In comparison, 37% of men who had received external radiotherapy as their primary therapy reported the ability to attain functional erections suitable for intercourse, along with 43% of men who had received brachytherapy as primary treatment. Pretreatment sexual health-related quality of life score, age, serum prostate-specific antigen (PSA) level, race or ethnicity, body mass index, and intended treatment details were associated with functional erections 2 years after treatment. [45]
Although not indicated for routine use, nocturnal penile tumescence (NPT) testing may be useful in the patient who reports a complete absence of erections (exclusive of nocturnal "sleep" erections) or when a primary psychogenic etiology is suspected. Such testing should be performed by those with expertise and knowledge of its interpretation, pitfalls, and usefulness. Various methods and devices are available for the evaluation of nocturnal penile tumescence, but their clinical usefulness is restricted by limitations of diagnostic accuracy and availability of normative data. Further study regarding standardization of NPT testing and its general applicability is indicated.
The 1985 National Ambulatory Medical Care Survey indicated that there were about 525,000 visits for erectile dysfunction, accounting for 0.2 percent of all male ambulatory care visits. Estimates of visits per 1,000 population increased from about 1.5 for the age group 25-34 to 15.0 for those age 65 and above. The 1985 National Hospital Discharge Survey estimated that more than 30,000 hospital admissions were for erectile dysfunction.
medicines called alpha-blockers such as Hytrin (terazosin
HCl), Flomax (tamsulosin HCl), Cardura (doxazosin
mesylate), Minipress (prazosin HCl), Uroxatral (alfuzosin HCl),
 Jalyn (dutasteride and tamsulosin HCl), or Rapaflo (silodosin).
Alpha-blockers are sometimes prescribed for prostate
problems or high blood pressure. In some patients, the use
of Sildenafil with alpha-blockers can lead to a drop in blood pressure or to fainting
An approach to the diagnosis and management of the impotent patient is presented in Figure 187.1. Apparent and likely causes of impotence should be considered first and, if possible, eliminated before the work-up continues. For instance, observing the patient for a few weeks off offending medication may be all that is necessary to establish the cause of impotence. When no obvious or remediable cause is present, the next step is based on the clinical impression of the likelihood of organic versus psychologic impotence. If the latter is considered more likely, it is perfectly reasonable to refer the patient directly for sexual therapy, with the option of reconsidering the diagnosis if, after appropriate therapy, there is no improvement. While an occasional patient with organic impotence will be misrouted, many more with psychogenic impotence will be spared an unnecessary and costly evaluation for organic causes. When organic impotence is likely, a serum testosterone level is the initial screening test for hypogonadism and should be obtained prior to urologic referral. Patients with low testosterone levels require further endocrine evaluations as depicted in Figure 187.1.

