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.
A 25-year-old male presents with a past medical history of mild traumatic brain injury, remote bilateral orchitis, depression, anxiety, and PTSD from childhood bullying. He presents with his mother. His chief complaint is ED that began at 19 years old. He reports that it is "hard to obtain an erection, takes a lot of work to get almost nothing out of it" and “extreme loss of sensation in specific areas” on his penis. He feels that this might be related to “over masturbation without lubricant” 1–3 times per day and reports that he is “addicted to masturbation”, using it as a coping mechanism to manage his PTSD. He reports strong, sustainable erections with tadalafil 5 mg and recovery of sensation when he uses marijuana. He has read extensively on the internet and self-treats with topical vitamin creams, self-administered laser treatment to the penis, pulsed electromagnetic therapy, and hyperbaric oxygen treatment for ED for the past 6 months. He reports no change with any of these treatments. He reports reduced libido and has recently started treatment with HCG and testosterone gel for testosterone of 198 without any change in his symptoms with T of 450. His free T is normal. He lives at home, is unemployed, and is sedentary. He takes Wellbutrin. His physical examination is normal. His CBC, CMP, pituitary, and thyroid functions are normal. Prior to the visit, his mother called the clinic to inform personnel that her son was very sensitive, potentially suicidal, and emotionally disturbed by this problem. He has seen two other urologists already for his erectile dysfunction and been displeased with the outcome of his visits.
Regardless of age, if a man is obese and sedentary, with poor dietary habits, he is at greater risk of developing diseases that can lead to erectile dysfunction. These include heart disease, hypertension and type 2 diabetes. Some forms of congenital heart disease may remain hidden and only cause problems in adulthood. Men of any age noticing a marked change in sexual function should contact their physicians to rule out the possibility of a more serious condition.
Though psychological causes of erectile dysfunction may be more complex than medical causes, they are still treatable. You should know, however, that resolving psychological impotence may not be quite as simple as taking Viagra (sildenafil citrate). ED drugs are designed to sidestep the physiological causes for ED such as low blood pressure or vascular damage – they won’t help you with issues of anxiety, stress, or low self-esteem. The best treatment for psychological ED will address the problem at its root.
Having learned a great deal more about erectile dysfunction including its risk factors and causes, you should be equipped to assess your own erectile function. If you have experienced erectile issues or you have some of the risk factors mentioned above, it may be worth making a trip to your doctor’s office. If you choose to seek help, give your doctor as much information as you can about your symptoms including their frequency and severity as well as the onset. With your doctor’s help, you can determine the best course of treatment to restore sexual function.
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The vacuum device creates a vacuum to pull blood into the penis. Unlike a normal erection, the inflow of blood does not continue once the individual removes the vacuum device. The rubber band placed at the base of the penis constricts the penis to prevent the blood from leaving the penis. As there is no inflow or outflow of blood when the rubber band is in place, it is uncommon for the tip of the penis (the glans) to appear a little blue and the penis to be cooler. Once intercourse is completed, the individual removes the rubber band and the blood drains out of the penis.
The prostaglandin E1 is contained in a small suppository located at the tip of an applicator. You should urinate first as this lubricates the urethra and makes it easier to insert the applicator into the tip of the urethra (urethral meatus, the opening at the tip of the penis that urine passes through). A patient can release the suppository into urethra by gently wiggling the applicator and pressing the button at the end. Rubbing the penis allows the suppository to dissolve, and the prostaglandin is absorbed through the tissue of the urethra into the penis. It takes 15 to 30 minutes for this occur. Once into the penis, the prostaglandin causes increased blood flow into the penis. The prostaglandin can be present in the ejaculate, and thus doctors recommend that men use a condom when having intercourse with a pregnant partner. Men may need to use a condom if vaginal irritation occurs in female partner.

