- Erectile Dysfunction
- What is erectile dysfunction (ED)?
- What are the risk factors for erectile dysfunction?
- What are the different types (and causes) of ED?
- Organic Erectile Dysfunction
- Premature Ejaculation (PE)
- How is ED diagnosed?
- What is the treatment for ED?
- Medical treatments:
- Hormone replacement therapy
- Penile implants
- How do couples cope with ED?
- Erectile Dysfunction After Prostate Cancer
- Following Nerve-Sparing Prostatectomy
- Following Radiation Therapy
- Management of Erectile Dysfunction
- Alternative Treatments
- Mechanical Devices
- Surgical Options
- Erectile Dysfunction Following Radical Prostatectomy
- What is the importance of preserved erectile function?
- What are the current expectations with regard to outcomes after radical prostatectomy?
- Why is there increasing concern at this time regarding erectile dysfunction issues following radical prostatectomy?
- Why does it take so long to recover erections after the very best surgery?
- What determines erection recovery after surgery?
- Are there any surgical techniques that have been developed to improve erectile function outcomes?
- Is another treatment option better for preservation of erectile function?
- What current options exist to treat erectile dysfunction after radical prostatectomy?
- Can erection “rehabilitation” be applied to improve erection recovery rates?
- Are there new strategies in the near future that may be helpful in improving erection recovery after surgery?
- Special Heart Risks for Men
- Heart Risk Factor: Erectile Dysfunction
- Heart Risk Factor: Low Testosterone
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What is erectile dysfunction (ED)?
Erectile dysfunction is defined as the persistent inability to achieve or maintain penile erection sufficient for satisfactory sexual performance.
The Massachusetts Male Aging Study surveyed 1,709 men aged 40–70 years between 1987 and 1989 and found there was a total prevalence of erectile dysfunction of 52 percent.
It was estimated that, in 1995, over 152 million men worldwide experienced ED. For 2025, the prevalence of ED is predicted to be approximately 322 million worldwide.
In the past, erectile dysfunction was commonly believed to be caused by psychological problems. It is now known that, for most men, erectile dysfunction is caused by physical problems, usually related to the blood supply of the penis. Many advances have occurred in both diagnosis and treatment of erectile dysfunction.
What are the risk factors for erectile dysfunction?
According to the NIH, erectile dysfunction is also a symptom that accompanies many disorders and diseases.
Direct risk factors for erectile dysfunction may include the following:
- Prostate problems
- Type 2 diabetes
- Hypogonadism in association with a number of endocrinologic conditions
- Hypertension (high blood pressure)
- Vascular disease and vascular surgery
- High levels of blood cholesterol
- Low levels of HDL (high-density lipoprotein)
- Chronic sleep disorders (obstructive sleep apnea, insomnia)
- Neurogenic disorders
- Peyronie's disease (distortion or curvature of the penis)
- Priapism (inflammation of the penis)
- Alcohol use
- Lack of sexual knowledge
- Poor sexual techniques
- Inadequate interpersonal relationships
- Many chronic diseases, especially renal failure and dialysis
- Smoking, which exacerbates the effects of other risk factors, such as vascular disease or hypertension
Age appears to be a strong indirect risk factor in that it is associated with increased lihood of direct risk factors, some of which are listed above.
Accurate risk factor identification and characterization are essential for prevention or treatment of erectile dysfunction.
What are the different types (and causes) of ED?
The following are some of the different types and possible causes of erectile dysfunction:
Organic Erectile Dysfunction
Organic ED involves abnormalities the penile arteries, veins, or both and is the most common cause of ED, especially in older men.
When the problem is arterial, it is usually caused by arteriosclerosis, or hardening of the arteries, although trauma to the arteries may be the cause.
The controllable risk factors for arteriosclerosis–being overweight, lack of exercise, high cholesterol, high blood pressure, and cigarette smoking–can cause erectile failure often before progressing to affect the heart.
Many experts believe that atrophy, a partial or complete wasting away of tissue, and fibrosis, the growth of excess tissue, of the smooth muscle tissue in the body of the penis (cavernous smooth muscle) triggers problems with being able to maintain a firm erection.
