Metabolism (breakdown) of vardenafil can be slowed by aging, liver disease, and concurrent use of certain medications (such as erythromycin [an antibiotic], ketoconazole [Nizoral, a medication for fungal/yeast infections], and protease inhibitors [medications used to treat AIDS]). Slowed breakdown allows vardenafil to accumulate in the body and potentially increase the risk for side effects. Therefore, in men over 65 years of age with liver disease, or who are also taking medication(s) that can slow the breakdown of vardenafil, the doctor will initiate vardenafil at low doses to avoid its accumulation. For example,
If the patient reports intermittent ability to obtain and maintain an erection, evaluation with combined injection and stimulation test (CIS) will give you additional diagnostic and potentially therapeutic answers. It will determine if he has adequate inflow to obtain erection and if he has adequate venous occlusive function to maintain erection. It may also provide reassurance to the patient that his anatomy is functional. However, it is well documented that due to increased sympathetic tone these young men will often require additional injection or a separate visit in order to respond appropriately with complete smooth muscle relaxation (7,20,21).
Patients should continue testosterone therapy only if there is improvement in the symptoms of hypogonadism and should be monitored regularly. You will need periodic blood tests for testosterone levels and blood tests to monitor your blood count and PSA. Testosterone therapy has health risks, and thus doctors should closely monitor its use. Testosterone therapy can worsen sleep apnea and congestive heart failure.
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.
Erectile dysfunction is a condition in which a man is unable to achieve an erection sufficient for sexual intercourse. In some cases the man is able to achieve an erection but unable to maintain it long enough to complete the sex act. Most men experience erectile difficulties at some point in their lives, but this is different from ED. According to the Mayo Clinic, those with ED will fail to achieve an erection at least 25 percent of the time. ED has several causes and alcohol consumption can be one of them.
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.
Keep your stress level down. Stress can interfere with sexual arousal and your ability to get an erection. Exercise, meditation, and setting aside time to do the things that you enjoy can help to keep your stress levels down and lessen your risk of ED. If you’re developing symptoms of anxiety or depression, consult your doctor. They may be able to refer you to a therapist who can help you work through anything that is causing you stress.
ICI therapy often produces a reliable erection, which comes down after 20-30 minutes or with climax. Since the ICI erection is not regulated by your penile nerves, you should not be surprised if the erection lasts after orgasm. The most common side effect of ICI therapy is a prolonged erection. Prolonged erections (>1 hour) can be reversed by a second injection (antidote) in the office.
Getting (and maintaining) an erection requires a surprising amount of things to go right. You have to get aroused, then pass that signal from your brain, through your nerves and hormones, to your blood vessels and muscles before an erection can even happen. If one thing goes wrong in that complicated exchange between your cardiovascular, and nerve system, and your hormone levels, blood vessels, and even your mood the result is usually erectile dysfunction. In other words, getting an erection is hard.
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?
Intermountain Healthcare is a Utah-based, not-for-profit system of 23 hospitals, a Medical Group with more than 1,600 physicians and advanced practice clinicians at about 180 clinics, a health plans division called SelectHealth, and other health services. Helping people live the healthiest lives possible, Intermountain is widely recognized as a leader in clinical quality improvement and in efficient healthcare delivery.

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.
One hundred male subjects, consecutively admitted to the Deaddiction Centre of the National Institute of Mental Health And NeuroSciences (NIMHANS), Bangalore, India, with a diagnosis of Alcohol Dependence Syndrome With Simple Withdrawal Symptoms (F10.30, ICD-10 criteria) [WHO][13] were recruited for the study. All subjects gave informed consent for taking part in the study. Subjects were initially assessed on the schedules for clinical assessment in neuropsychiatry (SCAN)[14] by a trained psychiatrist (VB). All patients were subjected to detailed clinical and biochemical examinations including blood glucose and liver enzymes. Patients with significantly high levels of liver enzymes or physical findings suggestive of hepatic cirrhosis were referred for ultrasound assessment of the abdomen.
Regular exercise for about 20 to 30 minutes a day may act as a libido enhancer and certainly will improve your overall health. "Exercising improves blood flow to all areas of your body and that includes the pelvic region where the blood vessels needed for sexual functioning are located," says Feloney. Some other ways that regular exercise can improve your sexual performance include building up your stamina, lowering your blood pressure, relieving stress, and helping you look and feel better.
As recently as two decades ago, doctors tended to blame erectile dysfunction on psychological problems or, with older men, on the normal aging process. Today, the pendulum of medical opinion has swung away from both notions. While arousal takes longer as a man ages, chronic erectile dysfunction warrants medical attention. Moreover, the difficulty is often not psychological in origin. Today, urologists believe that physical factors underlie the majority of cases of persistent erectile dysfunction in men over age 50.
Few men want to talk about their inability to get or maintain an erection, however, erectile dysfunction can have a profound impact on relationships and self-esteem. Fortunately, trouble in the bedroom doesn't necessarily mean you're dealing with erectile dysfunction. Most men will have problems with an erection at some point in their sexual history. But one bad day in the bedroom doesn't mean major sexual health problems. So how can you know if you're dealing with erectile dysfunction?
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.
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.
People sometimes refer to ED as "impotence," although the two aren't really the same condition. ED is the physical inability to develop or maintain an erection that is rigid enough for sex. Impotence is a broader term. While one cause of it is ED, impotence may also involve a lack of sexual desire, an inability to ejaculate, or problems with orgasm.
Erectile dysfunction is no laughing matter. And although it is not an easy thing to talk about, there are trained professionals who can give you good advice about what may be the cause of your current predicament. Many men like to talk about sex, but like women, they may find it harder to talk about sex when it is not going well. You won’t be judged or talked about at BPAS. We are here to help you with some of the more private things in life.

