Other medical therapies under evaluation include ROCK inhibitors and soluble guanyl cyclase activators. Melanocortin receptor agonists are a new set of medications being developed in the field of erectile dysfunction. Their action is on the nervous system rather than the vascular system. PT-141 is a nasal preparation that appears to be effective alone or in combination with PDE5 inhibitors. The main side effects include flushing and nausea. These drugs are currently not approved for commercial use.
Erection is a vascular event. The penis becomes rigid when blood flow to the corpora cavernosa increases sixfold and venous outflow is physiologically impeded. Penile perfusion is governed by three organ systems—the neurologic, circulatory, and endocrinologic systems—each necessary for potency. The neurologic system accounts for vasodilation and venoconstriction of the corporal blood vessels so that blood is shunted to the erectile tissues; the circulatory system provides adequate blood flow to the hypogastric-cavernous bed, a distal branch off the internal iliac vessels; and the endocrine system, mediated by testosterone, plays a permissive role through mechanisms that have yet to be elucidated.

There's no right number of times to tell people you love them. Some people might love hearing "I love you" 15 times a day, and, for some people, 50 might not be enough. There's no rule, so it's tricky. You could just tell your boyfriend to dial it back, but he'll probably need an explanation. I think you need to think about why all of his lovey-dovey talk bothers you, so you know what to tell him.
The main medical causes of erectile dysfunction are based around poor blood flow (due to furring of the arteries thanks to raised cholesterol or high blood pressure), poor nerve supply caused by diabetes-related nerve damage, or low testosterone as a result of obesity, old age or failing gonads. We doctors get just as concerned with men who have variable erections as well as those that can't get an erection at all. Failing to get an erection occasionally is pretty normal as you get older. But if you have unreliable erections for a prolonged period of time – more than six months – this could suggest an early sign of physical problems such as cardiovascular disease or diabetes which could develop further so get yourself checked out.
Psychosocial factors are important in all forms of erectile dysfunction. Careful attention to these issues and attempts to relieve sexual anxieties should be a part of the therapeutic intervention for all patients with erectile dysfunction. Psychotherapy and/or behavioral therapy alone may be helpful for some patients in whom no organic cause of erectile dysfunction is detected. Patients who refuse medical and surgical interventions also may be helped by such counseling. After appropriate evaluation to detect and treat coexistent problems such as issues related to the loss of a partner, dysfunctional relationships, psychotic disorders, or alcohol and drug abuse, psychological treatment focuses on decreasing performance anxiety and distractions and on increasing a couple's intimacy and ability to communicate about sex. Education concerning the factors that create normal sexual response and erectile dysfunction can help a couple cope with sexual difficulties. Working with the sexual partner is useful in improving the outcome of therapy. Psychotherapy and behavioral therapy have been reported to relieve depression and anxiety as well as to improve sexual function. However, outcome data of psychological and behavioral therapy have not been quantified, and evaluation of the success of specific techniques used in these treatments is poorly documented. Studies to validate their efficacy are therefore strongly indicated.
Many factors can contribute to sexual dysfunction in older men, including physical and psychological conditions, comorbidities and the medications used to treat them. Aspects of an ageing man’s lifestyle and behaviour and androgen deficiency, most often decreasing testosterone levels, may affect sexual function as well. A study of men between the ages of 30 and 79 years showed that 24% had testosterone levels below 300 ng/dL and 5.6% had symptomatic androgen deficiency.2

Surgery to repair arteries (penile arterial reconstructive surgery) can reduce impotence caused by obstructions that block the flow of blood to the penis. The best candidates for such surgery are young men with discrete blockage of an artery because of a physical injury to the pubic area or a fracture of the pelvis. The procedure is less successful in older men with widespread blockage of arteries.