Poor ability to maintain an erection is often an early symptom of erectile dysfunction. Although the condition is called venous leak, the real problem is not with the veins but malfunction of the smooth muscle that surrounds the veins.
The end result is difficulty with maintain a firm erection (losing an erection too quickly) that is now believe to be an early manifestation of atherosclerosis and vascular disease.
- Diabetes. Erectile Dysfunction is common in people with diabetes. An estimated 10.9 million adult men in the U.S. have diabetes, and 35 to 50 percent of these men are impotent. The process involves premature and unusually severe hardening of the arteries. Peripheral neuropathy, with involvement of the nerves controlling erections, is commonly seen in people with diabetes.
- Depression. Depression is another cause of ED and is closely related to erectile dysfunction. Because there is a triad relationship between depression, ED and cardiovascular disease, men with depression should be fully evaluated for medical illness as well as psychological factors. Some antidepressant medications cause erectile failure.
- Neurologic causes. There are many neurological (nerve problems) causes of ED. Diabetes, chronic alcoholism, multiple sclerosis, heavy metal poisoning, spinal cord and nerve injuries, and nerve damage from pelvic operations can cause erectile dysfunction.
- Drug-induced ED. A great variety of prescription drugs, such as blood pressure medications, antianxiety and antidepressant medications, glaucoma eye drops, and cancer chemotherapy agents are just some of the many medications associated with ED.
- Hormone-induced ED. Hormonal abnormalities, such as increased prolactin (a hormone produced by the anterior pituitary gland), steroid abuse by bodybuilders, too much or too little thyroid hormone, and hormones administered for prostate cancer may cause ED. Low testosterone can contribute to ED but is rarely the sole factor responsible for ED.
Premature Ejaculation (PE)
Premature ejaculation is a male sexual dysfunction characterized by:
- Ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration.
- Inability to delay ejaculation on all or nearly all vaginal penetrations; and, negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.
Premature ejaculation is divided into lifelong and acquired categories:
- Lifelong premature ejaculation. With lifelong premature ejaculation, the patient has experienced premature ejaculation since first beginning coitus.
- Acquired premature ejaculation. With acquired premature ejaculation, the patient previously had successful coital relationships and only now has developed premature ejaculation.
- Performance anxiety. Performance anxiety is a form of psychogenic ED, usually caused by stress.
How is ED diagnosed?
Diagnostic procedures for ED may include the following:
- Patient medical or sexual history. This may reveal conditions or diseases that lead to impotence and help distinguish among problems with erection, ejaculation, orgasm, or sexual desire.
- Physical examination. To look for evidence of systemic problems, such as the following:
- A problem in the nervous system may be involved if the penis does not respond as expected to certain touching.
- Secondary sex characteristics, such as hair pattern, can point to hormonal problems, which involve the endocrine system.
- Circulatory problems could be indicated by an aneurysm.
- Unusual characteristics of the penis itself could suggest the basis of the impotence.
Laboratory tests. These can include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. Measurement of testosterone in the blood is often done in men with ED, especially with a history of decreased libido or diabetes.
Psychosocial examination. This is done to help reveal psychological factors that may be affecting performance. The sexual partner may also be interviewed to determine expectations and perceptions encountered during sexual intercourse.
What is the treatment for ED?
Specific treatment for erectile dysfunction will be determined by your doctor :
- Your age, overall health, and medical history
- Extent of the disease
- Your tolerance for specific medications, procedures, or therapies
- Expectations for the course of the disease
- Your opinion or preference
Some of the treatments available for ED include:
- Sildenafil. A prescription medication taken orally for the treatment of ED. This drug works best when taken on an empty stomach and many men can get an erection 30 to 60 minutes after taking the medication. Sexual stimulation is required for sildenafil citrate to have the best efficacy.
- Vardenafil. This drug has a similar chemical structure to sildenafil citrate and works in a similar manner.
- Tadalafil. Studies have indicated that tadalafil citrate stays in the body longer than other medications in its class. Most men who take this medication find that an erection occurs within 4 to 5 hours after taking the pill (slow absorption) and the effects of the medication may last up to 24 to 36 hours.
