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.”
In many ways, performance anxiety becomes a self-fulfilling prophecy wherein you become nervous about being able to satisfy your partner and the nerves lead to sexual dysfunction. In many cases, performance anxiety is triggered by negative self-talk – worries about being able to achieve an erection, pleasing a partner, or ejaculating too early. If you have had erectile issues in the past, those experiences will add to the weight of performance anxiety.
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.
The number of symptoms reported appeared to be a function of the amount of alcoholic beverage consumed. The chance of developing sexual dysfunctions appears to increase with increasing quantity of alcohol consumed. Higher levels of alcohol intake may result in greater neurotoxic effects. It has been reported that heavy alcohol use may contribute to a reversible vagal neuropathy, which is perhaps reversible on abstinence. However, chronic heavy use of alcohol is also known to significantly alter gonadal hormones.
Treatments include psychotherapy, adopting a healthy lifestyle, oral phosphodiesterase type V (PDE5) inhibitors (Viagra, Levitra, Cialis, Stendra, and Staxyn), intraurethral prostaglandin E1 (MUSE), intracavernosal injections (prostaglandin E1 [Caverject, Edex], Bimix and Trimix), vacuum devices, penile prosthesis and vascular surgery, and (in some cases) changes in medications when appropriate.
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.
“I’d like to say that men are regularly screened for ED, but when it comes to busy doctors taking care of patients with diabetes, sexual function tends to fall lower on the list of complications,” said Stan Honig, MD, Director of Men’s Health, Yale School of Medicine. “I’d like to think that every doctor asks every man about sexual function, but I don’t think that’s the case.”
A daily glass of wine, beer or single malt over dinner or after work with your buddies will not lead to erectile dysfunction (ED), inability to get or maintain an erection during sex. Overindulging, though, will short-circuit your sex life. Besides waking up with a major hangover, overdoing it will eventually lead to hardening of the arteries and cardiovascular disease, which interferes with blood flow to your equation is simple: the less blood flow, the soft and skimpier the erection. Unless you can drink in moderation, avoid alcohol if you want to be at your best in bed.
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.
As a starting point, consider the National Health and Social Life Survey, which was the first nationally representative sex survey conducted in the United States . The data were collected in 1992 from thousands of Americans aged 18-59. As part of this survey, male participants were asked whether they’d had trouble maintaining or achieving an erection any time in the last year, to which they provided a simple yes/no answer.
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.
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.
Alcohol use. Excessive drinking of alcohol and binge drinking among young men, especially between the ages of 22 and 30, can lead to ED. I did my share of drinking in college, and found it was difficult to perform while intoxicated. Mild or moderate alcohol use can result in temporary impotence, and erections will return once the alcohol is out of your system. But, when drinking becomes excessive, it is believed that alcohol acts as a sedative on the central nervous system, thus depressing the male libido and sexual desire, which in turn inhibits the brain from sending signals to the heart to pump blood to the penis. A lack of blood flow to the penis prevents your ability to maintain or achieve an erection.
Aging: There are two reasons why older men are more likely to experience erectile dysfunction than younger men. First, older men are more likely to develop diseases (such as heart attacks, angina, cardiovascular disease, strokes, diabetes mellitus, and high blood pressure) that are associated with erectile dysfunction. Second, the aging process alone can cause erectile dysfunction in some men by causing changes in the muscle and tissue within the penis.
These findings demonstrate the importance of recognizing a possible organic component of ED even in younger men. In fact, in younger, more than in older men, who are by definition at high CV risk, searching for signs of metabolic or CV disorders can help identify those men who apparently healthy, have subtle and subclinical conditions that can be treated before the damage becomes clinically overt.
Multiple authors have demonstrated that anxiety, depression, and stress clearly produce major neurochemical and neuroendocrine changes in the brain (10,11). Changes in neurobiology would be expected to contribute to impaired erectile function. Stress and anxiety lead to increased epinephrine production, and heightened sympathetic tone leads to exaggerated cavernosal smooth muscle contraction, inability of smooth muscle to relax, and subsequent erectile dysfunction (6,7). Failure to achieve a fully rigid erection may aggravate performance anxiety leading to a vicious cycle.