Acetylcholine released by the parasympathetic nerves is thought to act primarily on endothelial cells to release a second nonadrenergic-noncholinergic carrier of the signal that relaxes the trabecular smooth muscle. Nitric oxide released by the endothelial cells, and possibly also of neural origin, is currently thought to be the leading of several candidates as this nonadrenergic-noncholinergic transmitter; but this has not yet been conclusively demonstrated to the exclusion of other potentially important substances (e.g., vasoactive intestinal polypeptide). The relaxing effect of nitric oxide on the trabecular smooth muscle may be mediated through its stimulation of guanylate cyclase and the production of cyclic guanosine monophosphate (cGMP), which would then function as a second messenger in this system.
Men with a rare heart condition known as long QT syndrome should not take vardenafil since this may lead to abnormal heart rhythms. The QT interval is the time it takes for the heart's muscle to recover after it has contracted. An electrocardiogram (EKG) measures the QT interval. Some people have longer than normal QT intervals, and they may develop potentially life-threatening abnormal heart rhythms, especially when given certain medications. Men with a family history of long QT syndrome should not take vardenafil, as it is possible to inherit long QT syndrome. Furthermore, vardenafil is not recommended for men who are taking medications that can affect the QT interval such as quinidine (Quinaglute, Quinidex), procainamide (Pronestyl, Procan-SR, Procanbid), amiodarone (Cordarone), and sotalol (Betapace).
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.

Injection of vasodilator substances into the corpora of the penis has provided a new therapeutic technique for a variety of causes of erectile dysfunction. The most effective and well-studied agents are papaverine, phentolamine, and prostaglandin E[sub 1]. These have been used either singly or in combination. Use of these agents occasionally causes priapism (inappropriately persistent erections). This appears to have been seen most commonly with papaverine. Priapism is treated with adrenergic agents, which can cause life-threatening hypertension in patients receiving monoamine oxidase inhibitors. Use of the penile vasodilators also can be problematic in patients who cannot tolerate transient hypotension, those with severe psychiatric disease, those with poor manual dexterity, those with poor vision, and those receiving anticoagulant therapy. Liver function tests should be obtained in those being treated with papaverine alone. Prostaglandin E[sub 1] can be used together with papaverine and phentolamine to decrease the incidence of side effects such as pain, penile corporal fibrosis, fibrotic nodules, hypotension, and priapism. Further study of the efficacy of multitherapy versus monotherapy and of the relative complications and safety of each approach is indicated. Although these agents have not received FDA approval for this indication, they are in widespread clinical use. Patients treated with these agents should give full informed consent. There is a high rate of patient dropout, often early in the treatment. Whether this is related to side effects, lack of spontaneity in sexual relations, or general loss of interest is unclear. Patient education and followup support might improve compliance and lessen the dropout rate. However, the reasons for the high dropout rate need to be determined and quantified.

The appropriate evaluation of all men with erectile dysfunction should include a medical and detailed sexual history (including practices and techniques), a physical examination, a psycho-social evaluation, and basic laboratory studies. When available, a multidisciplinary approach to this evaluation may be desirable. In selected patients, further physiologic or invasive studies may be indicated. A sensitive sexual history, including expectations and motivations, should be obtained from the patient (and sexual partner whenever possible) in an interview conducted by an interested physician or another specially trained professional. A written patient questionnaire may be helpful but is not a substitute for the interview. The sexual history is needed to accurately define the patient's specific complaint and to distinguish between true erectile dysfunction, changes in sexual desire, and orgasmic or ejaculatory disturbances. The patient should be asked specifically about perceptions of his erectile dysfunction, including the nature of onset, frequency, quality, and duration of erections; the presence of nocturnal or morning erections; and his ability to achieve sexual satisfaction. Psychosocial factors related to erectile dysfunction should be probed, including specific situational circumstances, performance anxiety, the nature of sexual relationships, details of current sexual techniques, expectations, motivation for treatment, and the presence of specific discord in the patient's relationship with his sexual partner. The sexual partner's own expectations and perceptions should also be sought since they may have important bearing on diagnosis and treatment recommendations.