The FDA recommends that men follow general precautions before taking a medication for ED. Men who are taking medications that contain nitrates, such as nitroglycerin, should NOT use these medications. Taking nitrates with one of these medications can lower blood pressure too much.
In addition, men who take tadalafil or vardenfil should use alpha blockers with care and only as instructed by their physician, as they could result in hypotension (abnormally low blood pressure). Experts recommend that men have a complete medical history and physical examination to determine the cause of ED.
Men should tell their doctor about all the medications they are taking, including over-the-counter medications.
Men with medical conditions that may cause a sustained erection, such as sickle cell anemia, leukemia, or multiple myeloma, or a man who has an abnormally-shaped penis, may not benefit from these medications. Also, men with liver diseases or a disease of the retina, such as macular degeneration or retinitis pigmentosa, may not be able to take these medications, or may need to take the lowest dosage.
These medical treatments should NOT be used by women or children. Elderly men are especially sensitive to the effects of these medical treatments, which may increase their chance of having side effects.
Hormone replacement therapy
Testosterone replacement therapy may improve energy, mood, and bone density, increase muscle mass and weight, and heighten sexual interest in older men who may have deficient levels of testosterone.
Testosterone supplementation is not recommended for men who have normal testosterone levels for their age group due to the risk of prostate enlargement and other side effects.
Testosterone replacement therapy is available as a cream or gel, topical solution, skin patch, injectable form and pellet form placed under the skin.
Two types of implants are used to treat ED, including:
- Inflatable Penile Prosthesis (3-piece hydraulic pump). A pump and two cylinders are placed within the erection chambers of the penis, which causes an erection by releasing a saline solution; it can also remove the solution to deflate the penis.
- Semi-rigid Penile Prosthesis. Two semi-rigid but bendable rods are placed within the erection chambers of the penis, which allows manipulation into an erect or non-erect position.
Infection is the most common cause of penile implant failure and occurs less that 2 percent of the time. Implants are usually not considered until other methods of treatment have been tried but they have a very high patient satisfaction rate and are an excellent treatment choice in the appropriate patient.
How do couples cope with ED?
Erectile dysfunction can cause strain on a couple. Many times, men will avoid sexual situations due to the emotional pain associated with ED, causing their partner to feel rejected or inadequate. It is important to communicate openly with your partner.
Some couples consider seeking treatment for ED together, while other men prefer to seek treatment without their partner's knowledge. A lack of communication is the primary barrier for seeking treatment and can prolong the suffering. The loss of erectile capacity can have a profound effect on a man.
The good news is that ED can usually be treated safely and effectively.
Feeling embarrassed about sexual health problems may prevent many men from seeking the medical attention they need, which can delay diagnosis and treatment of more serious underlying conditions. Erectile Dysfunction itself is often related to an underlying problem, such as heart disease, diabetes, liver disease, or other medical conditions.
Since ED can be a forewarning symptom of progressive coronary disease, doctors should be more direct when questioning patients about their health. By asking patients more directly about their sexual function through conversation or a questionnaire during a checkup, doctors may be able to detect more serious health conditions sooner.
Dr. Adrian Dobs and her team are interested in finding out whether men could benefit from testosterone replacement therapy as they age. Discover more.
Erectile Dysfunction After Prostate Cancer
Nearly all men will experience some erectile dysfunction for the first few months after prostate cancer treatment. However, within one year after treatment, nearly all men with intact nerves will see a substantial improvement.
Following Nerve-Sparing Prostatectomy
Within one year, about 40 to 50% of men will have returned to their pre-treatment function. After two years, about 30 to 60% will have returned to pre-treatment function. These rates vary widely depending on the surgeon and how the extent of “nerve sparing” a surgeon can perform at the time of surgery.
Following Radiation Therapy
About 25 to 50% of men who undergo brachytherapy will experience erectile dysfunction vs. nearly 50% of men who have standard external beam radiation. After two to three years, few men will see much of an improvement and occasionally these numbers worsen over time.
Men who undergo procedures not designed to minimize side effects and/or those whose treatments are administered by physicians who are not proficient in the procedures will fare worse.
