Erectile dysfunction (ED): diagnosing and treatment

Diagnosing Impotence

Discuss any medical conditions that you may have with your doctor. Sharing your medical history with a doctor can help him or she determine what is causing your impotence. Let your doctor know if you are taking medication. Include the name of the medication, how much you take, and when you began taking it. Also, let him or her know if the impotence was first experienced after taking medication.

Some things your doctor may ask you about include:

• your symptoms
• your overall physical and mental health
• your alcohol consumption
• whether you take drugs

Your doctor will also need to ask you detailed questions about your sexual history. Try not to be embarrassed because ED is a common problem.

Your doctor may ask about:

• your previous and current sexual relationships
• what your sexual orientation is
• how long you have been experiencing ED
• whether you can get any degree of erection with your partner, on your own, or when you wake up in the morning
• whether you have been able to ejaculate or orgasm
• your libido (your level of sexual desire)

ED that occurs all the time may suggest an underlying physical cause. If ED only occurs when you are attempting to have sex with your partner it may suggest that there is an underlying psychological (mental) cause.

An important cause of ED has narrowed blood vessels. These are also linked with cardiovascular disease (conditions that affect the heart and blood flow). Your doctor may therefore assess your cardiovascular health by seeing if you have any of the symptoms of cardiovascular disease. If you do, it is likely to be causing your ED.

Your doctor may:

• measure your blood pressure to see if you have high blood pressure (hypertension)
• listen to your heart rate to check for any abnormalities
• measure your height, weight, and waist circumference to see if you are a healthy weight for your height
• ask you about your diet and lifestyle, for example, how much exercise you do
• test a sample of your blood for glucose (sugar) and lipids (fatty substances), as high levels can indicate conditions affecting your heart or blood vessels

The doctor will give you a physical examination. This includes a visual inspection of the penis to make sure there are no external causes for the impotence, such as trauma or lesions from sexually transmitted infections (STIs).

Blood tests may also be used to check for possible underlying health conditions. For example, measuring the levels of hormones such as testosterone can rule out hormonal conditions, such as hypogonadism (an abnormally low level of testosterone) or a blood test to check your blood glucose levels. This will let him or her know if diabetes may be to blame. Other tests that may be administered include:

• ECG (electrocardiogram)
• ultrasound
• urine test

If there may be an underlying psychological cause for your ED, your doctor may refer you for a psychological assessment. This could be with:

1. a psychologist – a healthcare professional who specializes in the assessment and treatment of mental health conditions
2. a psychiatrist – a qualified medical doctor who has received further training in treating mental health conditions

How Is Erectile Dysfunction Treated?

If you have erectile dysfunction (ED) the treatment that you will receive will depend on the underlying cause of the condition. The cause and severity of your condition, and underlying health problems, are important factors in your doctor’s recommending the best treatment or treatments for you. Your doctor can explain the risks and benefits of each treatment and will consider your preferences. Your partner’s preferences also may play a role in treatment choices.

In some cases, simple lifestyle changes, such as losing weight, drinking less alcohol, or quitting smoking, may improve erectile dysfunction.

If the erectile dysfunction is caused by a certain medication, your doctor may suggest reducing the dose or trying an alternative drug.

Treatment options for erectile dysfunction include:

• Psychotherapy (counseling)
• Medications (drug therapy)
• Vacuum devices (pumps)
• Surgery

Medications for Erectile Dysfunction

Men have different options in the types of drugs for ED. Medicines can be taken orally, inserted into the urethra, or injected into the penis.

The first medications usually prescribed to men with erectile dysfunction are called phosphodiesterase (PDE) type 5 inhibitors. These include:

• sildenafil (Viagra)
• tadalafil (Cialis)
• vardenafil hydrochloride (Levitra, Staxyn)
• avanafil (Stendra)

All three medications work in much the same way. These drugs enhance the effects of nitric oxide, a natural chemical your body produces that relaxes muscles in the penis. This increases blood flow and allows you to get an erection in response to sexual stimulation. These medications vary in dosage, how long they work, and their side effects. Your doctor will take into account your particular situation to determine which medication may work best.

They are generally taken by mouth about one hour before having sex and should not be used more than once a day. Sildenafil and vardenafil work for about eight hours and they are designed to work ‘on demand’. Tadalafil lasts for up to 36 hours and is more suitable if you require treatment for a longer period, for example, over a weekend. Staxyn dissolves in the mouth.

About 80% of men who take PDE-5 inhibitors have firmer and longer-lasting erections. However, if your erection lasts more than four hours, seek emergency medical help.

These medications may not fix your erectile dysfunction immediately. You may need to work with your doctor to find the right medication and dose for you.

