Erectile Dysfunction

Erectile Dysfunction - Causes, Symptoms, Diagnosis and Treatment

What is Erectile Dysfunction (ED)?

Erectile dysfunction (ED) is the inability to achieve and sustain an erection suitable for sexual intercourse. Reliable estimates suggest that one of every ten men will suffer from ED at some point during his lifetime, and it is important to understand that in the great majority of cases, ED is a symptom of an underlying problem. This condition is not considered normal at any age and may be associated with other problems that interfere with sexual intercourse, such as lack of desire and problems with orgasm and ejaculation.

How common is erectile dysfunction?

It is estimated that approximately one in 10 adult males will suffer from ED on a long-term basis.

Many men do experience the occasional failure to achieve erection, which can occur for a variety of reasons, such as drinking too much alcohol, stress, relationship problems, or from being extremely tired.

The failure to achieve an erection less than 20 percent of the time is not unusual and typically does not require treatment. However, the failure to achieve an erection more than 50 percent of the time generally means that there is a problem and treatment is required.

ED does not have to be a part of getting older. While it is true that some older men may need more stimulation, they should still need to be able to achieve an erection and enjoy intercourse.

What causes erectile dysfunction?

ED can be caused by a number of factors, including:

  • Vascular disease: blood supply to the penis can become blocked or narrowed as a result of vascular disease such as atherosclerosis (hardening of the arteries).
  • Neurological disorders (such as multiple sclerosis): nerves that send impulses to the penis can become damaged from stroke, diabetes, or other causes.
  • Psychological states: these include stress, depression, lack of stimulus from the brain, and performance anxiety.
  • Trauma: an injury could contribute to symptoms of ED.

Chronic illness, certain medications, and a condition called Peyronie's disease can also cause ED. Operations for the prostate, bladder, and colon cancer may also be contributing factors.

Medications That May Cause Erectile Dysfunction

Erectile dysfunction (ED) is a common side effect of a number of prescription drugs. While these medications may treat a disease or condition, in doing so they can affect a man's hormones, nerves or blood circulation, resulting in ED or increasing the risk of ED. If you experience ED and think that it may be a result of the medication you are using, DO NOT stop taking the medication. If the problem persists, contact your doctor and he or she may be able to prescribe a different medication. Common medications that may list ED as a potential side effect include:

  • diuretics
  • antihypertensives
  • antihistamines
  • antidepressants
  • Parkinson's disease drugs
  • antiarrhythmics
  • tranquilizers
  • muscle relaxants
  • nonsteroidal anti-inflammatory drugs
  • histamine H2-receptor antagonists
  • hormones
  • chemotherapy medications
  • prostate cancer drugs
  • anti-seizure medications

Other substances or drugs that can cause or lead to ED include these recreational and frequently abused drugs:

  • alcohol
  • amphetamines
  • barbiturates
  • cocaine
  • marijuana
  • methadone
  • nicotine
  • opiates

These drugs not only affect and often suppress the central nervous system, but can also cause serious damage to the blood vessels, leading to permanent ED.

Can ED be prevented?

For people who are at risk of developing ED due to personal behavior, steps may be taken to try to prevent its occurrence. However, other causes may not be preventable.

There are now a number of epidemiologic studies that suggest a link between ED and obesity, high cholesterol, hypertension, diabetes, and heart disease.

The following recommendations may play a role in the prevention of ED or improvement (if the problem is already present):

  • Eat a healthful diet. A diet that limits saturated fat intake and includes several portions of fruits, vegetables, and whole grains can benefit men with ED.
  • Reduce cholesterol. High cholesterol can harden, narrow, or block the arteries (atherosclerosis) leading to the penis. Men can lower cholesterol through diet, exercise, and medication.
  • Maintain a healthy weight.
  • Exercise regularly. Regular exercise may reduce the risk of ED. Choose exercises that you enjoy and will make a regular part of your day. In addition to reducing the risk of ED, exercise also can help you manage stress. Check with your doctor before starting any exercise program.

What doctors treat erectile dysfunction?

The type of medical specialist who treats ED will depend on the cause of the problem. Based on your family's medical history, as well as your own medical history and current health, your doctor may treat you with oral medications (Viagra, Levitra, Cialis) or other non-surgical options (vacuum device, injections, etc.). If these options fail, you may be referred to a urologist who can assist with surgical treatment options. Your doctor may also refer you to a psychologist specializing in sexual dysfunction, if need be. What should I do if I am having problems achieving/maintaining an erection?

What should I do if I am having problems achieving/maintaining an erection?

If you suspect you have erectile dysfunction, please see your primary care physician or a urologist. He or she can perform a variety of tests to identify what is causing your problem and refer you to a specialist if needed. Once the cause is identified, there are several treatment options to consider.

Does insurance cover erectile dysfunction treatment?

Insurance coverage for ED depends on the type of treatment prescribed and whether your insurance covers sexual dysfunction at all. If there is a documented medical condition that is shown to be causing ED, insurance often covers the cost. Sex therapy and medications that are not approved by the FDA generally are not covered.

Speak with your insurance provider to determine if the option you are considering will be covered.

How is erectile dysfunction treated?

