Normal male sexual function requires a complex interaction of vascular, neurological, hormonal, and psychological systems. The initial obligatory event is acquisition and maintenance of an erect penis, which is a vascular phenomenon. Normal erections require blood flow into the corpora cavernosae and corpus spongiosum. As the blood accelerates, the pressure within the intracavernosal space increases dramatically to choke off penile venous outflow. This combination of increased intracavernosal blood flow and reduced venous outflow allows a man to acquire and maintain a firm erection.

The obvious risks are the same that accompany any surgery: infection, pain, bleeding, and scarring. If for some reason the prosthesis or parts become damaged or dislocated, surgical removal may be necessary. With a general success rate of about 90 percent, any of the devices will restore erections, but they will not affect sexual desire, ejaculation, or orgasm.
Injury to the nerves and arteries near the penis can lead to erectile dysfunction. According to the National Institutes of Diabetes and Digestive and Kidney Diseases, surgeries for prostate and bladder cancer can injure penile nerves and arteries, although it doesn’t always happen. Spinal cord injuries can affect the ability to achieve and maintain an erection, as can injuries to the penis, prostate, bladder and pelvis.
Men with diabetes are at a higher risk of erectile dysfunction or impotence, especially if their diabetes is not well controlled. Erectile dysfunction means you cannot have an erection that is sufficient to perform sexual intercourse. Many men experience short-term episodes of erectile dysfunction but, for about one in 10 men, the problem may continue.
The medications are extremely effective, which is very good. And the medications are, for the most part, extremely well-tolerated. But there are, like with any medications, a potential downside. The one absolute downside to the use of any of these erection what we call PDE5 medications is if a patient is using a nitroglycerin medication. And nitroglycerins are used for heart disease and for angina, for the most part, although there are some recreational uses of nitrites. And that’s important because your blood vessels will dilate and your blood pressure will drop. And that is an absolute contraindication.
But when you or your partner notice a change in your erections, it’s important to talk to a doctor to discover the underlying cause of your ED. Erectile dysfunction is often an early warning sign of serious health conditions, like heart disease. High blood pressure, diabetes, low testosterone, and high cholesterol are all causes of ED in otherwise healthy men. Don’t assume that it’ll pass—especially if symptoms get worse over time.
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.
If you have symptoms of ED, it’s important to check with your doctor before trying any treatments on your own. This is because ED can be a sign of other health problems. For instance, heart disease or high cholesterol could cause ED symptoms. With a diagnosis, your doctor could recommend a number of steps that would likely improve both your heart health and your ED. These steps include lowering your cholesterol, reducing your weight, or taking medications to unclog your blood vessels.
Aging, liver and kidney problems, and concurrent use of certain medications (such as erythromycin [an antibiotic] and protease inhibitors for HIV) slows the metabolism (breakdown) of sildenafil. Slowed breakdown allows sildenafil to accumulate in the body and potentially may increase the risk of side effects. Therefore, in men over 65 years of age, in men with significant kidney and liver disease, and in men who also are taking medications called protease inhibitors, the doctor will initiate sildenafil at a lower dose (25 mg) to avoid accumulation of sildenafil in the body. A protease inhibitor ritonavir (Norvir) is especially potent in increasing the accumulation of sildenafil, thus men who are taking Norvir should not take sildenafil doses higher than 25 mg and at a frequency of no greater than once in 48 hours. Other medications that may affect the level of sildenafil include erythromycin and ketoconazole.
In the popular media, it’s easy to find claims of a rising “epidemic” of erectile dysfunction in young men. For example, this article argues that the rate of ED in young men has increased 1000% in the last decade alone—though, problematically, no research is cited to back it up, which makes this a very questionable claim. So what does the science say on this subject? Are erectile difficulties really rising at a dramatic rate in young guys? Let’s take a look.
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.
Once observed that the organic component of ED is the most important one in younger patients (Figure 2), the summarized evidence underlines that metabolic and CV risk must not be underestimated in younger men even when they are apparently healthy. In fact, it is particularly in these men that recognizing the presence of risk factors can help in changing life-style, thus really changing the natural history of metabolic and CV diseases. In older men the damage is often already established and the identification of further risk factors usually does not add information to the estimation of CV risk. ED is a symptom that can provide a chance for both the patients and physicians to unearth the presence of CV risk factors and improve both the quality and length of life of these men.
Poor sleep patterns can be a contributing factor for erectile dysfunction, Mucher says. One review published in the journal Brain Research emphasized the intricate relationship between the level of sex hormones like testosterone, sexual function, and sleep, noting that testosterone levels increase with improved sleep, and lower levels are associated with sexual dysfunction. Hormone secretion is controlled by the body’s internal clock, and sleep patterns likely help the body determine when to release certain hormones. 
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.
For patients who have ED related to hypertonic cavernous smooth muscle and excessive sympathetic discharge, we recommend a trial of a low-dose alpha adrenergic blocker, such as terazosin 1 mg PO at bedtime nightly. We typically increase the dosage as needed every 2–3 weeks for 3–5 months until the patient experiences improvement of the erection or we determine that treatment is ineffective. We explain the potential side effects of orthostasis, dizziness, and retrograde ejaculation in detail. We also take great care and time in explaining to the patient, and his family/partner if present, the pathophysiologic mechanism of their erectile dysfunction and the biological basis of the treatment plan. This detailed discussion helps to engage the patient in the treatment plan and provides encouragement regarding the potential for response to treatment and recovery. During these encounters, we utilize teaching tools, such as diagrams, drawings, printed handouts, and other visual aids to ensure that the discussion is patient-focused and patient-friendly. Patient education is critical to exploring treatment options and developing confidence in our ability to treat the ED, and their own ability to overcome and eventually resolve the problem of ED.
Medications used in the treatment of other medical disorders may cause erectile dysfunction. If you think erectile dysfunction is caused by a medication, talk with your doctor about drugs that might not cause this side effect. Do not just stop taking a prescribed medication before talking with your health care provider. Common medications associated with erectile dysfunction are:

