“Although having sex at 70 is not the same as having sex at 20, erectile dysfunction is not a normal part of aging,” according to Michael Feloney, MD, urologic surgeon and expert on sexual dysfunction issues at the Nebraska Medical Center in Omaha. “You should still be able to have a satisfying sex life as you age." If you are experiencing erectile dysfunction, these 10 dos and don'ts may help.
Until recently, erectile dysfunction (ED) was one of the most neglected complications of diabetes. In the past, physicians and patients were led to believe that declining sexual function was an inevitable consequence of advancing age or was brought on by emotional problems. This misconception, combined with men’s natural reluctance to discuss their sexual problems and physicians’ inexperience and unease with sexual issues, resulted in failure to directly address this problem with the majority of patients experiencing it.
Knowing about your history of ED will help your health provider learn if your problems are because of your desire for sex, erection function, ejaculation, or orgasm (climax). Some of these questions may seem private or even embarrassing. However, be assured that your doctor is a professional and your honest answers will help find the cause and best treatment for you.

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.
Many younger men are concerned that this will create a dependency on the medication.  However, you cannot become dependent because there is no tachyphylaxis to these medications.  This means, that unlike some other drugs (opiates, benzodiazepines) your body does not get used to these medications over time, so you won’t need to up the dosage over time to get the same effect.  In fact, we have found the opposite to be true.  Over time, many of our younger patients need less medication and need it less frequently.
Erectile dysfunction is your body’s “check engine light” because ED can be an early sign of serious health problems like high blood pressure, diabetes, high cholesterol or low testosterone. The blood vessels in the penis are smaller than other parts of the body. So ED symptoms often occur long before more serious problems like a heart attack or stroke. When an otherwise healthy man in his 20’s experiences ED, it’s cause for concern.

Diabetes is one of the most common causes of ED. Men who have Diabetes are three times more likely to have Erectile Dysfunction than men who do not have Diabetes. Among men with ED, those with Diabetes are likely to have experienced the problem as much as 10 to 15 years earlier than men without Diabetes. A recent study of a clinic population revealed that 5% of the men with ED also had undiagnosed Diabetes. The risk of ED increases with the number of years you have Diabetes and the severity of your Diabetes. Even though 20% to 75% of men with Diabetes have ED, it can be successfully managed in almost all men.


Long-term erectile dysfunction. The risk for long-term erectile dysfunction has been linked to chronic heavy use of alcohol. In fact, studies show that men who are dependent on alcohol have a 60 to 70 percent chance of suffering from sexual problems. The most common of these are erectile dysfunction, premature ejaculation, and loss of sexual desire.
Unconventional CV risk factors, such as impaired erections during masturbation and reduced flaccid acceleration, are interesting parameters to implement in Sexual Medicine context, because they can help fill the gap of information on CV risk, left by the conventional risk factors (the so-called residual risk) (38). However, it should be recognized that not all the healthcare professionals who deal with the complaint of ED (i.e., general practitioners, diabetologists, cardiologists, sport physicians, nurses, etc.) have the facilities or competence for the specific assessment of these parameters. In contexts different than Sexual Medicine and Andrology, the assessment of conventional risk factors is certainly more convenient. Metabolic syndrome (MetS) represents a cluster of metabolic derangements easily and commonly evaluated in several different medical contexts. In a population of more than 600 subjects attending the Sexual Medicine and Andrology Unit of the University of Florence for ED, the presence of MetS was associated with an increased incidence of MACE during 4.3 years of follow-up in younger (first tertile of age: 18–52 years) (Figure 3, Panel A and B) but not in middle aged and older men (second and third tertiles of age: 53–60 and 61–88 years, respectively) (Figure 3, Panel B). Similar to MetS, the algorithms for estimating the risk of developing MACE are easily computed and they take into account factors largely available in a clinical setting. In Europe, the most commonly used algorithm is the SCORE, which takes into account age, smoking habits, systolic blood pressure and total cholesterol (26). These parameters are introduced in a calculation tool that returns the 10-year risk of developing the first MACE. The same estimated risk rate can obviously be derived from different combinations and extent of the single risk factors and, as aforementioned, age has a heavy weight in the amount of risk, even when the other parameters are normal. For overcoming this overestimation, the concept of vascular age, based on the predicted CV risk, has been introduced. Vascular age of a subjects with a specific CV risk profile corresponds to the chronological age of a subjects who has the same estimated risk but only due to chronological age, because of the absence of the other modifiable risk factors (i.e., a non-smoker, normotensive and normocholesterolemic subject) (39,40). Vascular age carries the advantage of easily and directly communicating the concept of high relative risk to patients, in particular to younger ones, who are by definition at low absolute risk (“Your CV risk is the same of a man that is 15 years older than you”). Based on this interesting and useful concept of vascular age, we recently studied the clinical consequences of having a high discrepancy between the estimated vascular and the actual chronological age in our population of men consulting for ED. In our sample, a greater difference between vascular and chronological age was associated with higher glucose and triglyceride levels as well as with impaired penile colour Doppler ultrasound parameters, suggesting a CV impairment (41). When evaluating the subset of men for whom information on incident MACE during a mean follow-up of 4.3 years was available, a greater difference between vascular and chronological age was associated with the incidence of MACE in younger, but not in older men (42).
Injury to the penis may cause the scar tissue to develop. Sex, sports, or an accident might cause the injury. However, most patients don’t remember any painful injury. There are risk factors that increase the chances that an injury may cause scar tissue. They are genetics, connective tissue disorders, and age. The risk of Peyronie’s increases with age.
Cigarette smoking is a risk factor for ED, according to the 2014 Report of the U.S. Surgeon General. Excess weight can also contribute to erectile dysfunction. A 2004 Italian study found that one-third of their 110 obese study subjects were able to eliminate their erectile dysfunction problems by losing fifteen percent of their weight through diet and exercise.