Men with other diseases or disorders that impair their ability to maintain an erection (diabetes, vascular problems, etc.) will have a more difficult time returning to pre-treatment function.
Management of Erectile Dysfunction
Oral medications relax the muscles in the penis, allowing blood to rapidly flow in. On average, the drugs take about an hour to begin working, and the erection-helping effects can last from 8 to 36 hours.
About 75% of men who undergo nerve-sparing prostatectomy or more precise forms of radiation therapy have reported successfully achieving erections after using these drugs. However, they are not for everyone, including men who take medications for angina or other heart problems and men who take alpha-blockers.
Men who do not recovery erectile function after treatment can try injectable medication that pharmacologically induced an erection. The most common drug used for this is Prostaglandin.
The vacuum constriction device creates an erection mechanically by forcing blood into the penis using a vacuum seal. A rubber ring rolled onto the base of the penis prevents blood from escaping once the seal is broken. About 80% of men find this device successful.
A three-pieced surgically inserted penile implant includes a narrow flexible plastic tube inserted along the length of the penis, a small balloon- structure filled with fluid attached to the abdominal wall, and a release button inserted into the testicle.
The penis remains flaccid until an erection is desired, at which point the release button is pressed and fluid from the balloon rushes into the plastic tube. As the tube straightens from being filled with the fluid, it pulls the penis up with it, creating an erection.
Assuming the mechanics are working correctly, it is 100% effective, and about 70% of men remain satisfied with their implants even after 10 years. Because this procedure is done under general anesthesia, it is not available to men who are not considered good candidates for surgery because of other health reasons.
Erectile Dysfunction Following Radical Prostatectomy
Assuming the management of erectile dysfunction requires expert diagnosis and treatment.
Diagnosis includes sexual function history, general medical history, psychosocial history, medication history, physical examination, and appropriate laboratory testing.
Treatment follows diagnosis, and we provide a range of treatment options through the Clinic. Minimally invasive treatment options range from oral medications to medications administered directly to the penis to a mechanical vacuum device applied to the penis.
Invasive treatments include implants or vascular surgery. We are particularly expert in the surgical treatment of patients with erectile dysfunction.
The range of conditions we manage include penile prosthesis complications, penile vascular abnormalities, penile curvature, and abnormally prolonged erection consequences.
Psychological treatment is an important adjunct to managing erectile dysfunction.
If our diagnosis suggests a psychological association with your erectile dysfunction, we may recommend that you pursue counseling with a qualified psychologist available through the Clinic.
For instance, there may be relationship problems that negatively affect sexual functioning with your partner. Referrals can be made to the Johns Hopkins' noted Sexual Behaviors Consultation Unit.
Erectile dysfunction following radical prostatectomy for clinically localized prostate cancer is a known potential complication of the surgery. With the advent of the nerve-sparing radical prostatectomy technique, many men can expect to recover erectile function in the current era.
However, despite expert application of the nerve-sparing prostatectomy technique, early recovery of natural erectile function is not common. Increasing attention has been given to this problem in recent years with the advancement of possible new therapeutic options to enhance erection function recovery following this surgery. Visit Dr. Burnett's Neuro-Urology Laboratory
This topic area was handled thoroughly in an article written by Dr. Arthur L. Burnett, entitled “Erectile Dysfunction Following Radical Prostatectomy,” published in the Journal of the American Medical Association, June 1, 2005. Using a question and answer format, excerpts from this article are provided below.
What is the importance of preserved erectile function?
In considering the impact of the various treatment approaches for prostate cancer on their quality of life, many patients place paramount importance on the possibility of retaining natural erectile function.
This matter is frequently important to young men who by age status are more ly to have intact erectile function than older men; however, for all men having normal preoperative erectile function irrespective of age, preservation of this function is understandably important postoperatively.
What are the current expectations with regard to outcomes after radical prostatectomy?
Following a series of anatomical discoveries of the prostate and its surrounding structures about 2 decades ago, changes in the surgical approach permitted the procedure to be performed with significantly improved outcomes.