Factors that mediate contraction in the penis include noradrenaline, endothelin-1, neuropeptide Y, prostanoids, angiotensin II, and others not yet identified. Factors that mediate relaxation include acetylcholine, nitric oxide (NO), vasoactive intestinal polypeptide, pituitary adenylyl cyclase–activating peptide, calcitonin gene–related peptide, adrenomedullin, adenosine triphosphate, and adenosine prostanoids.
The most common treatment for erectile dysfunction is drugs known as phosphodiesterase-5 (PDE-5) inhibitors. These include tadalafil (Cialis), vardenafil (Levitra), and sildenafil citrate (Viagra). These are effective for about 75% of men with erectile dysfunction. They are tablets that are taken around an hour before sex, and last between 4 and 36 hours. Sexual stimulation is required before an erection will occur. The PDE-5 inhibitors cause dilation of blood vessels in the penis to allow erection to occur, and help it to stay rigid. Men using nitrate medication (e.g. GTN spray or sublingual tablets for angina) should not use PDE-5 inhibitors.
So not only are erectile problems common, they're nothing for you or your special friend to be freaked out about. Check out the nine most common reasons that dudes sometimes can't get it up, and get ready to become the soothing voice of reason the next time the guy you're with has a hard time pitching his tent in your happy valley. Everything (and every penis) is gonna be fine!
In the majority of patients the impotence is organic, though not endocrinologic, and there is no easily remedied cause. These patients require physiologic testing and urologic consultation for specific diagnosis. Likely causes of impotence in this group include vascular and neurologic diseases. These patients are candidates for penile prostheses or, in special cases, for revascularization. Patients interested in surgical approaches should be referred for further testing. There is little to be gained by continuing the work-up of patients who prefer not to have an operation.
Dr. Liou says that some men come to him after getting a prescription from their primary care doctors, claiming that the drug doesn't work. Sometimes it's because they used it incorrectly. "The biggest misconception is that these drugs are an on/off switch for erections," Dr. Liou says. But the drugs don't work well without sexual stimulation. "During that time, you need to be with your partner and have foreplay," Dr. Liou says. "Don't take it, do the taxes or the dishes, and then meet at the bedroom thinking you'll be ready to go. It's not like that."
But if the blood flow is weak here, it is highly likely that it is also weak in arteries supplying the heart, raising the risk of a heart attack. In fact, some studies suggest that women with heart disease may also suffer sexual dysfunction: the clitoris, like the penis, is a vascular organ, and also relies on healthy blood flow for successful orgasms.
2 inability of the adult male to achieve or sustain a penile erection or, less commonly, to ejaculate after achieving an erection. Several forms are recognized. Functional impotence has a psychological basis. Organic impotence includes vasculogenic, neurogenic, endocrinic, and anatomical factors. Anatomical impotence results from physically defective genitalia. Atonic impotence involves disturbed neuromuscular function. Poor health, old or advancing age, drugs, smoking, trauma, and fatigue can induce impotence. Also called erectile dysfunction, impotency. impotent, adj.
Maybe your performance issues stem from feelings of discomfort relating to something you've done. Are you having trouble performing because you're feeling uncertain about whether you really love your partner? Or because you feel like you crossed a line in terms of infidelity and now the guilt is tearing you up inside? Maybe your conscience is what's wreaking havoc with your sex.
"One couple came to see me, and when I asked the man how long he'd had erectile dysfunction, he told me it had been happening for five years. His wife looked at him and said: 'But this is the first I've heard of this.'" He adds that Viagra-type drugs can mask the problem, and many men still buy them online to avoid talking to their doctor about their difficulties in the bedroom. As a result, their risk of heart attack is never picked up.
If you have unstable heart disease of any kind, heart failure or unstable, what we call angina, contraindication to using the medications. All right? So if you’re in an unstable medical state, these medications are not a good idea. Now, there are relative issues. If you may be taking a blood pressure medicine or a medicine for your prostate which dilates your blood vessel a little bit– you know, the typical ones are what we call the alpha blockers– you may have an additive effect from the medication. But for the most part, the medicines are incredibly safe.

The penis contains three cylinders, the two corpora cavernosa, which are on the top of the penis (see figure 1 below). These two cylinders are involved in erections. The third cylinder contains the urethra, the tube that the urine and ejaculate passes through, runs along the underside of the penis. The corpus spongiosum surrounds the urethra. Spongy tissue that has muscles, fibrous tissues, veins, and arteries within it makes up the corpora cavernosa. The inside of the corpora cavernosa is like a sponge, with potential spaces that can fill with blood and distend (known as sinusoids). A layer of tissue that is like Saran Wrap, called the tunica albuginea, surrounds the corpora. Veins located just under the tunica albuginea drain blood out of the penis.
The Massachusetts Male Aging Study (MMAS) documented an inverse correlation between ED risk and high-density lipoprotein (HDL) cholesterol levels but did not identify any effect from elevated total cholesterol levels. [15] Another study involving male subjects aged 45-54 years found a correlation with abnormal HDL cholesterol levels but also found a correlation with elevated total cholesterol levels. The MMAS included a preponderance of older men.
Treatments include psychotherapy, adopting a healthy lifestyle, oral phosphodiesterase type V (PDE5) inhibitors (Viagra, Levitra, Cialis, Stendra, and Staxyn), intraurethral prostaglandin E1 (MUSE), intracavernosal injections (prostaglandin E1 [Caverject, Edex], Bimix and Trimix), vacuum devices, penile prosthesis and vascular surgery, and (in some cases) changes in medications when appropriate.