Medications: Many common medicines produce erectile dysfunction as a side effect. Medicines that can cause erectile dysfunction include many used to treat high blood pressure, antihistamines, antidepressants, tranquilizers, and appetite suppressants. Examples of common medicines that can cause erectile dysfunction include propranolol (Inderal) or other beta-blockers, hydrochlorothiazide, digoxin (Lanoxin), amitriptyline (Elavil), famotidine (Pepcid), cimetidine (Tagamet), metoclopramide (Reglan), naproxen, indomethacin (Indocin), lithium (Eskalith, Lithobid), verapamil (Calan, Verelan, Isoptin), phenytoin (Dilantin), gemfibrozil (Lopid), amphetamine/dextroamphetamine (Adderall), and phentermine. Prostate cancer medications that lower testosterone levels such as leuprolide (Lupron) may affect erectile function. Some chemotherapies such as cyclophosphamide (Cytoxan) may affect erectile function.


Diabetes, high blood pressure (hypertension), elevations in blood lipids or cholesterol are considered blood vessel problems and have all been associated with Erectile Dysfunction. The blood vessel abnormalities caused by these diseases affect vessels throughout the body and often produce other symptoms of vascular diseases. Diabetics and patients with hypertension frequently have heart disease. These conditions typically interfere with the ability of the penile vessels to work properly and ultimately cause ED.
Natural treatments: Although natural remedies are increasingly available for sale over the counter, there is little scientific evidence to support their claims of improving ED. These remedies may produce adverse side effects or react negatively with other medications a man is taking. Before trying any over-the-counter treatments, it is essential to consult a doctor.
Erectile dysfunction is a common problem for more than half of men with diabetes. Musicki says that an estimated "50 percent to 75 percent of diabetic men have erectile dysfunction to some degree, [a rate] about threefold higher than in non-diabetic men."  This is not the same type of erectile dysfunction seen in non-diabetics, and it is less effectively treated with conventional drugs like Viagra. 

