Topic Overview
What are erection problems?
A man has erection
problems if he cannot get or keep an erection that is firm enough for him to
have sex. Erection problems are also called erectile dysfunction or
impotence.
Erection problems can occur at any age. But they are
more common in older men, who often have other health problems. Treatment can
help both older and younger men.
What causes erection problems?
Erection problems
may be caused by physical problems, such as injury to nerves or loss of
blood supply to the penis.
They can also be linked to other
health problems. These include
diabetes,
high blood pressure,
high cholesterol, and
atherosclerosis. Erection problems can also be linked
to problems with the
nervous system, such as
multiple sclerosis and
Parkinson's disease.
Many medicines for
other health problems may cause erection problems, but most do not. If you
recently began taking a new medicine and started having erection problems, this
could be a side effect of the medicine. Talk with your doctor. He or she may be
able to change the dose or type of medicine you take.
Men who
drink
too much alcohol, smoke, or use illegal drugs also are
at risk for erection problems.
Anxiety
,
stress, or
depression can cause erection problems.
Other causes include surgery, such as for prostate cancer, or injury to the
pelvic area.
What are the symptoms?
The only symptom of an
erection problem is being unable to get and keep an erection that is firm
enough to have sex. But even with an erection problem, a man may still have
sexual desire and be able to have an orgasm and to ejaculate.
How are erection problems diagnosed?
Your doctor
can find out if you have an erection problem by asking questions about your
health and doing a physical exam. Your doctor will want to know if the problem
happens all the time or just from time to time. The exam, lab tests, and
sometimes mental health tests can help find out the cause of the
problem.
How are they treated?
There are a number of
treatments for erection problems. Doctors usually start with lifestyle changes
and medicines. They usually don't advise surgery or other treatments unless
those first steps don't help.
Treatment can include:
- Making lifestyle changes, such as avoiding
tobacco, drugs, and alcohol. It may also help to talk about the issue with your
partner, do sensual exercises, and get counseling.
- Finding and
then stopping medicines that may be causing the problem. In some cases you can
take a different medicine that does not cause erection problems.
-
Taking prescription medicine that can help you get erections. These include
pills such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil
(Levitra). Check with your doctor to see if it is safe for you to take one of
these medicines with your other medicines. These can be dangerous if you have
heart disease that requires you to take nitroglycerin or other medicines that
contain nitrates.
- Taking medicines and getting counseling for
depression or anxiety.
- Using vacuum devices or getting shots of
medicine into the penis.
- Having surgery to place an implant in the
penis.
Can you prevent erection problems?
Because
erection problems are most often caused by a physical problem, it’s important
to eat healthy foods and get enough exercise to help you stay in good
health.
To reduce your risk of having an erection problem, do not
smoke, drink too much alcohol, or use illegal drugs.
You may be
able to avoid erection problems related to anxiety and stress by talking with
your partner about your concerns. This may help you relax.
Frequently Asked Questions
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Learning about erectile dysfunction (erection problems):
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Being diagnosed:
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Getting treatment:
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Ongoing concerns:
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Living with erectile dysfunction:
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Cause
Erection problems
(erectile dysfunction) may be caused by physical problems
related to the blood vessels, nerves, and hormones or by psychological issues. Physical problems cause about 8 out of 10 cases of erectile dysfunction.
Normally, an erection
occurs when your imagination or senses (vision, hearing, touch, smell, taste)
are stimulated and you become aroused. Your central nervous system sends nerve
impulses that increase blood flow to your penis. Blood fills the spongy
chambers (corpora cavernosa) in the penis, causing them to expand and become
rigid.
Four requirements for a normal erection are:
- A properly functioning nervous system that
sends the necessary signals to the penis.
- An intact system of blood
vessels (vascular system) to allow blood to flow into and out of the
penis.
- Normal smooth muscle in the penis, which must relax so the
penis can fill with blood and enlarge.
- The ability to trap the
blood in the penis so that it stays firm.
Physical causes of erection problems
include long-term (chronic) and short-term (acute) injuries and complications
of
prostate or other surgery that interfere with nerve
impulses or blood flow to the penis. Physical problems are often the cause of
erection difficulties in men age 50 or older.