3. Are there physical causes of erectile dysfunction? Erectile dysfunction may be a symptom of underlying medical conditions, which if not detected may cause further medical problems. A prior history of cigarette smoking, heart attacks, strokes, and poor circulation in the extremities (for example, intermittent claudication or cramping in your leg[s] when you walk) suggest atherosclerosis as the cause of the erectile dysfunction. Loss of sexual desire and drive, lack of sexual fantasies, gynecomastia (enlargement of breasts), and diminished facial hair suggest low testosterone levels. A prior history of pelvic surgery or radiation and trauma to the penis/pelvis/perineum can cause problems with the nerves and blood vessels. Symptoms of intermittent claudication of the lower extremities with exercise may suggest a vascular problem as a cause of the erectile dysfunction.


A system for inserting a pellet of alprostadil into the urethra is marketed as MUSE. The system uses a pre-filled applicator to deliver the pellet about an inch deep into the urethra at the tip of the penis. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects of the preparation are aching in the penis, testicles, and area between the penis and rectum; warmth or burning sensation in the urethra; redness of the penis due to increased blood flow; and minor urethral bleeding or spotting.

Watts and coworkers, in their review article, make several points about this ED/CAD nexus. Endothelial dysfunction is present in both CVD and ED, and is linked through the NO mechanism. The authors note that PDE5 inhibitors improve endothelial function and have a salutary effect on both CVD and ED. Both ED and cardiac disease respond to modifications in lifestyle as well as pharmacologic manipulation. These authors also report that the presence of ED gives the clinician an opportunity to assess CVD and prevention as well.20
In a prospective study from the Prostate Cancer Prevention Trial database, Thompson et al reported that men presenting with ED had a significantly higher chance of developing a cardiovascular event over a 7-year follow-up period. [55] The hazard ratio was 1.45, which is in the range of risk associated with current smoking or a family history of MI.
It can also help to tell your partner (either before you start or when it happens) that hey, sometimes it takes your penis a while to warm up or sometimes it comes and goes as it pleases — and that they shouldn't take it personally and you won't let it ruin the moment. When it happens, take a few deep breaths, focus on your partner, and go back to doing whatever was feeling good before. "If they approach that with authentic confidence, the partner is usually like 'OK, cool,'" says Skyler. "Remember, you're more than just your penis."
If PDE-5 inhibitors are not suitable or don’t work, other therapies include injections into the base of the penis, which cause flow of blood into the penis and a fairly immediate erection that lasts around an hour. The drugs injected are alprostadil (Caverject and Erectile dysfunctionex) and Invicorp (VIP and phentolamine). Alprostadil may also be inserted as a gel into the opening of the penis. This is not suitable if your partner is pregnant.

The percentage of men who engage in some form of sexual activity decreases from 73% for men aged 57–64 years to 26% for men aged 75–85 years.3 For some men, this constitutes a problem, but for others it does not. The aetiology for this decline in sexual activity is multifactorial and is in part due to the fact that most of the female partners undergo menopause at 52 years of age with a significant decline in their libido and desire to engage in sexual activity. A study by Lindau and colleagues3 that examined sexuality in older Americans showed that 50% of the men in a probability sample of more than 3000 US adults reported at least one bothersome sexual problem and 33% had at least two such problems.3 This article will review the normal changes that occur with ageing, factors that influence these changes, individual variations and perspectives, and the available treatment options for ED and androgen deficiency.