The neurologic pathways required for erection originate in the cerebral cortex where visual, auditory, and psychic stimuli are processed, and in the pudenal nerve, an afferent nerve that transmits tactile sensations from the genitals to the sacral segments of the spinal cord and cortex. Efferent signals from the spinal cord pass along the pelvic parasympathetic nerves and dilate the corporal vessels. The specific neurotransmitters have not been fully defined; acetylcholine, and perhaps vasoactive intestinal peptide, appears to be important. There are many causes of neurogenic impotence. Anything that disrupts neural pathways or blocks neurochemical transmission will have an adverse effect on erection. Psychologic factors probably interfere with erection by inhibiting corticosacral efferent pathways.
Lindsay Mitchell, ARNP is a Board Certified Family Nurse Practitioner and graduated with high honors from South University in Savannah, GA. She has a background in primary care, women’s health and focusing on evidence based practices. She has a strong passion for providing efficient and accessible patient care, along with caring for underserved patient populations. Prior to becoming an ARNP, she worked as a registered nurse in the emergency department in Jacksonville, Fl.
Some men should not take PDE5 inhibitors. They can cause hypotension (abnormally low blood pressure that can lead to fainting and even shock) when given to patients who are taking nitrates (medications taken for heart disease). Therefore, patients taking nitrates daily should not take any of the PDE5 inhibitors. Nitrates relieve angina (chest pain due to insufficient blood supply to the heart muscle because of narrowing of the coronary arteries); these include nitroglycerine tablets, patches, ointments, sprays, and pastes, as well as isosorbide dinitrate and isosorbide mononitrate. Other nitrates such as amyl nitrate and butyl nitrate also are in some recreational drugs called "poppers."
Vardenafil and tadalafil belong to the same group of chemical compounds as sildenafil, namely phos-phodiesterase type 5 (PDE-5) inhibitors. Some men cannot benefit from sildenafil or the two newer PDE-5 inhibitors because they have low levels of nitric oxide. British investigators reported in late 2002 that three different types of compounds are being studied as possible medications for men with low levels of nitric oxide. They are Rho-kinase inhibitors, soluble guanylate cyclase activators, and nitric oxide-releasing PDE-5 inhibitors.
If you just got off solo, you might have to wait before you can hop into bed with your partner, says Dr. Brahmbhatt. It might have something to do with a spike in the hormone prolactin after you orgasm, according to a study published in the International Journal of Impotence Research. This hormone has been linked to difficulties maintaining an erection or even ejaculating.
Traditionally, erectile impotence (the classical definition of impotence) is the failure to achieve penile erection during intercourse. It may have either physical or psychological causes. Alcoholism, endocrine disease, and neurological disorders are typical physical causes. Psychological causes include anxiety over performance, hostility or other negative feelings toward the sexual partner, and stress, anxiety, depression, or other emotional conflicts outside of the relationship. Erectile impotence occasionally occurs with age and, although attributed by the individual to the aging process itself, it is usually secondary to disorders of aging, such as faulty blood circulation or prostate disease. In cases of impotence caused by blood vessel dysfunction, an insufficient supply of blood flows into the penis, or the blood diffuses out into adjacent tissues.
It is essential to discuss erectile dysfunction with your doctor, so any serious underlying causes can be excluded and treatment options can be discussed. Many men are embarrassed discussing this issue with their doctor, or even their partner. Open communication with your doctor, and in your relationship, is important for effectively managing this common problem.
Dr. Matthew Walvick, D.O. is a board certified Internal Medicine physician. He completed his undergraduate education at UCLA. He received his medical degree from Touro University College of Osteopathic Medicine in Vallejo, California. He completed his Internal Medicine residency at UCSF's Fresno Medical Education Program. Prior to joining Lemonaid Health, Dr. Walvick was a practicing primary care physician at John Muir Health and then doing house calls with the start-up Heal. Dr. Walvick is excited to be a part of the Lemonaid Health team making healthcare refreshingly simple.