Poor cardiovascular health reduces your body’s ability to deliver blood needed to produce erections. In a study published in 2004, researchers followed male participants for 25 years. The researchers found that heart disease risk factors predicted which men were most at risk of future ED. Numerous studies have strongly tied four major cardiovascular risk factors to ED:

Experts often treat psychologically based impotence using techniques that decrease anxiety associated with intercourse. The patient's partner can help apply the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety during treatment of physical impotence. If these simple behavioral methods at home are ineffective, a doctor may refer an individual to a sex counselor.
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.
The condition is often an early warning sign of heart disease and other circulatory problems. To achieve and maintain an erection, extra blood must be able to flow unimpeded. Anything that interferes with healthy flow – for example atherosclerosis, the artery-clogging process at the root of most heart attacks, strokes, and other cardiovascular conditions – has the potential to cause erectile dysfunction, too.

The association between psychiatric conditions and sexual dysfunctions, including ED, is well known. Data from population-based studies demonstrate a cross-sectional association between depressive symptoms and ED (65-68) and, among men seeking medical care for ED, depression is significantly associated with a greater severity of the impairment in erectile function (69,70). A meta-analysis of the available prospective studies has shown the role of depression as a significant risk factor for development of ED (71). However, the relationship seems to be bidirectional, as also ED has been associated with the occurrence of depression (72). In addition, treatment with PDE5i is related with an improvement in depressive symptoms (72). Most of this evidence comes from studies not specifically designed for the assessment of this relationship in younger men. However, few studies available in younger populations seem to confirm these results. In an internet-based survey, involving more than 800 North American medical students with a mean age of 25.7 years, ED was reported by 13% of them and it showed a significant association with depressive symptoms, whose frequency got higher as a function of ED severity (73). In a population of more than 2,500 very young Swiss men, aged 18–25 years, participating to a survey on sexual function while attending the medical screening for the evaluation of military capability, ED had a prevalence of 30%. Among the possible correlated conditions, mental health showed an independent association, besides the use of medications without medical prescription, a shorter sexual lifespan and impaired physical health (74). The results from this Swiss study were then prospectively extended on a sample of 3,700 men evaluated at baseline and 15.5 months later (75). Among a number of different possible predictors, including life-style, drug abuse, perceived physical fitness and BMI, only perceived impairment in mental health and depression, either newly occurred or continuously present, were associated with both persistence and development of ED (75). In a retrospective population-based study from Finland, involving almost 3,500 men aged 18–48 years, the role of depression as a significant predictor for ED was confirmed, but this study also showed that anxiety plays a significant role and that ED is significantly less frequent in men with a longer lasting sexual life, thus underlining the positive role of sexual experience and self-confidence (76). Anxiety is often involved in the pathogenesis of ED at the beginning of sexual life. In fact, anxiety can lead to an excessive focus on quality of erection, thus providing a cognitive distraction that negatively affects the arousal and consequently the erection itself (77-79). On the other hand, anxiety can result from one or more sexual failures, with loss of sexual confidence, increasing fears and avoidance for sexual experiences that, in the end, lead to an increased probability of new failures, thus creating a vicious circle (77). Cognitive distraction could be also provided by excessive worry for physical, and in particular genital, self-image. In fact, it has been proposed that when most mental energy is focused on monitoring body, psychological resources are distracted from sex, resulting in an impaired functioning (80,81). In line with this cognitive explanation, a recent study conducted on 367 military personnel younger than 40 years showed that a deteriorated genital self-image is associated with sexual anxiety which, in turn, is associated with a higher probability of sexual dysfunction (82).


