Erectile Dysfunction: Complete and Partial Loss of Erection (4)

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Erectile dysfunction (ED) is the term used when a man is unable to achieve or maintain an erection sufficient for sexual pleasure.

Many men have this problem at least once in their lives, but are not affected long-term by it. Unfortunately, however, some men have chronic erectile dysfunction which is complete and permanent....at least, that's what conventional wisdom suggests. But the common effects of erectile dysfunction, which include damage to a man's relationship, emotional stress, and lowered sexual self-esteem, are not inevitable, nor are they untreatable. ED is multi-factorial, and is neither inevitable nor a sentence to a life without sexual pleasure.

Because the definition of erectile dysfunction is so vague - it can mean permanent impotence, or occasional loss of erection, or anything in between - it is hard to know how many men it affects. But the chronic form probably affects about 10% or more of the male population. it is more common in older age groups: erectile dysfunction affects about 5% of men in their 40s, and three times as many by the age of 65. Almost all men will have some experience of it by the age of 50.

The conventional view is that alcoholism, atherosclerosis, diabetes, and kidney disease account for as much as 71% of chronic erectile dysfunction. But it is hard to separate the psychological and the physical factors, since any event of ED causes stress and anxiety which makes the physical problems worse.

Physical Causes of Erectile Dysfunction

Erection begins in the brain as physical or psychological arousal makes nerves send messages to the circulatory system: this results in arteries in the penis increasing blood flow to the erectile tissues so that the corpora cavernosa become engorged. Blood is trapped in the penis by a fibrous elastic sheath which prevents blood from leaving via the penile veins during erection. Anything which affects this mechanism will interfere with a man's capacity to become erect.

Vascular Disease

Arteriosclerosis, the hardening of the arteries, reduces blood flow to the penis and can lead to impotence. It accounts for 50% to 60% of ED in men over 60. Risk factors for arteriosclerosis include: diabetes, high blood pressure, high cholesterol, and smoking.

Prescribed Drugs

More than 190 prescribed drugs cause or contribute to erection issues, including drugs for high blood pressure, antidepressants, tranquilizers, sedatives, and heart medications.

Hormone Levels

Low testosterone levels cause loss of libido and erection. An excess level of prolactin, caused by pituitary gland tumor, can be a factor in reduced testosterone, but usually it is due to age.

Neurologic Conditions

Spinal cord and brain injuries cause impotence when they affect nerve impulses going from the brain to the penis. Multiple sclerosis (MS), Parkinson's disease, and Alzheimer's, also result in impotence.

Pelvic Trauma, Surgery, Radiation Therapy

The effects of surgery to the prostate have been devastating to a man's ability to become erect. Recent developments of nerve-sparing techniques in surgery are now used and have reduced the unfortunate consequences of these operations, although even with these techniques it may take up to 18 months for full erectile capacity to return. However, expectations must be managed correctly. Radiation therapy for cancer also can permanently damage the nervous mechanism, responsible for erection.

Venous Leak

If the veins in the penis cannot prevent blood from leaving the penis during erection, erection cannot be maintained. Venous leak can be a result of injury, disease, or damage to the veins in the penis.

Psychological Conditions Causing Erectile Dysfunction

All emotional problems such as depression, worry, stress, anxiety, and guilt, may all contribute to loss of sexual drive and erectile dysfunction. The classic situation is that a man experiences temporary loss of erection, but then worries that it occur once again. This can produce sexual performance anxiety which leads to a negative spiral which leads to chronic erection problems during sex. Psychological factors often reinforce physical problems.

Impotence Diagnosis

Blood tests show up conditions that affect normal erectile function: for example, they measure hormone levels, cholesterol levels, blood sugar levels, kidney and liver function, and thyroid hormone levels. Levels of sex hormones may be measured; if they are low, an endocrinologist should be consulted.

A count of red blood cells and white blood cells is used to determine whether any anemia is present. The level of blood lipids such as cholesterol and triglycerides can be a sign of atherosclerosis which can reduce blood flow to the penis.

Erectile function tests assess erectile function by reviewing the state of health of the blood vessels, nerves and muscles of the penis, genital, and pelvic region. Ultrasound is used to check blood flow, venous leakage, to detect atherosclerosis, and the condition of erectile tissue. Another option is to induce an erection using prostaglandin, and then test for vascular dilation and penile blood pressure. The results are compared to measurements taken when the penis is flaccid.

An enlarged prostate can be detected with a digital rectal examination (DRE). If enlarged, it may affect blood flow to the penis.

Tests such as the bulbocavernosus reflex test signify when there is adequate nerve sensitivity in the penis. A squeeze to the penile glans should cause the anus to contract if nerve function is normal. Any delay is indicative of nerve damage. More specific tests are used to detect nerve damage caused by diabetes or nervous system problems.

Nocturnal penile tumescence tests show if a man has any erections during the night. The snap gauge uses plastic bands of varying durability around the penis and checking which one breaks in response to erection. The strain gauge uses an elastic band at the penis base and penis tip. Any stretch during erection and changes in circumference show the capacity of the penis to become erect.

Penile biothesiometry – This sophisticated test uses vibration to check sensitivity and nerve function in the glans and penile shaft. A low perception of such stimulation may indicate nerve damage in the pelvic area, which can of course be a cause of impotence.