There was never any claim for Normal Sexual Decline as being applicable to all men all of the time. The point is that males and females should be made aware of what to reasonably expect and to be aware as well as to the incomplete writings / hidden agendas of the reports in this area. Research has clearly show what to reasonably expect. Meta Analysis can illucidate what is very likely normal for most males / what is hidden, etc.

There's no right number of times to tell people you love them. Some people might love hearing "I love you" 15 times a day, and, for some people, 50 might not be enough. There's no rule, so it's tricky. You could just tell your boyfriend to dial it back, but he'll probably need an explanation. I think you need to think about why all of his lovey-dovey talk bothers you, so you know what to tell him.

Organic Impotence. Diabetes mellitus, thyroid disease, and dysfunction of the pituitary gland or testes can cause impotence, as can certain medications. Other organic causes include arterial ischemia associated with atherosclerosis of the aorta and common iliac arteries, extensive pelvic surgery such as radical prostatectomy, spinal cord injury and other neurologic disorders, and a history of cigarette smoking. Because certain medications can cause impotence, it is recommended that in cases of recent impotence it be determined whether the patient has started on a new drug. The most common offenders are diuretics, antihypertensives, and vasodilators. Alcohol, which sometimes is ignored as a drug, is often a contributor to the problem of impotence.

Infection is a concern after placement of a prosthesis and is a reported complication in 8%-20% of men undergoing placement of a penile prosthesis. If a prosthesis becomes infected (redness, pain, and swelling of the penis and sometimes purulent drainage are signs of infection), the prosthesis must be removed. Depending on the timing and severity of the infection and your surgeon's preference, the area can be irrigated extensively with antibiotic solutions and a new prosthesis placed at the same time or removal of the infected prosthesis and an attempt to place a new prosthesis made at a later time when the infection is totally cleared.
If you are taking medications (alpha-blockers) for problems with an enlarged prostate, you should discuss your prostate medications with your doctor. Alpha-blockers also can cause lowering of the blood pressure. Thus your doctor will need to carefully watch your blood pressure when you start the PDE5 inhibitor. Common alpha-blockers include doxazosin (Cardura), terazosin (Hytrin), and tamsulosin (Flomax).
An analysis of 14 studies involving more than 90,000 patients with ED confirmed the relation between ED and an increased risk of cardiovascular events and mortality. [56] Compared with patients without ED, those with ED had a 44% increased risk of cardiovascular events, a 25% increased risk of all-cause mortality, a 62% increased risk of MI, and a 39% increased risk of cerebrovascular events. Treatment of ED, either through lifestyle interventions or by pharmacologic means, may improve prognosis and reduce risk.
It appears that testosterone has NOS-independent pathways as well. In one study, castrated rats were implanted with testosterone pellets and then divided into a group that received an NOS inhibitor (L-nitro-L-arginine methyl ester [L-NAME]) and a control group that received no enzyme. [24] The castrated rats that were given testosterone pellets and L-NAME still had partial erections, a result suggesting the presence of a pathway independent of NOS activity.
Male/Female Perceptions and Influences. The diagnosis of erectile dysfunction may be understood as the presence of a condition limiting choices for sexual interaction and possibly limiting opportunity for sexual satisfaction. The impact of this condition depends very much on the dynamics of the relationship of the individual and his sexual partner and their expectation of performance. When changes in sexual function are perceived by the individual and his partner as a natural consequence of the aging process, they may modify their sexual behavior to accommodate the condition and maintain sexual satisfaction. Increasingly, men do not perceive erectile dysfunction as a normal part of aging and seek to identify means by which they may return to their previous level and range of sexual activities. Such levels and expectations and desires for future sexual interactions are important aspects of the evaluation of patients presenting with a chief complaint of erectile dysfunction.
While pills for ED are convenient, some men sustain stronger erections by injecting medication directly into the penis. Drugs approved for this purpose work by widening the blood vessels, causing the penis to become engorged with blood. Another option is inserting a medicated pellet into the urethra. The pellet can trigger an erection within 10 minutes.
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