Whenever I am prescribing a medication to a patient, I’m always asking myself, what can the patient do before requiring the medication? What changes do they have to make in order to reduce the amount of medication or preclude their even needing it? So a good candidate is somebody who has an understanding of a healthy lifestyle, about physical activity, about sleep, about nutrition, alcohol, smoking. So patients, individuals, have to do their share before they’re a candidate for anything. All right?
What you need to know about delayed ejaculation Delayed ejaculation is a sexual disorder that can be distressing for a man and his partner and may disrupt a relationship. There are many reasons why delayed ejaculation occurs, including tissue damage, age, drugs, and the side effects of medication. They may be physiological or psychological. Find out how to get help. Read now
Ultrasound with Doppler imaging (ultrasound plus evaluation of blood flow in the arteries and veins) can provide additional information about blood flow of the penis and may help in the evaluation of patients prior to surgical intervention. This study is typically performed after the injection of a chemical that causes the arteries to open up, a vasodilator (prostaglandin E1), into the corpora cavernosa in order to cause dilation of blood vessels and promote blood flow into the penis. The rate of blood flow into the penis can be measured along with an evaluation of problems with compression of the veins.
Phosphodiesterase inhibitors: This class of medications includes sildenafil, tadalafil, and vardenafil. They work by inhibiting an enzyme called phosphodiesterase type 5 (PDE-5), allowing more blood to enter the penis and helping to produce an erection. These medications are often taken before sex and will cause an erection only when the man is sexually stimulated.
Vascular: Anything that affects the flow of blood to the penis can result in erectile dysfunction. The main culprit tends to be atherosclerosis, the condition that narrows arteries and which can result in poor blood circulation, high blood pressure, heart disease and stroke. Atherosclerosis causes about half the cases of erectile dysfunction in men over 50. Also, the veins through which the blood leaves the penis may not be working properly, allowing the blood to leave too soon.
By contrast, psychogenic impotence typically is abrupt in onset, often in relation to psychological trauma, and may wax and wane. Patients with psychogenic impotence may have total erectile failure with one partner but not another, or be impotent during sexual intercourse but not during self-stimulation. Normally occurring spontaneous erections in the morning suggest psychogenic rather than organic causes for impotence.
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.

Men who wear tight underwear may also experience the same problems. Because of the constriction, feeling may be lost, and even if unnoticed actively, the brain will notice. This is part of the complication with erectile dysfunction between the brain and the body. While you may be in the mood, if the proper electrical signals are not sent back and forth, nothing will happen.
My fear of this happening has prevented me from getting with girls who aren't randoms in fear that they'll tell people about it. I've been thinking that maybe I should pop a Viagra or something the next time I think I'm gonna get lucky, just to build my confidence a bit, but that's really my last resort. Is there any advice you guys might be able to give me here?

Yohimbine: The main component of an African tree bark, yohimbine is probably one of the most problematic of all natural remedies for ED. Some research suggests that yohimbine can improve a type of sexual dysfunction that is linked with a drug used to treat depression. However, studies have linked yohimbine to a number of side effects, which can include anxiety, increased blood pressure, and a fast, irregular heartbeat. Like all natural remedies, yohimbine should only be used after advice and under supervision from a doctor.

Diabetes is one of the most common causes of ED. Chronically high blood sugar levels can result in nerve damage that affects your body’s ability to translate pleasurable sexual stimulation into an erection. Diabetes can also lead to issues with circulation, which reduces blood flow to the penis and makes it more difficult to keep an erection that is hard enough for intercourse.
Because adequate arterial supply is critical for erection, any disorder that impairs blood flow may be implicated in the etiology of erectile failure. Most of the medical disorders associated with erectile dysfunction appear to affect the arterial system. Some disorders may interfere with the corporal veno-occlusive mechanism and result in failure to trap blood within the penis, or produce leakage such that an erection cannot be maintained or is easily lost.
As a retired police Sgt. Mid 50's I always had a few anxiety or medicine related ED' s but those were women that didn't matter and I always made sure to have a laugh and good time. Now Been with one great women 16 years. Now I'm heavy, drink more than I should, take pain med for chronic pain and watch tv. Anyone here recognize this. how about those recreational drugs I don't do. Before complaining do what I just started. Lose weight, stop reading this and shut off the tv, STOP smoking, go to the Dr. Get blood work done, talk to someone even or especially your better half, talk to and trust your Dr. Trust me, he's heard much worse. Trust that inner voice or gut, it's there for you. And mostly stop saying what about me and my winky, and take care of the other one who loves, cleans, sleeps and whatever else he/she does For u. This won't work for all but I know somehow it will help... AND YOU MIGHT BE DAMN SURPRISED!!!