Now after the surgery, expectations are that physical capacity is fully recovered in most patients within several weeks, return of urinary continence is achieved by more than 95% of patients within a few months, and erection recovery with ability to engage in sexual intercourse is regained by most patients with or without oral phosphodiesterase 5 (PDE5) inhibitors within 2 years.
Why is there increasing concern at this time regarding erectile dysfunction issues following radical prostatectomy?
The reality of the recovery process after radical prostatectomy today is that erectile function recovery lags behind functional recovery in other areas. Patients are understandably concerned about this issue and, following months of erectile dysfunction, become skeptical of reassurances that their potency will return.
Why does it take so long to recover erections after the very best surgery?
A number of explanations have been proposed for this phenomenon of delayed recovery, including mechanically induced nerve stretching that may occur during prostate retraction, thermal damage to nerve tissue caused by electrocoagulative cautery during surgical dissection, injury to nerve tissue amid attempts to control surgical bleeding, and local inflammatory effects associated with surgical trauma.
What determines erection recovery after surgery?
The most obvious determinant of postoperative erectile dysfunction is preoperative potency status. Some men may experience a decline in erectile function over time, as an age-dependent process.
Furthermore, postoperative erectile dysfunction is compounded in some patients by preexisting risk factors that include older age, comorbid disease states (e.g., cardiovascular disease, diabetes mellitus), lifestyle factors (e.g.
, cigarette smoking, physical inactivity), and the use of medications such as antihypertensive agents that have antierectile effects.
Are there any surgical techniques that have been developed to improve erectile function outcomes?
At this time, there are several different surgical approaches to carry out the surgery, including retropubic (abdominal) or perineal approaches as well as laparoscopic procedures with freehand or robotic instrumentation. Much debate but no consensus exists about the advantages and disadvantages of the different approaches. Further study is needed before obtaining meaningful determinations of the success with different new approaches.
Is another treatment option better for preservation of erectile function?
The growing interest in pelvic radiation, including brachytherapy, as an alternative to surgery can be attributed in part to the supposition that surgery carries a higher risk of erectile dysfunction.
Clearly, surgery is associated with an immediate, precipitous loss of erectile function that does not occur when radiation therapy is performed, although with surgery recovery is possible in many with appropriately extended follow-up.
Radiation therapy, by contrast, often results in a steady decline in erectile function to a hardly trivial degree over time.
What current options exist to treat erectile dysfunction after radical prostatectomy?
Options include pharmacologic and nonpharmacologic interventions.
Pharmacotherapies include the oral PDE-5 inhibitors (sildenafil [Viagra®], tadalafil [Cialis®], and vardenafil [Levitra®]), intraurethral suppositories (MUSE®), and intracavernous injections (prostaglandin E1and vasoactive drug mixtures).
Non-pharmacologic therapies, which do not rely on the biochemical reactivity of the erectile tissue, include vacuum constriction devices and penile implants (prostheses).
Men who have undergone nerve-sparing technique should be offered therapies that are not expected to interfere with the potential recovery of spontaneous, natural erectile function.
In this light, penile prosthesis surgery would not be considered an option in this select group, at least in the initial 2 year post-operative period, until it becomes evident in some individuals that such recovery is unly.
Can erection “rehabilitation” be applied to improve erection recovery rates?
A relatively new strategy in clinical management after radical prostatectomy has arisen from the idea that early induced sexual stimulation and blood flow in the penis may facilitate the return of natural erectile function and resumption of medically unassisted sexual activity.
There is an interest in using oral PDE5 inhibitors for this purpose, since this therapy is noninvasive, convenient, and highly tolerable.
However, while the early, regular use of PDE5 inhibitors or other currently available, “on-demand” therapies is widely touted after surgery for purposes of erection rehabilitation, such therapy is mainly empiric. Evidence for its success remains limited.
Are there new strategies in the near future that may be helpful in improving erection recovery after surgery?
Recent strategies have included cavernous nerve interposition grafting and neuromodulatory therapy.
The former, as a surgical innovation meant to reestablish continuity of the nerve tissue to the penis may be particularly applicable when nerve tissue has been excised during prostate removal.