At the same time, people with diabetes are susceptible to a type of blood vessel damage known as endothelial dysfunction. A recent study found that men with ED are at a greater risk of heart disease, which is also associated with endothelial dysfunction. If blood vessels aren't in good working order, the penis may not get enough blood for an erection.
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.
Side effects of sildenafil are similar to those from taking niacin or any vasodilator, namely, headaches, lightheadedness, dizziness, and flushing. Some individuals experience a bluish tinge of their cornea, which makes them feel as if they are wearing light blue–tinted sunglasses. This effect can last for several hours. Syncope and myocardial infarction, the most serious side effects, are seen in men who are also taking nitrates for coronary heart disease. Sildenafil also has adverse effects in people with hypertrophic cardiomyopathy because a decrease in preload and after load in the cardiac output can increase the outflow obstruction, culminating in an unstable hemodynamic state.
Erectile dysfunction (ED) is commonly called impotence. It’s a condition in which a man can’t achieve or maintain an erection during sexual performance. Symptoms may also include reduced sexual desire or libido. Your doctor is likely to diagnose you with ED if the condition lasts for more than a few weeks or months. ED affects as many as 30 million men in the United States.

Penile prosthesis is a viable option for men who cannot use sildenafil and who find the injections or vacuum erection therapy distasteful. A non-adjustable semi-rigid prosthesis is easy to insert and has no postoperative mechanical problems. The inflatable prosthesis has a pump that is put in the testicular sac for on-demand inflation and deflation. Future versions will have a remote control device similar to a garage-door opener.

Another risk factor is that men with type 2 diabetes may produce less than normal amounts of testosterone, a condition called hypogonadism. A 2007 study found that one-third of men with type 2 diabetes had low testosterone levels. Those men were also more likely to have ED, though the link may have to do with weight, not diabetes per se. Being overweight or obese is a risk factor for hypogonadism.


“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.
Think of erectile dysfunction as your body’s “check engine light.” The blood vessels in the penis are smaller than other parts of the body, so underlying conditions like blocked arteries, heart disease, or high blood pressure usually show up as ED before something more serious like a heart attack or stroke. ED is your body’s way of saying, “Something is wrong.” And the list of things that cause erectile dysfunction can include:
Neurologic illnesses leading to ED have been recently reviewed (64). The most common of them (i.e., consequences of prostatic surgery, stroke and Parkinson’s disease) are not typical of younger age and, similarly to conditions less common but more typical of younger men, such as spinal cord injury, multiple sclerosis and spina bifida, the clinical features of the underlying disease are clearly apparent, being ED one of the multiple manifestations, rather than a harbinger of a subtle condition. Diagnosis of neurologic origin of ED is often quite simple, based on medical history and physical exam. The clinical management is a multidimensional and coordinated work of rehabilitation and medical therapy, which includes ICI injection of vaso-relaxant drugs, vacuum device and surgery (64).
Chronic stress dumps adrenaline in your system multiple times a day. And that can lead to high blood pressure, heart disease, obesity, and diabetes. Chronic stress is like red-lining your car all day long. When you drive 100 mph all the time, something is going to break down. A high-stress environment can actually change the way your brain sends messages to your body. Dumping too much adrenaline into your bloodstream can affect blood flow and severely limit your ability to achieve and maintain an erection.