Side effects of medications are usually mild but may include:

• headaches and migraines
• flushing (redness)
• indigestion
• nausea (feeling sick)
• vomiting (being sick)
• a blocked or runny nose
• back pain
• vision disturbances
• muscle pain

Your doctor should explain the benefits of each medication and how it works. The choice may depend on:

• how often you are sexually active
• whether you have tried any of the medications before

Before taking any prescription erectile dysfunction medication (including over-the-counter supplements or herbal remedies), get your doctor’s OK. Although these medications can help many people, not all men should take them to treat erectile dysfunction. These medications may not work or may be dangerous for you if you:

1. Take nitrate drugs — commonly prescribed for chest pain (angina) — such as nitroglycerin (Nitro-Bid, Nitro-Dur, Nitrostat, others), isosorbide mononitrate (Imdur, Monoket), and isosorbide dinitrate (Dilatrate, Isordil)
2. Take a blood-thinning (anticoagulant) medication, alpha-blockers for enlarged prostate (benign prostatic hyperplasia), or high blood pressure medications
3. Have heart disease or heart failure
4. Have had a stroke
5. Have very low blood pressure (hypotension) or uncontrolled high blood pressure (hypertension)
6. Have uncontrolled diabetes

Psychotherapy for treating Erectile Dysfunction

Talk therapy may be the initial treatment option for men with anxiety or stress-related erectile dysfunction. Relationship difficulties, work problems, financial woes, and other, everyday stressors can trigger erectile dysfunction. If your erectile dysfunction is caused by stress, anxiety, or depression, your doctor may suggest that you, or you and your partner, visit a psychologist or counselor. Talking about worries and stressors to a licensed therapist can ease sexual anxiety and provide strategies to boost intimacy. Usually, only three to four sessions are needed. Including your partner in therapy can also be helpful.

Penis pumps, surgery, and implants

Medications may not work or may not be a good choice for you. If this is the case, your doctor may recommend a different treatment. Other treatments include:

1. Penis pumps. It consists of a clear plastic tube that is connected to a pump, which is either hand or battery operated. The tube is placed over your penis, and then the pump is used to suck out the air inside the tube. This creates a vacuum that pulls blood into your penis. Once you get an erection, you slip a tension ring around the base of your penis to hold in the blood and keep it firm. You then remove the vacuum device. The erection typically lasts for around 30 minutes to have sex. you remove the tension ring after intercourse. Side effects of vacuum pumps include pain or bruising, although these occur in less than a third of men, and also bruising of the penis is a possible side effect, and ejaculation may not be as forceful. If a penis pump is a good treatment choice for you, your doctor may recommend or prescribe a specific model. That way you can be sure it suits your needs and that it’s made by a reputable manufacturer.
2. Penile implants. This treatment involves surgically placing devices into the two sides of the penis. These can be: *semi-rigid implants – consist of either semirigid rods and keep the penis firm but bendable, which may be suitable for older men who do not have sex regularly; *inflatable implants – which consist of two or three parts that can be inflated to give a more natural erection and allow you to control when and how long you have an erection. This treatment is usually not recommended until other methods have been tried first. As with any surgery, there is a risk of complications such as infection. Mechanical problems with the implants may occur within five years in five percent of cases.
3. Surgery.

Surgery for ED is usually only recommended if all other treatment methods have failed. It may also be considered in:

• younger men who have experienced trauma (serious injury) to their pelvic area – for example, in a car accident
• men with a significant anatomical problem with their penis

Surgery blood vessels could unblock the blood vessels to restore a normal supply of blood. However, research now suggests that the long-term results of this type of surgery are poor, so it is unlikely to be used.

Other medications

Other medications for erectile dysfunction include:

• Alprostadil self-injection. With this method, you use a fine needle to inject alprostadil (Caverject Impulse, Edex) into the base or side of your penis. In some cases, medications generally used for other conditions are used for penile injections on their own or in combination. Examples include papaverine, alprostadil, and phentolamine. Each injection generally produces an erection that lasts about an hour. Because the needle used is very fine, pain from the injection site is usually minor. Side effects can include bleeding from the injection, prolonged erection, and formation of fibrous tissue at the injection site.
• Alprostadil penis suppository. Alprostadil intraurethral (Muse) therapy involves placing a tiny alprostadil suppository inside your penis in the penile urethra. You use a special applicator to insert the suppository into your penile urethra. The erection usually starts within 10 minutes and lasts between 30 and 60 minutes. Side effects can include pain, minor bleeding in the urethra, and the formation of fibrous tissue inside your penis.
• Testosterone replacement. Some men have erectile dysfunction caused by low levels of the hormone testosterone and may need testosterone replacement therapy.