Erectile dysfunction means the same thing as impotence. Both erectile dysfunction and impotence mean the inability to have or keep an erection that is good enough for sexual intercourse. If you have erectile dysfunction, it does not mean that you have an inability to have orgasm or a decreased libido (sex drive) or have premature ejaculation; although if you have these other conditions, they can affect the extent of your erectile dysfunction.
What Is an Erection?
How your body actually produces an erection and then maintains it is a complicated process that depends on
- blood flow
- steroid (androgen) production
- nervous system (neurological) stimulation
- chemical signals from the brain (neurotransmitters)
- enzymes
The increase in blood into the penis also compresses the blood vessels (veins) that allow blood to circulate back out of the penis. So once blood flows in, it is trapped and cannot flow out. This allows the erection to be maintained during sexual activity.
What Are the Causes of Erectile Dysfunction?
The causes of erectile dysfunction or impotence can be divided into two broad groups: organic and non-organic.
Organic
Organic causes are related to physical problems, problems involving your body. Examples include:
- neurological deficits caused by diabetes, spinal cord injuries, or brain (cerebral) injuries
- physical injury (trauma)
- poor blood circulation caused by atherosclerotic disease often related to smoking
- inadequate blood vessel compression, which does not allow the erection to be maintained
- drug-induced changes that decrease erectile ability (listed in Table 1)
| Antidepressants | amitriptyline, doxepin, phenelzine |
| Benzodiazepines | diazepam, midazolam |
| Anti-androgens | medications for prostate cancer like flutamide (Eulexin) and leuprolide |
| Antihypertensives | atenolol, propranolol, nifedipine, enalapril, thiazide, clonidine |
| Other | digoxin, cimetidine |
Non-Organic
Non-organic causes are related to psychological factors. The non-organic causes of erectile dysfunction are less well understood. Personal issues, such as marital problems, performance anxiety, or lack of desire, can and do affect erectile ability. (This is also called psychogenic impotence.)
Evaluation of Erectile Dysfunction
My evaluation of erectile dysfunction can be extensive but initially involves a careful history and physical examination. I often order blood tests to look at hormone levels and other elements in your blood. Some examples of the many possible tests that I might use include a test to measure the largeness and frequency of your night time erections (also called nocturnal penile tumescence), Doppler ultrasound to examine blood flow, and different forms of penile pressure measurements.
What Are the Treatment Options?
Unfortunately, despite the recent press involving Viagra, there is no cure-all for impotence. Depending on your medical and surgical history, there are different treatment options that are best suited for your situation and should be discussed with your urologist. Some options may work for some individuals but may prove unsatisfactory for others. Every treatment option has its advantages and disadvantages, and each one should be considered carefully before choosing any of them.
Oral Medication
Viagra is the best known, but others will soon be available. The side effects of Viagra include headache, nausea, and vision changes. You should not use Viagra if you have heart or high blood pressure problems before discussing carefully this with your physician.
Intraurethral Medication
This is a small pellet that is placed into the penis at the tip and the medication is then absorbed. It is the same medication that is often used for injection therapy. This method avoids many of the side effects of injections but is often not as effective.
Intracavernous Medication
This is often called penile injection therapy. Using a small needle or an auto-injection device, medication is injected at the base of the penile shaft that causes increased blood flow and an erection. Possible side effects include pain, toughening of the penis (penile fibrosis), and prolonged, unwanted erections (priapism) of several hours or more that must be treated medically or sometimes surgically. The chance of this is small but real. The first injection is given at the clinic after carefully teaching you how the injection should be administered.
Vacuum Constriction Devices
These devices fit over the penis and have a pump that pulls blood into the penis. The blood pulled into the penis is trapped by a ring-like device that is placed at the base of the penis. Possible problems include bruising, difficulty in ejaculation, and decreased sensation.
Penile Prosthesis Surgery
There are different types of prostheses. All involve surgery, and each type has its own advantages and disadvantages. Semi-rigid devices are not as life-like but are associated with less injuries and complications. The various inflatable prostheses available, however, are much more life-like and tend to be more satisfying for both partners. Over a period of time, there is a possibility of infection and mechanical problems that would require another operative procedure. A penile prosthesis should be the last resort, and other treatment attempts should be made before pursuing surgery.
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