For most men, improving erectile dysfunction means improving blood flow to the penis. Immediate relief often requires medications that increases nitric oxide (NO) in the blood vessels of the penis. NO causes the smooth muscle cells in the blood vessels of the penis to stretch, which increases the flow of blood. NO also keeps the smooth muscle cells younger and helps prevent and even reverse hardening and narrowing of the blood vessels over time. Proper diet (see more below) and regular exercise are key because both can boost NO.
Diabetes is an example of an endocrine disease that can cause a person to experience impotence. Diabetes affects the body’s ability to utilize the hormone insulin. One of the side effects associated with chronic diabetes is nerve damage. This affects penis sensations. Other complications associated with diabetes are impaired blood flow and hormone levels. Both of these factors can contribute to impotence.
Research is mixed on the effectiveness of acupuncture as an erectile dysfunction cure, but one study published in November 2013 in the Journal of Alternative and Complementary Medicine found that acupuncture can be beneficial for men experiencing erectile dysfunction as a side effect of antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs).

The best policy is honesty and clarity. If you understand the cause of your ED, as well as the solution, you can enlighten your partner and allow both of you to enjoy sexual intimacy along with everything else you both enjoy about each other. It doesn’t have to be a secret shame, because it’s a medical condition just like any other and fortunately its very treatable.


Erectile function can be impaired in several endocrine disorders and treating these conditions can improve ED (43). This is the case of adrenal insufficiency, whose treatment with glucocorticoid and mineralocorticoid replacement is able to improve erectile function (44). Similarly, an adequate control of thyroid function in hyper- and hypothyroid patients is associated with an improvement in ED (45,46). However, although ED is a common complaint in subjects with Addison’s disease, hypo- and even more hyperthyroidism (45-48), the prevalence of these disorders is subjects with ED is not so high for recommending the routine screening of adrenal and thyroid hormone in these men (49). In contrast with the low prevalence of adrenal or thyroid disturbances in ED subjects, testosterone (T) deficiency is frequently found in subjects with ED (49,50) and, in turn, low T is frequently associated with the occurrence of sexual dysfunctions, including ED, even in general population (51). Accordingly, the Fourth ICSM recommends the routine assessment of T levels in patients with ED (43). The assessment of prolactin (PRL) in ED patients is controversial because an actual pathological increase in PRL levels (severe hyperprolactinemia: prolactin ≥735 mU/L or 35 ng/mL) is rarely found in ED men (52). Furthermore, the role of PRL in inducing ED is still not clarified. Hyperprolactinemia has been consistently associated with loss of sexual desire (43,53) and development of hypogonadotropic hypogonadism, both conditions that can in turn induce ED. However, a direct role of high PRL levels in inducing an impairment of erectile function is not consistently proven (52,54) and, conversely, more recent evidence suggests that lower, rather than higher, PRL levels are associated with impaired erectile function (55-57). For these reasons, at present, the assessment of PRL levels in subjects with ED is not routinely recommended (43) and it could be advisable only in men with hypogonadotropic hypogonadism, as a possible cause of this condition.
A man needs to try the medicine at least four times before he concludes that it doesn’t work for him. It is unlikely that a man with diabetes who has other medical problems such as high blood pressure, is taking multiple medicines, and has not had sexual intercourse for several years will be able to have an erection adequate for intercourse the first time he takes a pill. Most men need to try the medicine several times before they have the desired results.
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. 

L-arginine is an amino acid that occurs naturally in the human body and helps make that magic nitric oxide so important for supporting an erection. A 1999 study observed the effects of six weeks of L-arginine administered daily among men with ED. One third of those who took five grams per day of L-arginine experienced significant improvements in sexual function.
Diabetes leads to vascular complications throughout the body and the penis is no exception. A large survey reported that the majority of men with diabetes and ED had never even been asked about their sexual function. That means they never received treatment for ED. If you think you might have diabetes or even prediabetes, talk to your doctor about ED.
There is no evidence that mild or even moderate alcohol consumption is bad for erectile function, says Ira Sharlip, MD, a urology professor at the University of California San Francisco School of Medicine. But chronic heavy drinking can cause liver damage, nerve damage, and other conditions -- such as interfering with the normal balance of male sex hormone levels -- that can lead to ED.