With sex therapy, your counselor looks at the sexual problems you and your partner are having. Sex therapy works with problems such as performance anxiety, which means that you worry so much about whether you will be able to have sex that you are not able to. It also helps when you have erection problems that are not due to physical or drug problems, or premature ejaculation (you come too quickly). It may help you to reach orgasm or to learn to relax enough to avoid pain during sex. Counseling can help you to adjust to the treatment you and your doctor choose.
Causes contributing to erectile dysfunction can be broadly classified into two categories: organic and psychologic. In reality, while the majority of patients with erectile dysfunction are thought to demonstrate an organic component, psychological aspects of self-confidence, anxiety, and partner communication and conflict are often important contributing factors.
None of the ED drugs is safe to take with cardiac drugs called nitrates because it could cause a dangerous drop in blood pressure. Drugs that many men take for urinary symptoms, called alpha blockers, can also lower blood pressure, so take them at least four hours apart from ED drugs. Your doctor may start you on a smaller dose of the ED drug if you already take an alpha blocker, or may recommend the alpha blocker tamsulosin (Flomax), which affects blood pressure less.
Although erectile dysfunction increases progressively with age, it is not an inevitable consequence of aging. Knowledge of the risk factors can guide prevention strategies. Specific antihypertensive, antidepressant, and antipsychotic drugs can be chosen to lessen the risk of erectile failure. Published lists of prescription drugs that may impair erectile functioning often are based on reports implicating a drug without systematic study. Such studies are needed to confirm the validity of these suggested associations. In the individual patient, the physician can modify the regimen in an effort to resolve the erectile problem.
The dorsal artery provides for engorgement of the glans during erection, whereas the bulbourethral artery supplies the bulb and the corpus spongiosum. The cavernous artery effects tumescence of the corpus cavernosum and thus is principally responsible for erection. The cavernous artery gives off many helicine arteries, which supply the trabecular erectile tissue and the sinusoids. These helicine arteries are contracted and tortuous in the flaccid state and become dilated and straight during erection. [9]

3. An intact, anatomically correct penis; 25% of impotence may be psychologic or 'partner-specific', 25% has an organic component and 50% of impotence is organic in nature; in organic impotence, nocturnal penile tumescence is absent Management-surgical Microvascular surgery to bypass occluded vessels–most effective in younger ♂, penile prosthesis Management-medical Combined therapy with phentolamine and papaverine–self-injected by the Pt, wielding an erection of 1 hr's duration is useful for arterial, neurologic, psychogenic impotence; other therapies–zinc, bromocriptine–Parlodel, isoxsuprine-Vasodilan, Voxsuprine, nitroglycerine, yohimbine–Yocon, Yohimex Etiology Smoking, CAD, HTN, DM, medications–hypoglycemic agents, vasodilators, cardiac drugs, antihypertensives, anger and depression; it is inversely correlated to dehydroepiandrosterone, HDL-C, and an index of dominant personality Primary impotence Complete absence of successful sexual coupling Secondary impotence Priapism, penile plaques, Peyronie's disease; drugs linked to impotence: antihypertensives–eg, methyldopa, guanethidine, reserpine, clonidine, due to ↓ BP, antidepressants–eg, phenelzine, isocarboxazide, amitriptyline–causing altered moods and decreased libido, tranquilizers–eg, chlordiazepoxide and lorazepam, and the muscle-relaxing diazepam, cimetidine, which ↑ prolactin, and is associated with impotence and loss of libido. Cf Infertility, Orgasmic dysfunction.


