or risks?
- How long should I give it to work?
- What should I do if my treatment doesn’t help?
- What happens if my treatment causes a prolonged erection? When should I get medical help?
Our caring staff and urologists in Myrtle Beach, Carolina Forest, Conway, Georgetown, Little River, Loris, and Murrells Inlet are experts in diagnosing and treating ED.
If you’re concerned about erectile dysfunction and need a urologist in South Carolina, call for an appointment at 843-347-2450.