Although ED can become a permanent condition, this typically isn’t the case for men who experience occasional erectile difficulties. If you have diabetes, you may still be able to overcome ED through a lifestyle that includes sufficient sleep, no smoking, and stress reduction. ED medications are usually well-tolerated, and can be used for many years to help overcome any ED problems.
If the patient reports intermittent ability to obtain and maintain an erection, evaluation with combined injection and stimulation test (CIS) will give you additional diagnostic and potentially therapeutic answers. It will determine if he has adequate inflow to obtain erection and if he has adequate venous occlusive function to maintain erection. It may also provide reassurance to the patient that his anatomy is functional. However, it is well documented that due to increased sympathetic tone these young men will often require additional injection or a separate visit in order to respond appropriately with complete smooth muscle relaxation (7,20,21).
Erectile dysfunction, often referred to as ED, is characterized by a persistent and recurring inability to achieve or maintain an erection sufficient for sexual intercourse. Psychological, physical and lifestyle issues can all cause ED, as can trauma to nerves and arteries. The incidence of erectile dysfunction increases with age, but young men can also experience it.
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.
Some men say certain alternative medicines taken by mouth can help them get and maintain an erection. However, not all “natural” medicines or supplements are safe. Combinations of certain prescribed and alternative medicines could cause major health problems. To help ensure coordinated and safe care, discuss your use of alternative medicines, including use of vitamin and mineral supplements, with a health care professional. Also, never order a medicine online without talking with your doctor.
In addition to these laboratory tests, your doctor may also ask you to complete a self-report to gauge your level of sexual function. You’ll be asked questions about your sexual desire (libido), your ability to achieve and maintain an erection, your ability to reach orgasm, your satisfaction level with intercourse, as well as your overall sexual satisfaction. Depending on your answers, and the results of your laboratory tests, your doctor may recommend a psychological evaluation to further explore the potential cause for your ED.
Monitoring erections that occur during sleep (nocturnal penile tumescence) can help you and your doctor to understand if the erectile dysfunction is due to psychological or physical causes. The nocturnal penile tumescence test is a study to evaluate erections at night. Normally men have three to five erections per eight hours of sleep. The test can be performed at home or in a sleep lab. The most accurate way to perform the test involves a special device that is connected to two rings. The rings are placed around the penis, one at the tip of the penis and the other at the bottom (base) of the penis. The device records how many erections occur, how long they last, and how rigid they are. The test is limited in that it does not assess the ability to penetrate.
Erectile dysfunction is a condition in which a man is unable to achieve an erection sufficient for sexual intercourse. In some cases the man is able to achieve an erection but unable to maintain it long enough to complete the sex act. Most men experience erectile difficulties at some point in their lives, but this is different from ED. According to the Mayo Clinic, those with ED will fail to achieve an erection at least 25 percent of the time. ED has several causes and alcohol consumption can be one of them.
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.

For many young men, performance anxiety plays a large role in erectile dysfunction. Other factors include money and work problems, as well as relationship issues and even issues about sexual orientation. Undiagnosed depression and post-traumatic stress disorder can cause erectile dysfunction--especially if the PTSD is related to a past sexual experience.
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.
Luckily, awareness of ED as a significant and common complication of diabetes has increased in recent years, mainly because of increasing knowledge of male sexual function and the rapidly expanding armamentarium of novel treatments being developed for impotence. Studies of ED suggest that its prevalence in men with diabetes ranges from 35–75% versus 26% in general population. The onset of ED also occurs 10–15 years earlier in men with diabetes than it does in sex-matched counterparts without diabetes.
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.
The key to treating erectile dysfunction is to identify the underlying cause. In many cases, it takes a fair bit of trial and error. Because the majority of ED cases are caused by physiological issues, your first step should be to talk to your doctor about your concerns. After completing a physical examination and reviewing your medical history, your doctor will ask you some questions and run some tests to rule out medical causes for your ED.
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.
Erectile Dysfunction is usually a condition faced by men over the age of 50, but based on the large number of inquiries on blogs and forums from young men dealing with the symptoms of impotence and over 500 hits to my article  titled “Can Men in Their 20’s and 30’s Have Erectile Dysfunction,”  this demonstrates erectile dysfunction at all ages is a serious issue, and particularly erection problems in young men is a key issue these days. If you are in this age group and are dealing with erectile dysfunction, then you have come to the right place to learn about the issues of erectile dysfunction in young  men.
The main surgical treatment of ED involves insertion of a penile implant (also called penile prostheses). Because penile vascular surgery is not recommended for aging males who have failed oral PDE5 inhibitors, ICI or IU therapies, implants are the next step for these patients. Although placement of a penile implant is a surgery which carries risks, they have the highest rates of success and satisfaction among ED treatment options.
Erectile dysfunction is more common than most people think. About 40% of men will notice some degree of problem by age 40. The aging of the penis can begin as early as the late 20s but becomes severe enough to notice typically starting in the 40s. As men get older, their odds of getting erectile dysfunction increases by about 10% per decade, and the severity of the problem also increases.
You might consider having a few drinks to get in the mood, but overindulging could make it harder for you to finish the act. Heavy alcohol use can interfere with erections, but the effects are usually temporary. The good news is that moderate drinking -- one or two drinks a day -- might have health benefits like reducing heart disease risks. And those risks are similar to erectile dysfunction risks.
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.
ED can also occur among younger men. A 2013 study found that one in four men seeking their first treatment for ED were under the age of 40. The researchers found a stronger correlation between smoking and illicit drug use and ED in men under 40 than among older men. That suggests that lifestyle choices may be a main contributing factor for ED in younger men.
Your doctor will ask you questions about your symptoms and health history. They may do tests to determine if your symptoms are caused by an underlying condition. You should expect a physical exam where your doctor will listen to your heart and lungs, check your blood pressure, and examine your testicles and penis. They may also recommend a rectal exam to check your prostate. Additionally, you may need blood or urine tests to rule out other conditions.