Chlamydia and erectile dysfunction: What's the link? Some people who have chlamydia also experience erectile dysfunction (ED), which involves problems getting or maintaining an erection. Chlamydia can infect the prostate gland, leading to prostatitis, pain, and ED. In this article, learn more about the link between this common infection and ED, and treatments for both. Read now
It is necessary to identify the causes of worry and try to remove these. They could include concern about personal relationships, work, family problems, health or even sexual “performance” with a new or old partner. It is often said that the brain is the biggest sex organ of them all – if it is too busy with other things, it will not be involved in arousal and the erection that follows.
Alprostadil should not be used in men at higher risk for priapism (erection lasting longer than six hours) including men with sickle cell anemia, thrombocytopenia (low platelet count), polycythemia (increased red blood cell count), multiple myeloma (a cancer of the white blood cells), and is contraindicated in men prone to venous thrombosis (blood clots in the veins) or hyperviscosity syndrome who are at increased risk for priapism.
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.
Erosion of the prosthesis, whereby it presses through the corporal tissue into the urethra, may occur. Symptoms and signs may include pain, blood in the urine, discharge, abnormal urine stream, and malfunction. If the prosthesis erodes into the urethra, a physician must remove it. If the other cylinder remains intact, it can be left in place. A physician leaves a catheter in place to allow the urethra to heal.

Stress is another factor that can be a cause or effect of ED. If you're stressed at work, at home, and in your relationships, it's going to take a toll on your sexual function. Your mind is elsewhere, and relaxing when you finally make it between the sheets is a long shot. Now you’re stressed because you can’t get it up (talk about the ultimate catch-22), so you're stuck in this sad, frustrating cycle. “ED really affects the psyche of a guy, regardless of the etiology, Gittens says. “If you have a problem getting an erection one night, you’re probably going to be anxious and worried your partner might see you as less of a man the next time you try to get an erection.” There's a pill that will help with this, and it's not promoted on television with middle-aged men in sports cars. It's a damn chill pill.
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. 

A number of herbs have been promoted for treating impotence. The most widely touted herbs for this purpose are Coryanthe yohimbe (available by prescription as yohimbine, with the trade name Yocon) and gingko (Gingko biloba), although neither has been conclusively shown to help the condition in controlled studies. In addition, gingko carries some risk of abnormal blood clotting and should be avoided by men taking blood thinners such as coumadin. Other herbs promoted for treating impotence include true unicorn root (Aletrius farinosa), saw palmetto (Serenoa repens), ginseng (Panax ginseng), and Siberian ginseng (Eleuthrococcus senticosus). Strychnos Nux vomica has been recommended, especially when impotence is caused by excessive alcohol, cigarettes, or dietary indiscretions, but it can be very toxic if taken improperly, so it should be used only under the strict supervision of a physician trained in its use.
This is similar to magnetic resonance imaging. Magnetic resonance angiography uses magnetic fields and radio waves to provide detailed images of the blood vessels. Doctors may inject a "contrast agent" into the patient's bloodstream that causes vascular tissues to stand out against other tissues. The contrast agent provides for enhanced information regarding blood supply and vascular anomalies.
Other hormone levels: Measurement of other hormones beside testosterone (luteinizing hormone [LH], prolactin level, and cortisol level) may provide clues to other underlying causes of testosterone deficiency and erectile problems, such as pituitary disease or adrenal gland abnormalities. Doctors may check thyroid levels in some individuals as both hypothyroidism (low thyroid function) and hyperthyroidism (overactive thyroid function) can contribute to erectile dysfunction.

Trauma to the pelvic blood vessels or nerves can also lead result in ED. Bicycle riding for long periods has been implicated as an etiologic factor; direct compression of the perineum by the bicycle seat may cause vascular and nerve injury. [37] On the other hand, bicycling for less than 3 hours per week may be somewhat protective against ED. [37] Some of the newer bicycle seats have been designed to diminish pressure on the perineum. [37, 38]

Yohimbine: The main component of an African tree bark, yohimbine is probably one of the most problematic of all natural remedies for ED. Some research suggests that yohimbine can improve a type of sexual dysfunction that is linked with a drug used to treat depression. However, studies have linked yohimbine to a number of side effects, which can include anxiety, increased blood pressure, and a fast, irregular heartbeat. Like all natural remedies, yohimbine should only be used after advice and under supervision from a doctor.