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Surgery: If neither drugs nor the vacuum pump works, your doctor may suggest surgery. With surgery, the doctor can place a device in your penis that will cause enough hardness for intercourse. In a few cases, infections may develop after the operation, and the doctor may have to remove the device. Another operation that may help you is rebuilding the blood vessels in the penis to increase blood flow into the penis or decrease blood flow out of the penis. These procedures can help you to get and maintain an erection.
In a randomized double-blind, parallel, placebo-controlled trial, sildenafil plus testosterone was not superior to sildenafil plus placebo in improving erectile function in men with ED and low testosterone levels. [19] The objective of the study was to determine whether the addition of testosterone to sildenafil therapy improves erectile response in men with ED and low testosterone levels.
My boyfriend, 25, can't get hard anymore!! He WANTS to have sex, but he just won't get hard, when just about a month ago he would get hard just by looking at me. We have been together for six months, and I'm starting to think he might be bored of me or that I'm the problem. He says it's not me at all. Our relationship is great, but I don't know what to do. Please help!!
You get to decide what is normal for you. That might include him still experiencing pleasure from you touching his penis even if he’s not hard. Some men can still orgasm without an erection. Or he may prefer not to have any touching while he is dealing with his erection problems. It is okay for you to orgasm even if he doesn’t. Reading about what might bring you pleasure, or considering how you think about sex can make this something enjoyable to explore together.
*all photos are models and not actual patients.If you are interested in a prescription product, Hims will assist in setting up a visit for you with an independent physician who will evaluate whether or not you are an appropriate candidate for the prescription product and if appropriate, may write you a prescription for the product which you can fill at the pharmacy of your choice.
Stiffy Solution: Again, saying "stop being so stressed out so you can get boners again" is easier said than done — but a lot of people find sexual dysfunction to be a stronger motivator to live a healthier lifestyle than the threat of, say, a heart attack down the road; so there's a chance that this could actually be a good thing in the long run for your boo, if it helps him take his stress seriously. Relaxation techniques like yoga, exercise, meditation, tai chi, and getting adequate sleep can all lessen the impact of stress on your body (and your dong).
Penile blood flow is measured using a Doppler probe and a 2.5 cm blood pressure cuff. Systolic pressures in the right and left corpora cavernosa are measured and the penile–brachial index is calculated taking a ratio of penile systolic pressure to brachial systolic pressure. These measures should be repeated before and after 3 minutes of exercising the pelvic and leg muscles. In normal men, the PBI should be 0.9 or greater. Ratios between 0.7 and 0.9 suggest vascular impotence; a ratio below 0.6 is diagnostic. Pelvic arteriography can be done if revascularization is considered.
A semi-firm penis if correctly handled can give a somewhat pleasant orgasm. I really don't think there is such a thing as an unpleasant orgasm though. I have have ED for two years. It has been than long since I had sex with my wife in her vagina. There has been plenty of oral sex for her. The ED drugs do not work with me. I take injectable Testosterone, and that does not make a big difference. About twice a month I am able to masturbate. Hey I am glad to know it still works. Next week I am going to see urologist number 2. The first one was a jerk and basically wrote me off because of my age. Now I have read about the Viberect device and the NEW pudendal artery (to the penis). There is hope, but in the mean time I will masturbate as often as I can.
Recently, the US Food and Drug Administration (FDA) has issued a safety announcement regarding TRT. In part it reads ‘The benefit and safety of these medications have not been established. We are also requiring these manufacturers to add information to the labeling about a possible increased risk of heart attacks and strokes in patients taking testosterone.’37

In addition to Viagra, other ED drugs available in the United States include avanafil (Stendra), tadalafil (Cialis) and vardenafil (Levitra). These all improve blood supply to the penis. In combination with sexual stimulation, the drugs can produce an erection sufficient to initiate and complete intercourse. There is also a fast-dissolving form of Levitra, called Staxyn, that you put under your tongue.
So what can you do to help things along a little?  Well, chances are it may sort itself out as you settle in to your relationship. But if it keeps happening and you see a future in the relationship, you need to talk about it, or it will soon become the elephant in the bedroom. Pick a time with no distractions and where nobody can overhear you. Tell them that you care about them and that you don’t need to rush things sexually. This can take the pressure off the need to perform. 
Did you know that erectile dysfunction precedes coronary artery disease in almost 70 percent of cases.2 The arteries in the penis are smaller than those that cause heart disease symptoms, which means they are likely to be affected by blockages sooner. When the arteries in the penis are blocked, keeping an erection will be difficult regardless of your level of arousal.
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