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. 

ICI Alprostadil may be used as a mixture with two other drugs to treat ED. This combination therapy called "bimix or trimix" is stronger than alprostadil alone and has become standard treatment for ED. Only the Alprostadil ingredient is FDA approved for ED. The amount of each drug used can be changed based on the severity of your ED, by an experienced health professional. You will be trained by your health professional on how to inject, how much to inject and how to safely raise the drug's dosage if necessary.
This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings through its clearinghouses and education programs to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.
After a full history and physical examination, the urologist likely has a perception of the etiology of the problem. Additional laboratory evaluations may be necessary to evaluate for specific types of organic disease. These tests might include serum chemistry, complete blood count, lipid profile, thyroid stimulation hormone/free thyroxine, and early morning serum testosterone to assess for metabolic abnormalities, such as diabetes mellitus, hyperlipidemia, renal dysfunction, thyroid disease, and hypogonadism (16). These are not mandatory components of the assessment in a patient with hypertonic cavernous smooth muscle as the source of ED.
This man’s situational ED, possibly due to performance anxiety or perhaps fear of a repeat injury and pain. Structural, neurogenic, arteriogenic, and venous occlusive erectile dysfunction can be ruled out as he has normal self-stimulated erections. He responds well to low dose oral PDE5 inhibitors. Additional assessment with cold and hot perception testing and biothesiometer were performed due to his complaint of decreased sensation; both test results were normal. He was started on low dose terazosin once daily at bedtime along with Cialis 5 mg as needed. He is responding well to treatment.
The relationship between ED and couple relation impairment is well documented. In our population of subjects consulting for sexual dysfunction, subjects reporting conflicts within the couple were characterized by a broad spectrum of sexual symptoms, including a severe extent of ED, and they had a higher SIEDY Scale 2 score, indicating a strong relational component in the pathogenesis of ED (88). If on one hand, it is easy to understand that problems in couple relationship can cause ED, the other way around is also feasible. In the Female Experience of Men’s Attitudes to Life Events and Sexuality (FEMALES) study, 292 female partners of men aged more than 20 years complaining for ED were involved in a survey assessing the quality of their sexual experience (89). In this study, women reported a significant deterioration of satisfaction for sexual intercourse after the onset of ED in their partners. The satisfaction, sexual desire, arousal and orgasm were then improved in women whose partner used PDE5i (89). The role of ED as a risk factor for female dysfunction, including impairment in arousal, orgasm, sexual satisfaction and sexual pain, has been also confirmed in a study involving 632 sexually active couples, whose male partner age ranged 18–80 years (90).
Third, men with Diabetes need to control their blood sugar levels. When your blood sugar is not under control, your body does not produce enough Nitric Oxide (NO) and vascular tissues don’t respond as effectively to NO. When enough blood flows into the penis, penile veins close off and block the blood from flowing out. This process results in an erection. If your body does not produce enough NO or if your penile tissues do not respond to NO, the pressure of the blood flowing into your penis is not sufficient to trap the blood, you penis will not get hard.
Control your blood sugar through your diet. Eating a diabetes-friendly diet will help you better control your blood sugar levels and lessen the amount of damage to your blood vessels and nerves. A proper diet geared at keeping your blood sugar levels in check can also improve your energy levels and mood, both of which can help reduce the risk of erectile dysfunction. You may consider working with a dietitian who is also a certified diabetes educator to help adjust your eating style.
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