Erectile dysfunction (ED) is one of the most common conditions affecting middle-aged and older men. Nearly every primary care physician, internist and geriatrician will be called upon to manage this condition or to make referrals to urologists, endocrinologists and cardiologists who will assist in the treatment of ED. This article will briefly discuss the diagnosis and management of ED. In addition, emerging concepts in ED management will be discussed, such as the use of testosterone to treat ED, the role of the endothelium in men with ED and treating the partner of the man with ED. Finally, future potential therapies for ED will be discussed.
In fact, one common reason many younger men visit their doctor is to get erectile dysfunction medication. Often, men with erectile dysfunction suffer with diabetes or heart disease, or may be sedentary or obese, but they don’t realize the impact of these health conditions on sexual function. Along with erectile dysfunction treatment, the doctor may recommend managing the illness, being more physically active, or losing weight.
All these treatments listed above do not provide immediate effect on your body. If you need an instant erection, you should take a look at the topical erection treatment. Targeted delivery has been recently identified as an emerging alternative to orally administered products mainly due to the current concerns of the side effects that may occur from taking prescription drugs. Topical erection treatment presents a preferable delivery method to get an erection that enhances the desired effect directly to the intended site of action while limiting the exposure of the rest of the body to the ingredients.
This process comprises a variety of physical aspects with important psychological and behavioral overtones. In analyzing the material presented and discussed at this conference, this consensus statement addresses issues of male erectile dysfunction, as implied by the term "impotence." However, it should be recognized that desire, orgasmic capability, and ejaculatory capacity may be intact even in the presence of erectile dysfunction or may be deficient to some extent and contribute to the sense of inadequate sexual function.
Psychological factors on their own are estimated to be the cause of 20% of all the cases of erectile dysfunction and account for most of the difficulties in young men. They can also contribute towards its continuation in all age groups where physical causes are the main culprit, but the man’s reaction to what he sees as his “failure” has added a psychological impact.
Stiffy Solution: Obviously, no one should ever go off a prescribed med without consulting with a doctor. But there are erection-friendly alternatives to nearly every daisy-wilting medicine listed above. And your dude shouldn't let embarrassment keep him from talking to his GP about this — doctors are well aware that erectile difficulties are a possible side effect for all of these medicines; they just don't know which patients will experience what side effects, so they're waiting for you, the patient, to bring it up.
There are no formal tests to diagnose erectile dysfunction. Some blood tests are generally done to exclude underlying disease, such as hypogonadism and prolactinoma. Impotence is also related to generally poor physical health, poor dietary habits, obesity, and most specifically cardiovascular disease such as coronary artery disease and peripheral vascular disease. Therefore, a thorough physical examination is helpful, in particular the simple search for a previously undetected groin hernia since it can affect sexual functions in men and is easily curable.[11]
Another potential new treatment consists of penile low-intensity shock wave lithotripsy. This consists of 1500 shocks twice a week for 3–6 weeks. The purpose is to stimulate neovascularisation to the corporal bodies with improvement in penile blood flow and endothelial function. The use of low-intensity shock wave lithotripsy may convert PDE5 inhibitor non-responders to responders.47
Psychotherapy, marital counseling, or sex therapy may be helpful in treating cases of impotence that have psychological or emotional causes. A range of other treatments exists for cases of impotence that arise from purely physiological causes. These treatments include vacuum devices, penile injections, and penile implants. These mechanical or physically invasive approaches have largely been superseded, however, by the drug sildenafil citrate (trade name Viagra), which is taken in pill form. This drug works by enhancing the effects of nitric oxide, a chemical that, upon sexual stimulation, is normally released to widen the blood vessels supplying the penis. The increased flow of blood through those vessels into certain tissues in the penis causes an erection. See also sexual dysfunction.
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.
Relationship problems can make it difficult for you to get or stay hard when you’re attempting to have sex with the person you’re in a relationship with. However, if you have this problem and you’re in a relationship that doesn’t mean your relationship is necessarily the reason. There are lots of other reasons you might not be able to get or stay hard (see above).
When stimulated by the nerves, the spongy tissue arranges itself in such a way that more blood can be stored in the penis. The veins running through the outer sheath of the penis then compress which stops the blood from leaving the penis. As the blood is stopped from flowing out, the penis fills with blood and stretches within the outer casing, giving an erection.
If you’re a woman whose partner who is struggling with ED treatment, you can talk to someone who knows exactly what you’re going through — and can help. The Coloplast Partner Support Network offers a free, confidential connection with the spouses or partners of men who’ve been treated with a penile implant. They will listen to your questions and concerns, and share their own knowledge and experiences of how to keep your relationship strong during this challenging time.
Hypogonadism may be suggested by the patient's general appearance. If testosterone deficiency antedates puberty, as in Klinefelter's syndrome, eunuchoid proportions—defined as an arm span 5 cm or more in excess of height, or a sole-to-pubis length exceeding crown-to-pubis length by more than 2 cm—may be present. In postpubertal males whose testosterone levels are markedly depressed, the secondary sexual characteristics may become atrophic. Testicles less than 4 cm in length or a prostate gland that is smaller than expected may be the only clues on physical examination to a pituitary tumor with secondary hypogonadism.
A number of herbs have been promoted for treating impotence. The most widely touted herbs for this purpose are Coryanthe yohimbe (available by prescription as yohimbine, with the trade name Yocon) and gingko (Gingko biloba), although neither has been conclusively shown to help the condition in controlled studies. In addition, gingko carries some risk of abnormal blood clotting and should be avoided by men taking blood thinners such as coumadin. Other herbs promoted for treating impotence include true unicorn root (Aletrius farinosa), saw palmetto (Serenoa repens), ginseng (Panax ginseng), and Siberian ginseng (Eleuthrococcus senticosus). Strychnos Nux vomica has been recommended, especially when impotence is caused by excessive alcohol, cigarettes, or dietary indiscretions, but it can be very toxic if taken improperly, so it should be used only under the strict supervision of a physician trained in its use.
In order to establish whether normal erections are occurring overnight (nocturnal erections), the doctor may organise nocturnal penile tumescence (NPT) testing. This involves wearing a monitor overnight in your own home. The data from this monitor is then assessed to analyse how often erections occurred, how long they lasted, and how rigid and large the penis was during the erections. If NPT testing is normal, the cause of erectile dysfunction is usually psychological. If not, further testing of the blood flow in the genital area may be required to see if there is blockage or leakage. The doctor may also organise a blood test of levels of hormones such as testosterone, prolactin and thyroid stimulating hormone to see if these are contributing to the erectile dysfunction.
Conditions that may be associated with ED include diabetes, [25, 26, 27] hypertension, [28] , and CAD, as well as neurologic disorders, endocrinopathies, benign prostatic hyperplasia, [29] , sleep apnea [30] , COPD, [31] and depression (see Table 1 below). [32, 33, 34, 35] In fact, almost any disease may affect erectile function by altering the nervous, vascular, or hormonal systems. Various diseases may produce changes in the smooth muscle tissue of the corpora cavernosa or influence the patient’s psychological mood and behavior.

