Understanding Erectile Dysfunction: Causes, Treatments, and More

Erectile dysfunction (ED) is a prevalent condition that affects millions of men worldwide. If you're suffering from infrequent, unreliable or unsatisfactory erections, understand that you're not alone.

While occasional difficulties with erections are normal – from stress, excessive drinking, or anxiety – chronic ED can significantly impact a man's quality of life, self-esteem, and intimate relationships. Thankfully, there are various treatment options and strategies for managing the condition effectively. Whether you're experiencing ED yourself or seeking to support a partner, seeing a physician can offer valuable insights into navigating this common, but often misunderstood, issue.

What is erectile dysfunction?

Erectile dysfunction (ED) is defined as the consistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity. This condition can affect men of all ages, though it becomes increasingly common with age. The key to distinguishing between occasional erection issues and chronic ED lies in the frequency and persistence of the problem.

Symptoms and diagnosis

The obvious symptom of ED is difficulty achieving or maintaining an erection. Other symptoms may include reduced sexual desire or libido. To be diagnosed, a physician typically look at patient history, perform a physical examination, and conduct medical tests.

• Patient history: A detailed conversation with a health care provider helps to identify the frequency and severity of the symptoms, as well as any underlying psychological or emotional factors.

• Physical examination: A thorough physical exam can reveal signs of underlying health conditions that may be contributing to ED. This can include assessment of the genital area, as well as evaluation of the heart and blood system.

• Medical tests: Blood and urine tests are often conducted to check for conditions like diabetes, heart disease, and low testosterone levels. Specialized tests, such as ultrasound or nocturnal penile tumescence (NPT) testing, might be used to assess blood flow and nerve function.

Differentiating between occasional and chronic ED

Temporary issues with erections can occur due to various factors such as stress, fatigue, or alcohol consumption. These instances are generally not a cause for concern. Chronic ED, however, is diagnosed when the problem persists over a significant period, typically for more than three months, and affects the man's ability to engage in satisfactory sexual activity consistently.

"There really is no line in the sand when it comes to diagnosis. It really just depends on how bothered that patient is. Even if it’s once and it causes a lot of bother, we treat them. If it’s five times a month and they’re not bothered by it, we leave them alone. It’s really more patient-driven and what they’re seeking to achieve," says Dr. Perlmutter.

Causes of erectile dysfunction

The condition can arise from a variety of factors, both psychological and physical. Some are out of your control while others can be managed to reduce the need for medication if you desire.

Psychological factors

Psychological issues play a significant role in many cases. High levels of stress or anxiety can interfere with the brain’s ability to send the necessary signals to trigger an erection. Depression can also diminish libido and sexual interest, leading to difficulties in achieving or maintaining an erection.

Many times, chronic ED can also be explained by worrying about sexual performance which can create a cycle of ongoing erectile issues.

"The psychological component is definitely the most difficult to treat. Sometimes these patients have anxiety from prior sexual encounters, or they have underlying anxiety or depression, and those medications to treat that can also lead to erectile dysfunction," says Dr. Perlmutter.

Physical conditions

Many times, physical conditions can cause ED, especially as patients get older and their chance for heart-related issues increases. While there are a variety of physical causes for ED, the two most common and likely are high-blood pressure and diabetes.

"As we age, the incidence goes up. The older men are more affected, but I've seen 18-year-olds in my practice. It affects all age ranges, but it definitely goes up as people get older," says Dr. Perlmutter.

High blood Pressure (Hypertension)

High blood pressure can damage blood vessels, including those that supply blood to the penis. Over time, this damage can result in reduced blood flow, making it difficult to achieve or maintain an erection. Additionally, some medications used to treat hypertension can have side effects that contribute to ED. It's essential for men with high blood pressure to manage their condition through lifestyle changes and medications, and to discuss any sexual health concerns with their doctor to find the most suitable treatment options.

Diabetes

Diabetes, particularly when poorly controlled, is a leading cause of ED. High blood sugar levels can cause damage to nerves and blood vessels, including those that are important for achieving an erection. The risk of ED is significantly higher in men with diabetes, and the condition often manifests earlier than in men without diabetes. Maintaining blood sugar levels within the recommended range through diet, exercise, and medication can help reduce the risk, but it's also important for diabetic men to have regular check-ups to monitor and manage potential complications related to sexual health.

• Other notable physical causes of ED include:

• Cardiovascular diseases

• Obesity

• Hormonal imbalances

• Neurological disorders

• Chronic kidney disease

• Peyronie's disease

Lifestyle factors

Lifestyle choices also play a significant role because they can lead to the aforementioned physical causes of ED.

• Smoking: Nicotine constricts blood vessels and can lead to vascular disease, reducing blood flow to the penis.

• Alcohol Consumption: Excessive drinking can impair the nervous system and reduce sexual responsiveness.

• Substance Abuse: Recreational drugs can damage blood vessels and nerves.

• Lack of Physical Activity: A sedentary lifestyle contributes to poor cardiovascular health.

• Poor Diet: Diets high in fat and sugar can lead to obesity and diabetes, increasing the risk of ED.

Treatment Options for Erectile Dysfunction

Treating erectile dysfunction (ED) requires a tailored approach that addresses the underlying causes and meets the specific needs of the patient. While the primary treatment option is medication, therapies and counseling, and surgical interventions can also help patients with more serious ED.