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

Obesity and metabolic syndrome can cause changes in blood pressure, body composition, and cholesterol which may lead to ED. Other conditions that may contribute to erectile dysfunction include Parkinson’s, multiple sclerosis, Peyronie’s disease, sleep disorders, alcoholism, and drug abuse. Taking certain medications can also increase your risk for ED.
Occasional difficulties in bed do not constitute ED – it is the persistent and consistent inability to maintain an erection through satisfactory intercourse. It is more common than men might think, given that they are loath to discuss it with others, often even their doctors. The condition has many causes and, as a result, affects men of all ages – though it becomes increasingly prevalent with age.
Dr. Niket Sonpal is the Associate Program Director of the Internal Medicine Residency at Brookdale Hospital Medical Center in Brooklyn and an Associate Professor at Touro College of Osteopathic Medicine. He’s a practicing Gastroenterologist and Hepatologist with a focus on Men’s and Women’s Health, and a regular contributor to Women’s health, Shape and Prevention Magazine.
This is a 17-year-old male with a past medical history of insomnia, anxiety and depression who presents with complaints of gradual onset (2 years ago) of decreased ability to obtain and maintain erections adequate for intercourse. He reports normal nocturnal erections “most days of the week”. He does not masturbate because he feels that masturbation may have desensitized his brain and caused ED; however, he can masturbate and have an erection with normal orgasm/ejaculation. He has had a successful erection and intercourse with a partner, last time 2 weeks ago. He feels that his ED might have been associated with SSRI treatment but noted no improvement after stopping his SSRI. Cialis 5 mg is effective. He reports normal libido “but not where it was”. His testosterone (T) and free T are normal. He is in the care of a sexual therapist and has read extensively on the internet. He takes trazodone nightly for sleep.
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?
That doesn’t mean you need to cut back completely — most experts say moderation is key. But what's “moderation” exactly? According to the U.S. Centers for Disease Control and Prevention (CDC), moderate drinking is no more than two drinks a day for men (and one drink a day for women). The liver can only break down the amount of alcohol in about one standard-size drink an hour, so regularly drinking more than that means that toxins from alcohol can build up in your body and affect your organs, including those involved in sex.
"Stress and anxiety can adversely affect sexual performance and are common causes of erectile dysfunction,” warns Feloney. “Feelings of stress and anxiety can also lead to depression and a loss of interest in sex." It's important to get these feelings out in the open where you can deal with them. Issues that can lead to erectile dysfunction include fear from previous bad experiences with sex, family or work related stress, poor communication with your partner, and unrealistic goals and expectations.
Booze. Most men have learned: One too many cocktails doesn’t improve performance; instead, it can have the opposite effect. During a recent study of 1,506 Chinese males, the men who drank three or more drinks a week were more likely to have ED or some form of sexual dysfunction. “Men may find that alcohol decreases social inhibition, which makes it easier to approach a woman,” says Montague. “But alcohol is a depressant, and at higher quantities it can reduce both a man’s desire and ability to perform.”
A 2009 study published in The Journal of Sexual Medicine found less volume of liquid in the body in conjunction with a depressed nervous system, led to a struggle with sexual performance. This is because alcohol can dehydrate the body, decreasing blood volume while increasing the hormone associated with erectile dysfunction — angiotensin. The body is able to work at optimal capacity by staying hydrated, since major biological activities and functions utilize water molecules.
Sexual dysfunction and ED become more common as men age. The percentage of complete ED increases from 5% to 15% as age increases from 40 to 70 years. But this does not mean growing older is the end of your sex life. ED can be treated at any age. Also, ED may be more common in Hispanic men and in those with a history of diabetes, obesity, smoking, and hypertension. Research shows that African-American men sought medical care for ED twice the rate of other racial groups.
The study, led by the University of Exeter and the University of Oxford, looked at data on more than 220,000 men across three cohorts, 6,000 of whom experienced erectile dysfunction. The research echoed recent findings that erectile dysfunction has a genetic cause, and goes further by opening the possibility that living a healthier lifestyle may help reduce risk.
Alcohol is a nervous system depressant and can actually block nerve impulses and messages between the brain and body. This is why drunk people often experience slurred speech, emotional outbursts and difficulty walking. But even small amounts of alcohol will affect the nervous system, causing slower reflexes and fuzzy thinking. Moderate drinking—one to two drinks a day, for men—of any type of alcohol, may actually improve cardiovascular health, according to the Mayo Clinic. Excessive alcohol use and alcohol abuse, can cause scarring of the liver, high blood pressure and an increased risk of some cancers.
Cardiovascular diseases account for nearly half of all cases of erectile dysfunction in men older than 50 years. Cardiovascular causes include those that affect arteries and veins. Damage to arteries that bring blood flow into the penis may occur from hardening of the arteries (atherosclerosis) or trauma to the pelvis/perineum (for example, pelvic fracture, long-distance bicycle riding).
Certain feelings can interfere with normal sexual function, including feeling nervous about or self-conscious about sex, feeling stressed either at home or at work, or feeling troubled in your current sexual relationship. In these cases, treatment incorporating psychological counseling with you and your sexual partner may be successful. One episode of failure, regardless of cause, may propagate further psychological distress, leading to further erectile failure. Los of desire or interest in sexual activity can be psychological or due to low testosterone levels.
Anxiety is the most common cause of erectile dysfunction in young men. This can include nervousness about getting your partner pregnant, losing your erection while putting a condom on, or your sexual performance. This often creates a negative spiral, because failure to achieve an erection causes yet more anxiety and stress. Depression, anxiety and stress can also cause ED by reducing libido.
There have been rare reports of priapism (prolonged and painful erections lasting more than six hours) with the use of PDE5 inhibitors such as sildenafil, vardenafil, and tadalafil. Patients with blood cell diseases such as sickle cell anemia, leukemia, and multiple myeloma have higher than normal risks of developing priapism. Untreated priapism can cause injury to the penis and lead to permanent impotence. Therefore, if your erection lasts four hours, you should seek emergency medical care.
Additionally, speaking to more than just the sexual issues related to erectile dysfunction, the research addresses implications related to the overall understanding of penile health. According to Arthur Burnett, M.D., a professor of urology and head of the research team, "eNOS plays roles in both immediate erectile response and the overall health and function of the penile tissue." 
Since the decrease in T levels is often a consequence of obesity or weight gain (51), the milestone of treating testosterone deficiency in obese men is encouraging substantial lifestyle changes, including physical activity and weight loss. In fact, it is universally recognized that a low calorie diet or bariatric surgery can induce a significant increase in T plasma levels, reaching 10 nmol/L with the most invasive surgical procedures (62). Weight loss-induced T rise is more evident in young individuals (62), and, therefore, it must be strongly recommended in this age band.