Psychotherapy and/or behavioral therapy may be useful for some patients with erectile dysfunction without obvious organic cause, and for their partners. These may also be used as an adjunct to other therapies directed at the treatment of organic erectile dysfunction. Outcome data from such therapy, however, have not been well-documented or quantified, and additional studies along these lines are indicated.
Because impotence can be due to health problems that can affect the whole body, and because it can interfere with one’s quality of life, it is important to talk with your doctor if you have trouble attaining or maintaining an erection. With increasing discussion of impotence in the media, coupled with advances in treatment, men are now much more comfortable talking with their doctors about impotence. It is currently estimated that between 15 and 30 million men in the United States are affected by impotence (Source: NIDDK).
Defined as experiencing difficulty having an erection at least 50 percent of the time, about 30 million men in the U.S. suffer from erectile dysfunction (ED), according to the National Institutes of Health. So, if odds are pretty good you’ll experience a failure to launch at some point in your life, take solace in this finding from the University of Adelaide: You can reverse ED by focusing on lifestyle factors, not just popping a blue pill.
Psychological factors on their own are estimated to be the cause of 20% of all the cases of erectile dysfunction and account for most of the difficulties in young men. They can also contribute towards its continuation in all age groups where physical causes are the main culprit, but the man’s reaction to what he sees as his “failure” has added a psychological impact.
An erection might last indefinitely if it weren’t for chemicals in the body called phosphodiesterases. They work at reversing the process trying to return the penis to being soft (i.e., flaccid). Usually there is a balance between the chemicals that result in an erection lasting for as long as it is needed, which allows the phosphodiesterases to do their job when they should and no sooner. You wouldn’t want an erection forever so it is a good thing that phosphodiesterases exist.
Ultrasound with Doppler imaging (ultrasound plus evaluation of blood flow in the arteries and veins) can provide additional information about blood flow of the penis and may help in the evaluation of patients prior to surgical intervention. This study is typically performed after the injection of a chemical that causes the arteries to open up, a vasodilator (prostaglandin E1), into the corpora cavernosa in order to cause dilation of blood vessels and promote blood flow into the penis. The rate of blood flow into the penis can be measured along with an evaluation of problems with compression of the veins.
On the horizon is gene therapy that would deliver genes that produce products or proteins that may not be functioning properly in the penile tissue of men with ED. Replacement of these proteins may result in improvement in erectile function. Experimental animal models have demonstrated improvement in erectile function with gene therapy. Human studies may also demonstrate success with this therapy. Gene therapy may take a long time for regulatory approval and public acceptance.