Additional information to obtain includes a psychosocial and cultural history to assess past and present relationships, emotional or professional stressors, current and previous psychological/behavioral diagnoses and treatments, educational level and employment status, and location of domicile. A methodical medical history should be obtained to identify medical conditions that might be contributing to the patient’s ED. A thorough physical examination should be performed on all new patients with emphasis on the cardiovascular, genital, endocrine, and neurologic systems. On physical examination in a man with hypertonic cavernous smooth muscle, the penis may initially be contracted and tender to palpation. As the exam proceeds and the patient becomes less anxious, the penile tissue will often noticeably relax.
A little wine every day or two is good for your heart, and that’s good for your sexual function. Men who drink moderately, one or two drinks a day, are actually at lower risk of developing erectile dysfunction (ED) than men who don’t drink at all. But if a little is good, too much is clearly bad. Drinking too much alcohol at one time can interfere with sexual performance, as many a college student has found to his dismay. Drinking too much alcohol over months and years can do something far worse. It can cause ED.
Association between severity of erectile dysfunction and SIEDY Scale 1, Scale 2 and Scale 3 (organic, relational and intrapsychic pathogenetic components of erectile dysfunction, respectively). Data are derived from a population of 1,873 men aged 18–44 years, representing the first tertile of age in a population of patients consulting the Sexual Medicine and Andrology Unit of the University of Florence for erectile dysfunction. Data are adjusted for age, smoking habits, alcohol intake and education. Erectile dysfunction is defined according to a previously validated definition (21) using the sum of the scores obtained from question 1A (Do you have full erection sufficient for penetration? Rating 0= always, 1= often, 2= quite often and 3= sometimes) and question 2 (Does it occur to have a normal erection which you are not able to maintain? Rating 0= sometimes, 1= quite often, 2= often, and 3= always) of SIEDY, which reproduce the definition of erectile dysfunction as “The persistent inability to achieve and/or maintain an erection adequate for satisfactory sexual activity” (1). SIEDY, Structured Interview on Erectile Dysfunction.
Erectile dysfunction (ED), also known as impotence, is the inability to achieve or sustain a hard enough erection for satisfactory completion of sexual activity. Erectile dysfunction is different from other health conditions that interfere with male sexual function, such as lack of sexual desire (decreased libido) and problems with ejaculation release of the fluid from the penis (ejaculatory dysfunction) and orgasm/climax (orgasmic dysfunction), and penile curvature (Peyronie's disease), although these problems may also be present. ED affects about 50% of men age 40 and over. This article focuses on the evaluation and treatment of erectile dysfunction.

Wing, R. R., Rosen, R. C., Fava, J. L., Bahnson, J., Brancati, F., Gendrano, I. N. C., … Wadden, T. A. (2010, January). Effects of weight loss intervention on erectile function in older men with type 2 diabetes in the Look AHEAD trial. The Journal of Sexual Medicine, 7(1), 156-165. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4461030/
Patients taking PDE5 inhibitors should avoid consuming large amounts of alcohol, which may cause a sudden decrease in blood pressure when getting up from a standing or reclining position. Although effects can be variable, symptoms may include a fast heart rate, dizziness, headache and fainting. Studies with some PDE5 inhibitors have shown a decrease in blood pressure and symptomatic effects when combined with alcohol.
Some doctors prefer to start a man on the lowest dose of an oral medicine and increase the dose until an effective one is found. Others prefer to start with the highest dose and go to a lower dose only if a man complains of side effects. In either case, it’s important for a man to communicate with his doctor to let him know how the dose he’s using is working.

There are two kinds of surgery for ED: one involves implantation of a penile prosthesis; the other attempts vascular reconstruction. Expert opinion about surgical implants has changed during recent years; today, surgery is no longer so widely recommended. There are many less-invasive and less-expensive options, and surgery should be considered only as a last resort.
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