Then you have to be able to make the right diagnosis. What is the basis for their erectile dysfunction? Is it psychogenic? Is it some sort of neurological or blood vessel or hormonal issue? So you have to make a diagnosis. You have to be able to make an assessment. And then only after those things are done, then you start to think about medications.
A 19-year-old male presents with a history of anxiety, depression, and asthma and chief complaint of ED that began 1-year ago after a “nerve twinge with subtle pain” during masturbation. He also reports decreased penile sensation since the event. He can obtain and maintain an erection with masturbation. He reports inability to obtain or maintain an erection with a partner unless he takes tadalafil 5 mg. He reports straight phallus, normal libido, orgasm, and ejaculation. The remainder of his history is negative. His physical examination is normal. His previous laboratory assessment, including CBC, CMP, TSH, T4, T and Free T, was normal.
All three of these involve specific bodily systems including the hormones, muscles, blood vessels, nervous system, and emotions. If any of these systems become compromised, it can cause ED. In the case of anxiety and stress, these things can affect the brain’s ability to send the necessary signals to trigger the desired physical response – an erection. Stress and anxiety can also contribute to an ongoing cycle of ED, as mentioned earlier.
Erections also require neural input to redirect blood flow into the corpora cavernosae. Psychogenic erections secondary to sexual images or auditory stimuli relay sensual input to the spinal cord at T-11 to L-2. Neural impulses flow to the pelvic vascular bed, redirecting blood flow into the corpora cavernosae. Reflex erections secondary to tactile stimulus to the penis or genital area activate a reflex arc with sacral roots at S2 to S4. Nocturnal erections occur during rapid-eye-movement (REM) sleep and occur 3–4 times nightly. Depressed men rarely experience REM sleep and therefore do not have nocturnal or early-morning erections.
"One of the reasons erectile dysfunction increases with age is that the diseases that lead to it also increase with age," notes Dr. Feloney. Evaluating the causes of erectile dysfunction starts with your doctor taking a good health history and giving you a physical exam. Common medical issues that can lead to erectile dysfunction include diabetes, high blood pressure, hardening of the arteries, low testosterone, and neurological disease. Talk to your doctor about better managing these health conditions.
What has been excluded entirely from all recent discussions of ED in young men is a concept presented many years ago—the concept of increased sympathetic tone as an organic etiology of “psychogenic” erectile dysfunction in young men (5). Previous studies have shown that elevated central sympathetic tone may be one cause of impotence (6,7). This article focuses on the presentation, work-up, and treatment of young men (age: 16–35 years old) with complaints of ED, and we will attempt to present a new method of approaching these patients. It is important to identify the precise etiology of ED in these men before proceeding with potentially unnecessary evaluation and treatment as the process can be anxiety-provoking, invasive, and costly and may provide an unreliable diagnosis which produces further psychological distress in these psychologically fragile young men.
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."
*all photos are models and not actual patients.If you are interested in a prescription product, Hims will assist in setting up a visit for you with an independent physician who will evaluate whether or not you are an appropriate candidate for the prescription product and if appropriate, may write you a prescription for the product which you can fill at the pharmacy of your choice.
These are not currently approved by the FDA for ED management, but they may be offered through research studies (clinical trials). Patients who are interested should discuss the risks and benefits (informed consent) of each, as well as costs before starting any clinical trials. Most therapies not approved by the FDA are not covered by government or private insurance benefits.
• Blood Vessels: Diabetes damages blood vessels, especially the smallest blood vessels such as those in the penis. Diabetes can also cause heart disease and other circulatory problems. Proper blood flow is absolutely crucial to achieving erection. “Erection is a hydraulic phenomenon that occurs involuntarily,” says Arturo Rolla, MD, of Harvard University School of Medicine. “Nobody can will an erection!” Anything that limits or impairs blood flow can interfere with the ability to achieve an erection, no matter how strong one’s sexual desire.