Risks associated with injection therapy including bleeding, pain with injection, penile pain, priapism, and corporal fibrosis (scarring inside of the corpora cavernosa). There is also concern that repetitive injections in the same area could cause scar tissue to build up in the tunica albuginea that could create penile curvature. Thus, doctors recommended that one alternate sides with injection and perform injections no more frequent than every other day.
The primary nerve fibers to the penis are from the dorsal nerve of the penis, a branch of the pudendal nerve. The cavernosal nerves are a part of the autonomic nervous system and incorporate both sympathetic and parasympathetic fibers. They travel posterolaterally along the prostate and enter the corpora cavernosa and corpus spongiosum to regulate blood flow during erection and detumescence. The dorsal somatic nerves are also branches of the pudendal nerves. They are primarily responsible for penile sensation. [10]

Lemonaid Health services are provided by one of our three medical groups. All three medical groups do business as 'Lemonaid Health'. In all states other than Texas and Kansas, Lemonaid services are provided by LMND Medical Group, Inc., A Professional Corporation, doing business as Lemonaid Health. In Texas, Lemonaid services are provided by LMND Medical Group, A Professional Association, with registered office 1999 Bryan Street, Suite 900, Dallas, TX 75201. In Kansas, Lemonaid services are provided by LMND Medical Group, A Professional Association, with registered office 112 SW 7TH Street, Suite 3C, Topeka, KS 66603. Our team is based at 150 Spear Street, Suite 350, San Francisco, California 94105, USA. You can call us on +1 415 926 5818.
A vacuum erection device helps draw blood into the penis by applying negative pressure. This type of device is sometimes referred to as penis pump and may be used just prior to sexual intercourse. Several types of FDA approved vacuum therapy devices are available with a doctor's prescription. When pharmacological methods fail, a purpose-designed external vacuum pump can be used to attain erection, with a separate compression ring fitted to the penis to maintain it. These pumps should be distinguished from other penis pumps (supplied without compression rings) which, rather than being used for temporary treatment of impotence, are claimed to increase penis length if used frequently, or vibrate as an aid to masturbation. More drastically, inflatable or rigid penile implants may be fitted surgically.

This inflatable penile prosthesis has 3 major components. The 2 cylinders are placed within the corpora cavernosa, a reservoir is placed beneath the rectus muscle, and the pump is placed in the scrotum. When the pump is squeezed, fluid from the reservoir is transferred into the 2 cylinders, producing a firm erection. The deflation mechanism is also located on the pump and differs by manufacturer.
Radical prostatectomy for the treatment of prostate cancer poses a significant risk of ED. A number of factors are associated with the chance of preserving erectile function. If both nerves that course on the lateral edges of the prostate can be saved, the chance of maintaining erectile function is reasonable. The odds depend on the age of the patient. Men younger than 60 years have a 75-80% chance of preserving potency, but men older than 70 years have only a 10-15% chance.
For many men, stopping smoking is an erectile dysfunction remedy, particularly when ED is the result of vascular disease, which occurs when blood supply to the penis becomes restricted because of blockage or narrowing of the arteries. Smoking and even smokeless tobacco can also cause the narrowing of important blood vessels and have the same negative impact. 
The physical examination can reveal clues for physical causes of erectile dysfunction. A doctor will perform an assessment of BMI and waist circumference to evaluate for abdominal obesity. A genital examination is part of the evaluation of erectile dysfunction. The examination will focus on the penis and testes. The doctor will ask you about penile curvature and will examine the penis to see if there are any plaques (hard areas) palpable. The doctor will examine the testes to make sure they are in the proper location in the scrotum and are normal in size. Small testicles, lack of facial hair, and enlarged breasts (gynecomastia) can point to hormonal problems such as hypogonadism with low testosterone levels. A health care provider may check pulses in your groin and feet to determine if there is a suggestion of hardening of the arteries that could also affect the arteries to the penis.