- Problems with the blood vessels (vascular problems) may prevent blood from filling the penis or from remaining
there long enough to maintain an erection. For example, long-term
high blood pressure can cause damage to blood vessels
and lead to erection problems.
- Problems with the nerves (neurologic
problems) may prevent arousal signals from traveling from the brain and spinal
cord to the penis. Nerve disorders such as
Parkinson's disease,
Alzheimer's disease,
multiple sclerosis, and
stroke may interfere with a man's ability to have an
erection and may lower sexual desire. Nerve damage from
diabetes, complications from surgery, and spinal cord
injury also may cause problems.
- Problems with the structure of the
penis or its surrounding tissues may prevent an erection.
-
Hormonal factors, such as a low level of the hormone
testosterone, may be involved in causing erection
problems.
-
Side effects of medicines (for example, some of
those taken for high blood pressure or
depression) may include erection problems. In some
cases it may be possible to change the dose of the medicine or to use another
medicine.
- The use of tobacco, alcohol, or illegal drugs can lead to
erection problems. Stopping or reducing the use of these substances may reduce
the severity of a man's erection problem.
Activities that restrict blood flow to the penis also may
result in erection problems. Some doctors have observed that men who regularly
ride bicycles over long distances are more likely to have erection problems
than men who ride only occasionally, especially if they ride on a narrow,
unpadded saddle. But the possible link between bicycle riding and erection
problems has not been proved.
A
vasectomy usually does not cause an erection problem.
But pain after the operation may affect sexual performance for a while. And if a
man was not comfortable with his decision to have a vasectomy, or is having
second thoughts, it could affect him psychologically.
Psychological causes of erection problems include depression
(which also has a physical component),
anxiety,
stress,
grief, or problems with current or past relationships.
These interfere with the erection process by distracting the man from things
that would normally arouse him. Erection problems in men younger than 40 who
have no physical risk factors are more likely to be caused by psychological
factors than physical causes.
Symptoms
Symptoms of
erection problems (erectile dysfunction) include being
unable to:
- Have an erection most of the time.
- Maintain an erection firm
enough for sexual intercourse.
- Maintain an erection long enough to
complete sexual intercourse.
Even with an erection problem, a man may still have sexual
desire and be able to have an orgasm and to ejaculate.
What Happens
Most men have occasional
erection problems (erectile dysfunction). But when
erection problems become persistent, they can affect your self-image, sex life,
and relationship. When you have persistent erection problems, "performance
anxiety" can make the problem worse. If you cannot maintain an erection that is
firm enough for intercourse, or you have an orgasm before or immediately after
entering your partner (premature ejaculation), you may feel
frustrated and believe you are not pleasing your partner. All of these factors
could influence how you view your relationship.
Fortunately, many
of the physical and psychological factors that cause erection problems respond
to treatment.
What Increases Your Risk
Your risk of having an
erection problem (erectile dysfunction) increases with
age.
Diseases, physical or psychological problems, and certain
activities also may increase your risk.
Diseases that affect blood vessels include:
Diseases or procedures that affect nerves include:
Other conditions include:
- Thyroid problems.
- Low levels of the
hormones needed for the normal development and function of the sex organs
(hypogonadism), leading to low
testosterone levels.
Injuries or treatment
include:
- Injury to the penis or pelvic
region.
- Injury to the spinal cord or nerves to the
penis.
- Pelvic surgery.
- Radiation in the pelvic
area.
Medicines and other substances that
increase your risk include:
- Some
medicines to treat high blood pressure or
depression.
- Long-term (chronic) alcohol abuse.
- Drug
abuse.
- Tobacco use.
Psychological risk factors
include:
-
Depression
.
-
Anxiety
or
stress.
- Relationship problems.
- A recent major life
change (birth of a child, retirement, job change, loss or death of a partner,
divorce, or marriage).
Activities that constrict blood flow to the penis—such as
frequent long-distance bicycle riding on a hard, narrow saddle—may increase a
man's risk of developing an erection problem. But experts continue to debate
this issue.