Vasoactive injection – Chemical solutions which cause an erection by dilating blood vessels in the penile tissue usually produce an erection lasting in the region of 20 minutes. During this time, the internal penile pressure is measured and may be supplemented by x-ray examination of the penile blood vessels with a dye which shoes up irregularities.

Effects of Impotence

Whether the cause of erectile dysfunction is physiological or psychological, both the man and his partner will undergo intense feelings and emotions, including a sense of despair, hopelessness and lowered self-esteem. Sexual insecurity caused by ED can reinforce any sexual performance anxiety a man happens to be experiencing and create a further cycle of repeated failures and increasingly negative self-esteem.

To get over this, it's necessary to accept the problem and communicate openly and honestly with one's partner.

Sexual performance - and especially the ability to get erect - is a big part of a man's sexual self-esteem, so erectile dysfunction (ED) can be devastating to a man's entire sense of being. Men with ED may well be uncertain of their masculinity and avoid sexually intimate situations with their partners; this causes more anxiety and is unnecessary because ED is often treatable. Men with ED may also withdraw emotionally and psychologically.

The psychological effects of ED can be widespread - it affects a man's social life, his work life, and his relationship. He needs to feel secure and safe to talk about it with his partner, doctor, and therapist so he can fid the right treatment. But of course erectile dysfunction can be hard to discuss with both health care providers and partners: women may think that initiating a discussion about the ED will induce embarrassment or even humiliation. And women themselves may develop a sense of personal inadequacy, possibly believing that their man's ED is somehow their fault (for example, they may conclude they are not sexually attractive to their partner).

It's said that ED is usually a result of physical causes, made worse by psychological factors, but our experience suggests that this is untrue in many cases. Where, for example, Viagra does not work, it may be the cause of a man's ED is psychological - e.g. the man does not wish to be in relationship with his partner. Such complex etiology means that treating ED may not be so simple as it first appears. And any anxiety around the situation will always make ED worse.

Treatment of Erectile Dysfunction

Sexual Psychotherapy

ED rooted in psychological causes can usually be overcome. And even when a physiological cause has been addressed, self-esteem problems or anxiety can impair the restoration of normal function and adequate sexual performance. Qualified sex counselors, or sexual psychotherapists, can reduce emotional tension, increase communication, and provide realistic expectations for sex, all of which can improve a man's sexual performance. Psychological therapy can back up medical or surgical treatment, since sex therapists will always emphasize how men and their partners can find the motivation to change psychological expectations and modify sexual behavior, especially after surgery or physical treatment.

Medical Treatment

Oral Medication

Oral medications for erectile dysfunction includes sildenafil also known as Viagra, vardenafil, also known as Levitra, and tadalafil, also known as Cialis. Yohimbine is not recommended.

These compounds are available by prescription and may be taken before lovemaking (Viagra) or once every three days in the case of Cialis. They inhibit the enzyme that is responsible for chemical reactions that allow the penis to lose blood after tumescence, and they increase levels of cyclic guanosine monophosphate, a compound which relaxes the smooth muscles of the penis, and thereby enables blood to flow into the corpora cavernosa.

Viagra is absorbed rapidly by the body so it is ingested 1 hour before sexual intercourse. It's effective in 75% of cases (one has to suspect that psychological factors are at work in the other 25%). It is especially useful when a man has erectile dysfunction linked to diabetes, spinal cord injuries, and radical prostatectomy. In clinical studies, Levitra works quickly, provides consistent results, and improves male sexual for most men the first time they take it. Again, it is useful for men with diabetes and men who have had a radical prostatectomy. Cialis stays in the body longer than the other compounds, and can work for up to 36 hours. Common side effects include headache, flushing of the face and neck, indigestion, and nasal congestion, and visual disturbances. Any loss of hearing is a serious side effect and needs medical attention.

Yohimbine is not recommended because side effects include dizziness, elevated heart rate and blood pressure, nervousness, and irritability; moreover, it doesn't work for many men.

Self-Injection for ED

Self-injection means injecting a drug through the side of the penis into the corpus cavernosum, a procedure which brings on an erection that can last from 30 minutes upwards to several hours. Prostaglandin (alprostadil, Caverject, Edex) is used to do this; it can produce vascular dilation and promotes the relaxation of smooth muscle.

These medications produce erections in about 80% of men, who say the process is painless and the erection feels natural. But you can see there is a lack of spontaneity in the process, and the repeated injection may induce scarring of the internal cavities of the penis, perhaps leading to Peyronie's disease. There is also a slight risk of priapism (which where an erection lasts for several hours and needs medical attention).

Pessaries containing prostaglandin (aprostadil) may be used as an alternative to penile injection. In this system, a man inserts a prostaglandin pellet down his urethral meatus into his urethra. Then, the MUSE system prostaglandin leaches through urethral mucosa into the erectile tissue. This apparently improves erections in 60% of men. But there are side effects: those associated with injecting aprostadil, plus pain in the penis and perineum.

Vacuum Devices

Vacuum devices work by means of a hand pump attached to a cylinder which is used to create a vacuum. This low pressure draws blood into the penis and causes it to become engorged. After a few minutes in this partial vacuum, an adequate erection can be maintained by means of a ring placed around the base of the penile shaft. This keeps the erection semi-rigid until it is removed - no longer than 25 to 30 minutes. The technology works best for men who can achieve partial erections on their own at home, since the method improves erections no matter what the cause of a man's impotence. but this can reduce feeling, and the penis is flaccid between the ring and the body, so that the erection may not be stable.