"The main treatment option is oral medications first. Behavioral therapy, diet, exercise—those things are easy to say but very hard to do, and patients get very discouraged. Most people nowadays are seeking a simple treatment option, and I don’t think there’s anything wrong with going to the pills right away if there are no contraindications," says Dr. Perlmutter.

Medications

The most commonly prescribed medications are phosphodiesterase type 5 (PDE5) inhibitors, which include Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra), and Avanafil (Stendra). These medications work by increasing blood flow to the penis, helping to achieve and maintain an erection in response to sexual stimulation. Each has their positives and negatives, and a physician will help you decide which one is right for you.

Sildenafil (Viagra): Viagra is effective for about four to six hours and should be taken on an empty stomach about an hour before sexual activity. It is best suited for men who prefer spontaneity and do not plan their sexual activities far in advance.

Tadalafil (Cialis): Cialis offers a longer duration of action, lasting up to 36 hours, and can be taken with or without food. It is available in a daily dose, allowing for more spontaneous sexual activity, making it ideal for men who prefer not to plan around a medication.

Vardenafil (Levitra): Levitra is similar to Viagra but can be taken with food, although a high-fat meal may slow down its absorption. It is effective for about four to five hours.

Avanafil (Stendra): Stendra has a quick onset of action, working in as little as 15 minutes, and is effective for up to six hours. It is suitable for men who require a rapid response.

While PDE5 inhibitors are generally safe and effective, they can cause side effects in some men. Common side effects include:

• Headaches

• Flushing

• Indigestion

• Nasal congestion

• Dizziness

• Visual disturbances (e.g., blue tinge to vision, increased sensitivity to light, or blurred vision)

Rare but serious side effects include:

• Priapism: A prolonged and painful erection lasting more than four hours, which requires immediate medical attention.

• Sudden hearing loss

• Heart attack or stroke: These are extremely rare and typically occur in men with pre-existing cardiovascular conditions.

"There are side effects; the biggest one is an erection that won’t go down. It’s a very low percentage of patients that have it, but if you’re mixing it with other drugs, prescription or nonprescription, you can be at risk. The biggest risk in the older population is it can drop blood pressure, so we always want to avoid it in patients taking nitroglycerin," says Dr. Perlmutter.

Contraindications

Men taking nitrate medications for chest pain (angina) should not use PDE5 inhibitors, as the combination can cause a dangerous drop in blood pressure. Additionally, men with severe heart disease, recent stroke or heart attack, or uncontrolled high or low blood pressure should consult their doctor before using these medications.

Therapies and counseling

Addressing issues like anxiety, depression, and stress can improve ED. Therapy can also help with performance anxiety and relationship issues. Not to mention that improving communication and intimacy with a partner can reduce ED symptoms and enhance the overall relationship.

Specific techniques and exercises provided by a sex therapist can also help reduce performance anxiety and improve sexual function.

Surgical interventions

If medication proves to be ineffective, surgery may be considered that give patients a more permanent alternative. Surgical implants, either inflatable or semi-rigid, can provide a permanent solution for ED. This option is typically considered when other treatments have failed.

In rare cases, surgery to repair arteries can improve blood flow to the penis, which may be beneficial for younger men with specific vascular injuries.

Each man’s experience with ED is unique, and the best treatment plan involves a thorough evaluation and personalized approach by a healthcare provider. Whether through medications, lifestyle changes, therapy, or surgery, many men can find relief and improve their sexual health and overall quality of life.

Living with erectile dysfunction

While ED can be embarrassing for men, with the right approach, it is possible to manage the condition effectively and maintain a fulfilling life. Managing ED often involves a combination of medical treatment and lifestyle adjustments, combined with practical strategies that you can start implementing today:

• Follow medical advice: Adhere to the treatment plan prescribed by your health care provider, whether it involves medications, lifestyle changes, or therapy. Regular follow-ups are crucial to monitor progress and make necessary adjustments.

• Adopt a healthy lifestyle: Embrace habits that promote overall health and improve erectile function. This includes a balanced diet, regular exercise, quitting smoking, limiting alcohol intake, and managing stress.

• Stay informed: Educate yourself about ED and its causes. Understanding the condition can reduce anxiety and help you make informed decisions about your health.

Stay communicative with your partner(s)

Many men have performance anxiety because they're worried about not satisfying their partner(s). However, communication can alleviate those feelings and lead to greater intimacy. Share your feelings and concerns with your partner. Honest communication fosters trust and can alleviate the pressure and anxiety associated with ED.

You can also involve your partner in the treatment process. Attend medical appointments together and discuss treatment options and progress. Remember that intimacy is not solely about sexual intercourse. Explore other forms of physical and emotional intimacy to maintain a close connection with your partner.

Living with erectile dysfunction requires a holistic approach that addresses both the physical and emotional aspects of the condition. By following medical advice, maintaining open communication with your partner, seeking support, and embracing a healthy lifestyle, you can effectively manage ED and lead a fulfilling life. Remember, ED is a treatable condition, and help is available—don’t hesitate to reach out and take the necessary steps toward improvement.

"If someone’s having a problem, especially a medical problem, they just have to be open and honest with the doctor. They have to realize we’ve seen it before. They’re not the first patient we’ve seen with that problem, and they’re not going to be the last," says Dr. Perlmutter.

Adam Perlmutter, DO, is a urologist on staff at Saint Joseph Health System. Dr. Perlmutter specializes in helping patients overcome erectile and other urologic conditions. To make an appointment with a Saint Joseph Health System urologist, please visit sjmed.com/saint-joseph-urology.