So here’s something that’s really fascinating. Healthy eating is a way to reduce anxiety and stress. Now how, you may be asking, right? Well, think about it. We live in a world where there are so many variables and where we don’t have control over our lives. But now, with healthy eating, we have control over what goes into our body. And now having that control empowers us to be even healthier, to be more directive in what we do. And certainly, that begins then to reduce the anxiety and the stress. So all in one, you have a healthier body, but certainly a healthier mind.
"Sexual relations are not only an important part of people's wellbeing. From a clinical point of view, the inability of some men to perform sexually can also be linked to a range of other health problems, many of which can be debilitating or potentially fatal," says Professor Gary Wittert, Head of the Discipline of Medicine at the University of Adelaide and Director of the University's Freemasons Foundation Centre for Men's Health.

An erection is a "neurovascular event" meaning that in order to have an erection there needs to be proper function of nerves, arteries, and veins. An erection involves the central nervous system, the peripheral nervous system, physiologic and psychological factors, local factors with the erection bodies or the penis itself, as well as hormonal and vascular (blood flow or circulation) components. The penile portion of the process leading to an erection represents only a single component of a very complex process.


Instead of injecting a medicine, some men insert a suppository of alprostadil into the urethra. A suppository is a solid piece of medicine that you insert into your body where it dissolves. A health care professional will prescribe a prefilled applicator for you to insert the pellet about an inch into your urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes.
Diabetes is known to sabotage two body parts that provide essential components of an erection: nerves and blood vessels. Studies suggest that diabetic nerve damage (neuropathy) is the most important risk factor for ED in people with diabetes. If pelvic nerves that trigger penis muscles to relax are impaired, there may be a break in the chain between brain and penis, disrupting erection. Some researchers suspect that an inadequate supply of oxygen to the nerves causes this damage.
Erectile Dysfunction is typically caused by a problem with blood flow in the penis due to the hardening and narrowing of the blood vessels of the penis. This occurs most commonly due to aging itself, which causes the smooth muscle cells that line the blood vessels to become stiffer and less able to stretch. This prevents the flow of blood that the penis requires to become erect.

The American Medical Association (AMA) estimates that more than 30 million men in the US experience ED. And they expect that number to double by 2025, largely due to the fact that erectile dysfunction is affecting more and more guys in their 20’s and 30’s. ED in your 20’s is becoming more common, and that can signal some serious health risks to a growing number of young men.
Medications used to treat high blood pressure (hypertension), including diuretics and beta-blockers, may cause ED. Not all blood pressure medications are associated with ED; alpha-blockers, ACE inhibitors, calcium channel blockers, and angiotensin II receptor blockers don't appear to cause ED. If you are on a blood pressure medication, have an ED talk with your doctor about whether or not your medication may be contributing to your ED and if there is an alternative blood pressure medication that is safe for you to try.
Anxiety, stress, and depression can lead to ED. In a small study, 31 men newly diagnosed with ED either took tadalafil (Cialis) only, or took tadalafil while also following an eight-week stress management program. At the end of the study, the group who participated in the stress management program saw more improvement in erectile function than the group who took only tadalafil.