#3 You’re not having enough sex. The more sex you’re having, the less likely you are to suffer from erectile issues. The American Journal of Medicine reports that men who had sex once *or more* a week were less likely to have issues getting and maintaining an erection. So, not having sex is actually one of the reasons you can’t get hard. [Read: 13 ways to have better sex and change the way you make love]

The 4 ED medicines we prescribe – Generic sildenafil 20 mg, Viagra (also sildenafil), Cialis (Tadalafil), or Levitra (Vardenafil) - are generally safe but shouldn’t be used as recreational drugs. They’re meant to treat a medical condition and can cause serious side effects including but not limited to an erection lasting more than four hours, sudden loss of vision in one or both eyes, and sudden decrease or loss of hearing.


Patients should continue testosterone therapy only if there is improvement in the symptoms of hypogonadism and should be monitored regularly. You will need periodic blood tests for testosterone levels and blood tests to monitor your blood count and PSA. Testosterone therapy has health risks, and thus doctors should closely monitor its use. Testosterone therapy can worsen sleep apnea and congestive heart failure.
Unfortunately, some patients may have an overly simplified understanding of the role of PDE5 inhibitors in ED management. Such patients may not expect or be willing to undergo a long evaluation and testing process to obtain a better understanding of their sexual problem, and they may be less likely to involve their partner in discussing their sexual relationship with the physician. They may expect to obtain medications through a phone call to their doctor or even over the Internet, with minimal or no physician contact at all.

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.
To reach the largest audience, communications strategies should include informative and accurate newspaper and magazine articles, radio and television programs, as well as special educational programs in senior centers. Resources for accurate information regarding diagnosis and treatment options also should include doctors' offices, unions, fraternal and service groups, voluntary health organizations, State and local health departments, and appropriate advocacy groups. Additionally, since sex education courses in schools uniformly address erectile function, the concept of erectile dysfunction can easily be communicated in these forums as well.
#4 You’re just plain turned off. It happens. Whether it’s the weight your partner has put on, the realization that you’re having period sex, or you’re just not getting what you need in the bedroom, at some point in your life, you’re going to be turned off enough to lose *or be unable to attain* your hard-on. [Read: Not attracted to your girlfriend anymore? The why and the fixes]
Most of us are raised to believe that men are ravenous sex-beasts, eternally horny and only pretending to be a part of polite society so that they can find some new crevice to jam their Jeremy Irons into. So the first time we cross paths (and genitals) with a guy who can't get an erection, many of us immediately panic and assume that the problem must be us. We must be profoundly unsexy. After all, what could else possibly stop these hormone-addled maniacs from getting an erection?

Endocrine evaluation consisting of a morning serum testosterone is generally indicated. Measurement of serum prolactin may be indicated. A low testosterone level merits repeat measurement together with assessment of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin levels. Other tests may be helpful in excluding unrecognized systemic disease and include a complete blood count, urinalysis, creatinine, lipid profile, fasting blood sugar, and thyroid function studies.
Patients should continue testosterone therapy only if there is improvement in the symptoms of hypogonadism and should be monitored regularly. You will need periodic blood tests for testosterone levels and blood tests to monitor your blood count and PSA. Testosterone therapy has health risks, and thus doctors should closely monitor its use. Testosterone therapy can worsen sleep apnea and congestive heart failure.
Cavallini, G., Modenini, F., Vitali, G., & Koverech, A. (2005, November). Acetyl-L-carnitine plus propionyl-L-carnitine improve efficacy of sildenafil in treatment of erectile dysfunction after bilateral nerve-sparing radical retropubic prostatectomy. Urology, 66(5), 1080-5. Retrieved from http://www.sciencedirect.com/science/article/pii/S0090429505006515

Vascular damage may result from radiation therapy to the pelvis and prostate in the treatment of prostate cancer. [36] Both the blood vessels and the nerves to the penis may be affected. Radiation damage to the crura of the penis, which are highly susceptible to radiation damage, can induce ED. Data indicate that 50% of men undergoing radiation therapy lose erectile function within 5 years after completing therapy; fortunately, some respond to one of the PDE5 inhibitors.