The common PDE5 inhibitor drugs approved in the United States are sildenafil (Viagra), vardenafil (Levitra and Staxyn, the generic form), tadalafil (Cialis), or avanafil (Stendra). All of the currently approved PDE5 inhibitors work in the same way. They differ in the number of available doses, how quickly they work and last in your system, the dosing, and to some extent in the side effects. However, they generally share the same indications and contraindications. Currently, tadalafil is the only medication that patients can take on a daily basis and is approved for the treatment of both ED and BPH (benign enlargement of the prostate).
If the inability to get or maintain an erection happens to you once or twice, you may not need to see a doctor. Many lifestyle factors, such as stress or drinking too much alcohol, can affect your sexual ability. If you notice the problem is happening on a routine basis and it’s impacting your ability to have a satisfying sex life, then it’s time to consider seeing a doctor.
A 2013 study published in The Journal of Sexual Medicine evaluated 439 men for erectile dysfunction and compared ED causes and frequency in men 40 or younger to men over 40. They found that 26 percent of the younger men had ED. Although these men were healthier and had higher levels of testosterone than the older men, they were more likely to be smokers or to have used illicit drugs. In almost half of the younger men with ED, the ED was considered severe.

For obvious reasons, ED can be a sensitive subject, one that until relatively recently men were more likely to try to hide than to deal with. Fortunately, a deeper understanding of the variety of causes of erectile dysfunction has led to medications, therapies, and other treatments that can be more individualized and more likely to be effective—and more open discussion about addressing the concern.
Smoking.   Smoking and erectile dysfunction are related as smoking leads to plaque build up in the arteries called cardiovascular disease, which restricts blood flow through the veins.  Arterial sclerosis from smoking restricts blood flow, and thus can prevent the massive amount of blood required for you to achieve an eretion, resulting in erectile dysfunction.
For obvious reasons, ED can be a sensitive subject, one that until relatively recently men were more likely to try to hide than to deal with. Fortunately, a deeper understanding of the variety of causes of erectile dysfunction has led to medications, therapies, and other treatments that can be more individualized and more likely to be effective—and more open discussion about addressing the concern.
The relaxing effect of alcohol and the feeling of well-being that comes with a drink or two have made alcohol humans’ favorite beverage for about 10,000 years. Though some studies confirm that alcohol (in moderation!) is good for your heart and circulation (which can work against erectile dysfunction), it’s important to remember that sex and alcohol are a delicate balancing act.
Carrying extra pounds can impact your sexual performance, and not just by lowering your self-esteem. Obese men have lower levels of the male hormone testosterone, which is important for sexual desire and producing an erection. Being overweight is also linked to high blood pressure and hardening of the arteries, which can reduce blood flow to the penis.
If the patient complains of loss of sensation on his penile shaft or glans, it is useful to perform hot and cold perception testing and/or additional vibratory sensory testing with biothesiometer. These are tests that can be performed quickly during the office visit and provide useful information about the function of the dorsal nerve of the penis (Table 3).
Diabetes can cause nerve, blood vessel, and muscle damage that results in problems like pain, numbing or loss of sensation in the hands and feet.12 These issues can also result in ED problems, because nerve signals and blood flow are necessary to the process of getting an erection.6 And as men with diabetes get older, ED problems become even more common.13

In patients with low testosterone, testosterone treatment can improve libido and erectile dysfunction, but many men still may need additional oral medications such as sildenafil, vardenafil, or tadalafil. Some studies suggest that men with ED and low testosterone may respond better to PDE5 inhibitors when given testosterone therapy; however, this is controversial.

Once you have talked to your partner about your issues, you may want to consider taking things one step further with psychosexual therapy. This is a form of therapy in which both you and your partner see a therapist together. The therapist will help you and your partner break out of the cycle of stress and disappointment that has been coloring your sex life and contributing to your ED. Going to a therapist with your partner may also help you work out any relationship issues that have been affecting your sex life so the both of you will be more satisfied.
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.

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.
The relaxing effect of alcohol and the feeling of well-being that comes with a drink or two have made alcohol humans’ favorite beverage for about 10,000 years. Though some studies confirm that alcohol (in moderation!) is good for your heart and circulation (which can work against erectile dysfunction), it’s important to remember that sex and alcohol are a delicate balancing act.
What young men should not do is take an ED drug like Viagra without a prescription, or mix them with other drugs. “This is a huge problem and not a safe practice,” says Penny Kaye Jensen, PhD, president of the American Academy of Nurse Practitioners. “Some young men are mixing ED drugs with mind-altering drugs, such as ecstasy or crystal methamphetamine. This is on the rise and is a potentially deadly combination.”

A sexually competent male must have a series of events occur and multiple mechanisms intact for normal erectile function. He must 1) have desire for his sexual partner (libido), 2) be able to divert blood from the iliac artery into the corpora cavernosae to achieve penile tumescence and rigidity (erection) adequate for penetration, 3) discharge sperm and prostatic/seminal fluid through his urethra (ejaculation), and 4) experience a sense of pleasure (orgasm). A man is considered to have ED if he cannot achieve or sustain an erection of sufficient rigidity for sexual intercourse. Most men, at one time or another during their life, experience periodic or isolated sexual failures. However, the term “impotent” is reserved for those men who experience erectile failure during attempted intercourse more than 75% of the time.
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