In the modern era of commonly early diagnosed prostate cancer, nerve-sparing technique remains indicated for the majority of surgically treated patients.
Neuromodulatory therapy, represents an exciting, rapidly developing approach to revitalize intact nerves and promote nerve growth. Therapeutic prospects include neurotrophins, neuroimmunophilin ligands, neuronal cell death inhibitors, nerve guides, tissue engineering/stem cell therapy, electrical stimulation, and even gene therapy.
Special Heart Risks for Men
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Men develop heart disease 10 years earlier, on average, than women do. They also have an early warning sign that few can miss: erectile dysfunction (ED). “It’s the canary in the coal mine,” says a Johns Hopkins expert. “Sexual problems often foretell heart problems.”
On the plus side, any risk factor—even ED—that gets your attention can put you on a path to better preventive care.
Heart Risk Factor: Erectile Dysfunction
“A lot of people think erectile dysfunction is the inability to get an erection at all, but an early sign of the condition is not being able to maintain an erection long enough to have satisfactory sexual intercourse,” says a Johns Hopkins expert. Erectile problems aren’t a normal part of getting older as many people think; rather, they almost always indicate a physical problem.
A key reason erectile dysfunction is considered a barometer for overall cardiovascular health is that the penis, the heart, is a vascular organ.
Because its arteries are much smaller than the heart’s, arterial damage shows up there first—often years ahead of heart disease symptoms.
Men in their 40s who have erection problems (but no other risk factors for cardiovascular disease) run an 80 percent risk of developing heart problems within 10 years.
Treatment tends to be successful when started as soon as you begin to notice erection problems over more than a couple of months. An ED workup by a doctor will address heart disease risk factors, such as prediabetes, high blood pressure or excess weight — hopefully, long before they result in a heart attack or stroke.
Heart Risk Factor: Low Testosterone
Having a low testosterone level is often thought of as just a diminished sex drive, but it’s increasingly seen as being linked to heart disease and type 2 diabetes, the expert says. He notes that a growing body of research indicates that “low T” can be considered a cardiovascular and metabolic risk factor.
“These ideas are still being studied, but we know, for example, that people with abdominal obesity [so-called ‘belly fat’] or metabolic syndrome often have low testosterone,” the expert says. Metabolic syndrome (which includes high blood sugar levels, unhealthy cholesterol levels, and too much weight in the midsection) and diabetes are leading risk factors for heart disease.
Low testosterone is simply one part of an overall picture of heart risk, the expert says. But it can be motivating, even lifesaving, to know that changes in your sexual function are closely interrelated to the rest of your body.
It’s worthwhile to get yourself checked out when something doesn’t seem right. “Men often don’t connect this problem to or get evaluated for stroke or heart attack risk until it happens,” he says.
“But sexual problems are a message they listen to.”
Men who have high levels of calcification in their arteries are more ly to develop erectile dysfunction, according to a Johns Hopkins–led study of nearly 1,900 men, aged 59 to 64, who were followed for nine years.
Calcification—calcium deposits in the arteries to the heart caused by damage—are a direct measure of blood vessel hardening, which indicates high cardiovascular disease risk. The men who were followed were heart-disease-free at the start of the study.
Those found to develop heavy calcium buildup were 43 percent more ly to develop erectile problems down the road.
The study emphasizes the importance of coronary calcium screenings, which are CT scans that measure calcium buildup in heart arteries.
Stress, anger and anxiety raise levels of blood pressure and stress hormones, and they can restrict blood flow to the heart. Some damage can be immediate. In the two hours after an angry outburst, for example, your risk of a heart attack is nearly five times greater and your risk of stroke three times higher, research has shown.
What’s more, the effects of chronic stress can build over time, damaging arteries. Men who have angry or hostile personalities, in particular, have a higher risk of developing heart disease. Sexual problems related to heart disease can cause added anxiety or relationship stress. Stress can also affect sleep, which in turn affects heart health.
“Physical, emotional and psychological factors are all related when it comes to heart health,” says a Johns Hopkins expert. “When someone has chronic stress, depression or anxiety, they should have a basic evaluation of all of the risk factors for heart disease.”