In prescribing sildenafil, a doctor considers the age, general health status, and other medication(s) the patient is taking. The usual starting dose for most men is 50 mg, however, the doctor may increase or decrease the dose depending on side effects and effectiveness. The maximum recommended dose is 100 mg every 24 hours. However, many men will need 100 mg of sildenafil for optimal effectiveness, and some doctors are recommending 100 mg as the starting dose.


Is your erectile dysfunction due to psychological (stress, relationship problems, etc.) or physical factors? Your doctor may ask if you note erections at night or in the early morning. Men have involuntary erections in the early morning and during REM sleep (a stage in the sleep cycle with rapid eye movements). Men with psychogenic erectile dysfunction (erectile dysfunction due to psychological factors such as stress and anxiety rather than physical factors) usually maintain these involuntary erections. Men with physical causes of erectile dysfunction (for example, atherosclerosis, smoking, and diabetes) usually do not have these involuntary erections. Men with psychogenic erectile dysfunction may relate the onset of problems to a "stressor," such as failed relationship. Your doctor may suggest a test to determine if you have erections during sleep, which may suggest that there may be a psychological cause of the erectile dysfunction.
5. Medline Plus. US National Library of Medicine. NIH National Institutes of Health. Drugs that may cause impotence (updated 21 Jan 2015). http://www.nlm.nih.gov/medlineplus/ency/article/004024.htm (accessed Nov 2016). myDr myDr provides comprehensive Australian health and medical information, images and tools covering symptoms, diseases, tests, medicines and treatments, and nutrition and fitness.Related ArticlesImpotence treatmentsIf you have impotence (erectile dysfunction), the treatment your doctor recommends will depend on thErectile dysfunction: visiting your doctorFind out what questions a doctor may ask when discussing erectile dysfunction (ED, or impotenceGum disease linked to erectile dysfunctionAdvanced gum disease (periodontitis) has been linked to an increased risk of erectile dysfunction, wPeyronie's diseasePeyronie’s disease is condition where a band of scar tissue forms in the penis, causing aAdvertisement
In regard to circulation, alcohol causes the blood vessels to dilate, which influences the way the blood moves in and out of the penis. A good blood flow regulates the relaxation and contraction of the penis, so it can get and maintain an erection. Without it, no matter how much you may want it to happen differently, your penis will simply remain flaccid.
An alprostadil cream that patients apply into the tip of the penis (the urethral meatus, the opening that urine passes through) is currently available in the UK and Europe. It is currently under review by the U.S. Food and Drug Administration (FDA). After application of the cream, an erection occurs within five to 30 minutes, and the erection lasts one to two hours in men who respond to the cream. Doctors recommend that one use the cream for a maximum frequency of two to three times per week and no more frequent than once every 24 hours. It has essentially the same contraindications and side effects as the other formulations of alprostadil. The cream may cause vaginal burning in roughly 4% of partners. Men should not use alprostadil cream for sexual intercourse with women of childbearing potential unless a condom is used. Researchers have performed controlled trial studies to evaluate the safety and effectiveness of this drug. Overall, 52% of men reported improvement in their erections compared to 20% of men receiving placebo. A later analysis demonstrated that 36% of men using the alprostadil cream had a clinically relevant improvement in vaginal penetration ability and 31% clinically relevant improvement in ability to have successful intercourse to ejaculation.
Lifestyle choices that impair blood circulation can contribute to ED. Smoking, excessive drinking, and drug abuse may damage the blood vessels and reduce blood flow to the penis. Smoking makes men with atherosclerosis particularly vulnerable to ED. Being overweight and getting too little exercise also contribute to ED.  Studies indicate that men who exercise regularly have a lower risk of ED.
Intraurethral alprostadil (Muse) provides a less invasive alternative to intrapenile injection. It is a pellet that is inserted 5–10 min before intercourse, and its effects last for 1 h. The response rate is ∼50–60%. It can be used twice daily but is not recommended for use with pregnant partners. Complications of priapism and penile fibrosis are less common than after alprostadil given by penile injection. The cost is ∼$18–24 per treatment.
Erectile dysfunction is a common occurrence in men with diabetes. The incidence of erectile dysfunction increases progressively with age, from 5% in men age 20 to 75% in men over age 65. The cause of erectile dysfunction in men with diabetes is usually related to a decrease in the blood supply to the penis as well as to injury to the nerves that are responsible for the erection mechanism. A decrease in testosterone production has also been identified as the cause in some men with diabetes.
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