Picture the scene. You get home from the bar with your date. You both decided to leave a little early, after only two drinks, because the chemistry was really there and both of you wanted to cut to the chase and get intimate. To discover each other's bodies. To eat of the fruits of passion. In short, to have sex. You stick the key in the lock, swing the door open, and invite her into your beautiful place. OK, well it might not be exactly beautiful. It might be a bit of a mess, frankly. But you don't let that ruin the moment. You turn around and passionately kiss her. How the two of you make it to your bedroom with some clothing still on is anybody's guess. You jump on the bed and hurriedly strip. God — can't this go any faster, you wonder? 
Whenever using any fluid or oil on sensitive areas of your body, it is best to test it out on a small scale first. If there are no problems on the test, try massaging the erection treatment gel into the penis all over until an instant erection is achieved. You should get an erection in a few minutes. When you first begin to use the product, we suggest masturbating with it before using it during sex to become more comfortable with the amount needed and the sensation it produces.
Another potential new treatment consists of penile low-intensity shock wave lithotripsy. This consists of 1500 shocks twice a week for 3–6 weeks. The purpose is to stimulate neovascularisation to the corporal bodies with improvement in penile blood flow and endothelial function. The use of low-intensity shock wave lithotripsy may convert PDE5 inhibitor non-responders to responders.47
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.
Sildenafil is available as oral tablets at doses of 25 mg, 50 mg, and 100 mg. Patients should take sildenafil approximately one hour before sexual activity. In some men, the onset of action of the drug may be as early as 11-20 minutes. It's best for men to take sildenafil on an empty stomach for best results since absorption and effectiveness of sildenafil can be diminished if it is taken shortly after a meal, particularly a meal that is high in fat. Sildenafil and the other PDE5 inhibitors don't cause an immediate erection. Sexual stimulation is necessary for these medications to work.
A rigid or nearly rigid erectile response to intracavernous injection of pharmacologic test doses of a vasodilating agent (see below) indicates adequate arterial and veno-occlusive function. This suggests that the patient may be a suitable candidate for a trial of penile injection therapy. Genital stimulation may be of use in increasing the erectile response in this setting. This diagnostic technique also may be used to differentiate a vascular from a primarily neuropathic or psychogenic etiology. Patients who have an inadequate response to intracavernous pharmacologic injection may be candidates for further vascular testing. It should be recognized, however, that failure to respond adequately may not indicate vascular insufficiency but can be caused by patient anxiety or discomfort. The number of patients who may benefit from more extensive vascular testing is small, but includes young men with a history of significant perineal or pelvic trauma, who may have anatomic arterial blockage (either alone or with neurologic deficit) to account for erectile dysfunction.
Thanks to over a decade of primetime television commercials, most of us can name at least one drug that treats erectile problems. However, far fewer of us can name drugs that may actually cause the problem. In reality, MedlinePlus reported that there are far more of these, and even common drugs such those to treat depression and heartburn can make it difficult to get an erection.
Thanks for your question, Frightened Turtle! To help answer it, we spoke with Dr. Darius Paduch, urologist and male sexual medicine specialist at New York Presbyterian/Weill Cornell Medical Center, and sex therapist Jenni Skyler, Ph.D., director of The Intimacy Institute for sex and relationship therapy in Boulder, Colorado. Here's what they had to say:

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.

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.

The mechanisms by which testosterone plays a role in erectile function are not completely understood. A study evaluating the effect of testosterone on erections in surgically castrated rabbits and control animals, in which the rabbits’ intracavernosal pressures were compared after cavernosal nerve stimulation, determined that castrated rabbits had much lower pressures after stimulation than control rabbits did. [21] Notably, the pressures increased when castrated rabbits received exogenous testosterone replacement.
In some cases, nocturnal penile tumescence testing is performed to find out whether the man has erections while asleep. Healthy men usually have about four or five erections throughout the night. The man applies a device to the penis called a Rigiscan before going to bed at night, and the device can determine whether he has had erections. (If a man is able to have normal erections at night, this suggests a psychological cause for his impotence.)
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.
An erection might last indefinitely if it weren’t for chemicals in the body called phosphodiesterases. They work at reversing the process trying to return the penis to being soft (i.e., flaccid). Usually there is a balance between the chemicals that result in an erection lasting for as long as it is needed, which allows the phosphodiesterases to do their job when they should and no sooner. You wouldn’t want an erection forever so it is a good thing that phosphodiesterases exist.
Her remark was entirely destructive of poetry, since it was to the effect that poetry had nothing whatever to do with her; all her friends spent their lives in making up phrases, she said; all his feeling was an illusion, and next moment, as if to taunt him with his impotence, she had sunk into one of those dreamy states which took no account whatever of his existence.