There are many different ways ED can be treated, including: oral medications, sex therapy, penile injections, vacuum devices, intraurethral medication, and surgery (penile implant). Each type has its own pros and cons. Discuss your options with your doctor to determine the best treatment for you.

The first step to treating ED is to find the underlying cause, then the appropriate treatment can be provided. There are a number of non-surgical and surgical options that can help a man regain normal sexual function.

Non-surgical treatments

Education and communication

Education about sex, sexual behaviors, and sexual responses may help a man overcome his anxieties about sexual dysfunction.

Open dialogue with your partner about your needs and concerns may also help to overcome many barriers to a healthy sex life.


Medications such as sildenafil (Viagra?), varderafil (Levita?), or tadalafil (Cialis?) may help improve sexual function in men by increasing blood flow to the penis. Men who are on medicines that contain nitrates such as nitroglycerine should not take oral ED medications. The combination of nitrates and these specific medications can cause low blood pressure (hypotension).

The most common side effects of these medications are indigestion, nasal congestion, flushing, headaches, and a temporary visual disturbance.

Mechanical aids

Aids such as vacuum devices and penile constriction rings serve as erectile aids for some men.

A vacuum constriction device is a cylinder that is placed over the penis. The air is pumped out of the cylinder, which draws blood into the penis and causes an erection. The erection is maintained by slipping a band off of the base of the cylinder and onto the base of the penis. The band can stay in place for up to 30 minutes. The vacuum device can be safely used to treat most causes of erectile failure. Lack of spontaneity, discomfort, and cumbersomeness of the device seem to be the biggest concerns of patients.

Penile injection therapy (intracavernosal injection therapy)

Men are taught how to inject medications directly into the erection chambers of the penis to create an erection.

Injection therapy is effective in treating a wide variety of erection issues caused by blood vessel, nerve, and psychological conditions.

Using a tiny needle and syringe, the man injects a small amount of medicine into the side of his penis. The medicine relaxes the blood vessels, allowing blood to flow into the penis. This treatment has been widely used and accepted since the early 1980s. The three most common medicines are prostaglandin E1 (alprostadil), papaverine (Papacon), and phentolamine (Regitine).

The most common side effects are pain and penile scarring (fibrosis). Patients with cerebral and vascular disease or severe cardiovascular diseases might not be able to tolerate the dizziness and high blood pressure occasionally caused by injection therapy.

A painful erection that lasts longer than two to three hours is called priapism and may occur with injection therapy. This can be lessened with proper dosing and by following the treatment guidelines.

Transurethral pharmacotherapy

For this treatment, a suppository is placed into the urinary tube (urethra) using a plastic applicator. The suppository contains the medicine alprostadil (MUSE), which is absorbed into the bloodstream. MUSE relaxes the blood vessels, allowing blood to flow into the penis.

MUSE appears to be less effective than either injection or vacuum therapy, although it can be used to treat erectile dysfunction due to a wide variety of causes.

Patients with urethral problems must use special care when using this treatment since the suppository is placed directly into the urethra.

Psychology and sex therapies

Psychological causes may contribute to erectile failure even when there is a clear organic cause.

Therapy with a trained counselor can help a person address feelings of anxiety, fear, or guilt that may have an impact on sexual dysfunction.

Sex therapy can be beneficial to most men when counseling is provided by a skilled sex therapist. Sex therapy also helps a man's partner accept and cope with the problems.

A patient whose ED has a clear psychological cause should receive sex therapy counseling before any invasive treatments are pursued.


Men with low levels of testosterone may benefit from hormone replacement. The use of a testosterone patch applied to the scrotum or other parts of the body has been approved by the Food and Drug Administration (FDA). The patch helps to increase testosterone levels to a normal range. Testosterone gels have also been approved for this purpose.

Testosterone replacement by pills and implantable pellets is also being evaluated.

Surgical treatment options

Penile prosthesis surgery

Inflatable penile prostheses are implanted during outpatient surgery. Once they are part of a man's body, they enable him to have an erection whenever he desires. The use of a prosthesis preserves penile sensation, orgasm, and ejaculation for most men.

The most commonly used penile implant consists of a pair of inflatable cylinders that are surgically implanted in the erection chambers of the penis. The cylinders are connected via tubing to a reservoir of fluid under the lower abdominal muscles and to a pump that is located within the scrotal sac.

To inflate the penile prosthesis, the man compresses the pump a number of times to transfer fluid from the reservoir to the cylinders. This causes the penis to become erect. When inflated, the prosthesis makes the penis stiff and thick, which is very similar to a natural erection. A penile prosthesis does not change the sensation on the skin of the penis or a man's ability to achieve orgasm or ejaculate. Pressing on a deflation valve attached to the pump returns the fluid to the reservoir, which returns the penis to a flaccid state.

The surgical procedure is performed through one or two small incisions that are generally well hidden. Other people will be unable to tell that a man has an inflatable penile prosthesis. In other words, most men would not be embarrassed in a locker room or public restroom. Complications following surgery are not common, but primarily include infection and mechanical device failure.

Approximately 95 percent of penile implant surgeries are successful in producing erections that enable men to have sexual intercourse. Moreover, patient satisfaction questionnaires show that up to 90 percent of men who have undergone penile implants say they would choose the surgery again, and overall satisfaction ratings are higher than those reported by men using oral medication or penile injection therapy.