Psychological factors — Psychological issues such as depression, anxiety, guilt or fear can sometimes cause sexual problems. At one time, these factors were thought to be the major cause of impotence. Doctors now know that physical factors cause impotence in most men with the problem. However, embarrassment or "performance anxiety" can make a physical problem worse.

More recent estimates suggest that the number of U.S. men with erectile dysfunction may more likely be near 10-20 million. Inclusion of individuals with partial erectile dysfunction increases the estimate to about 30 million. The majority of these individuals will be older than 65 years of age. The prevalence of erectile dysfunction has been found to be associated with age. A prevalence of about 5 percent is observed at age 40, increasing to 15-25 percent at age 65 and older. One-third of older men receiving medical care at a Department of Veterans' Affairs ambulatory clinic admitted to problems with erectile function.


It is estimated that up to 20 million American men frequently suffer from impotence and that it strikes up to half of all men between the ages of 40 and 70. Doctors used to think that most cases of impotence were psychological in origin, but they now recognize that, at least in older men, physical causes may play a primary role in 60% or more of all cases. In men over the age of 60, the leading cause is atherosclerosis, or narrowing of the arteries, which can restrict the flow of blood to the penis. Injury or disease of the connective tissue, such as Peyronie's disease, may prevent the corpora cavernosa from completely expanding. Damage to the nerves of the penis, from certain types of surgery or neurological conditions, such as Parkinson's disease or multiple sclerosis, may also cause impotence. Men with diabetes are especially at risk for impotence because of their high risk of both atherosclerosis and a nerve disease called diabetic neuropathy.

Diet can also affect a man’s ability to achieve or maintain an erection. As stated, men who indulge in alcohol may have trouble with erections, but men who have poor diets, suffer from diabetes, or who are overweight can also restrict blood flow to the penis or suffer from poor body image. All of these factors, especially when combined, can lead to erectile dysfunction.
For the past few months I’ve been dating a lovely man but our relationship is at risk because he can’t get it up. He says he fancies me and always seems turned on. Sometimes he gets hard - but when we try for sex he loses his erection. On the few occasions he has got hard, he doesn’t orgasm. I’ve always been a very sexual person and would like a lot of sex. We’re hardly having any. I find it difficult to orgasm even if he tries other things because I keep thinking. Why can’t he have proper sex with me?

Yes, the vacuum device is effective. In fact, with use of the vacuum device, 88% of men will have an erection that is satisfactory for completion of sexual activity. The vacuum device may be the only therapy that is effective after the removal of a penile prosthesis. Patients also use vacuum devices as part of penile rehabilitation after radical prostatectomy to help preserve the tissue of the penis and prevent scarring within the penis and loss of penile length. Its use, however, is limited by the mechanical nature of it and the time taken to pump the device and apply the band. Sex partners may complain of the penis being cool to touch.
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."
While impotence may be the presenting symptom of vascular disease, in neurologic disease impotence generally occurs in the setting of an obvious nervous system disorder, typically in patients known to have spinal cord pathology or neuropathy. Impotent patients should be questioned about decreased genital sensation, which would suggest diabetic, alcoholic, or other forms of neuropathy; weakness, which may accompany multiple sclerosis or spinal cord tumors; and back pain, bowel, and bladder symptoms, which raise concern for cauda equina syndrome. A careful drug history is important in the evaluation of impotence. Drugs that cause impotence (Table 187.3) generally do so by interfering with neurotransmission.
Relationship problems can make it difficult for you to get or stay hard when you’re attempting to have sex with the person you’re in a relationship with. However, if you have this problem and you’re in a relationship that doesn’t mean your relationship is necessarily the reason. There are lots of other reasons you might not be able to get or stay hard (see above).
Now, there are lots of ways that you can reduce stress and anxiety in your life. One of those things you can do is exercising daily. Now, it doesn’t mean getting into a gym all the time, but it can just be doing sit-ups at home, long walks at the grocery store, bicycling, and if you can afford the gym, getting there maybe two to three days a week. But don’t forget, a healthy body equals a healthy mind. Meditation, yoga, breathing exercises– now, here’s where you can take a few moments to be centered and communicate with your inner self, peace. Healthy eating– now, taking control of the intake of what goes into your body makes you to start feeling better and looking better. That wellness is the opposite of anxiety. And treating issues and tackling things that are weighing you down, taking that very first step is liberating.
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