A
vasectomy usually does not cause erection problems.
But pain after the operation may affect sexual performance for a time, and if a
man was not comfortable with his decision to have a vasectomy, or is having
second thoughts, it could affect him psychologically.
When To Call a Doctor
Call your doctor now or seek immediate medical care if:
- You have an erection that lasts longer than 3 hours.
- You have taken Cialis, Levitra, or Viagra in the past 24 hours, and you have chest pain. Do not take nitroglycerin.
- You have erection problems that occur along with pain or difficulty with urination, fever, or pain in the lower belly.
Call a doctor if erection problems occur:
- With any type of injury to the back, legs, buttocks, groin, penis, or testicles.
- With other symptoms such as loss of hair, enlargement of the breasts, or backache.
- With any change to the medicine you take.
If your erection problem is occasional, there is no reason
to call your doctor. If it happens often and upsets you or your partner, it is okay to call your doctor. If an erection problem does not bother
you or your partner, you may choose not to call your doctor.
Watchful Waiting
Watchful waiting means a "wait-and-see"
approach. A single episode of an erection problem is often a temporary and
easily reversible problem. Do not assume it will happen again. If possible,
forget about it and expect a more successful experience the next time. If you
or your partner is concerned about it, talk about the problem and openly
discuss your fears and anxieties.
If self-care has not helped
after 2 weeks and you are concerned about your inability to have an erection,
see a doctor who has experience in dealing with erection
problems.
Who To See
Some health professionals, including doctors and
mental health professionals, may not feel comfortable discussing sexuality and
erection problems. Ask your health professional if he or she feels comfortable
with and has experience in working with men who have erection problems.
The following health professionals can evaluate symptoms of erection
problems:
If it is possible that a psychological problem is
contributing to your erection problem, your doctor may refer you to a health
professional such as a:
-
Psychiatrist
.
-
Psychologist
.
- Certified licensed social
worker.
- Counselor with special training in sexuality or
relationship problems.
To prepare for your appointment, see the topic Making the Most of Your Appointment.
Exams and Tests
Because both physical and
psychological factors are often involved, it may be difficult to diagnose the
exact cause of your
erection problem.
As part of the initial
evaluation, your health professional may:
- Review your risk factors for an erection
problem. For more information, see the What Increases Your Risk section of this
topic.
- Ask
questions about your sexual function.
- Do a
complete physical exam of the abdomen, penis, prostate, rectum, and
testicles.
- Do laboratory tests for:
- Testosterone.
A low testosterone level may reduce sexual desire, leading to an erection
problem.
- Prolactin. A
high level of prolactin (hyperprolactinemia) may mean there is a small tumor in the
brain, which can affect other hormone levels in the body. When hormone levels
are affected, an erection problem may result.
- Thyroid hormone. Either a high or low level of thyroid
hormone may cause problems with sexual desire or erections.
- Blood glucose. Elevated blood sugar (glucose) levels
may mean the presence of
diabetes, which can contribute to erection
problems.
At this point, oral medicines such as
sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) are often recommended unless an easily treated cause (such as
a medicine side effect or testosterone deficiency) has been identified. If oral
medicines do not work or your doctor feels more testing is needed, he or she
may recommend:
-
Specific tests for erection problems, such as a
nocturnal penile tumescence testing (rigidity test) and an intracavernosal
injection test. These both help determine whether physical or psychological
factors are causing your erection problem.
- A psychological
evaluation, if a psychological issue is suspected.
An
ultrasound may be done if your doctor suspects you
have a circulation problem (peripheral arterial disease). Even if
the blood vessels cannot be repaired, it may be helpful to know if you have
this condition because it may mean you have a risk for other blood vessel
(vascular) problems.
In very rare cases, an angiography may be done. This is an X-ray
test of blood flow through an artery. Its usefulness is limited, because
treatment to repair the blood vessels that supply blood to the penis is
appropriate for very few men.
Treatment Overview
Treatment for an
erection problem (erectile dysfunction) depends on the
cause of the problem, which may be psychological, physical, or a combination of
both. Erection problems that have one or more major physical causes also often
have psychological factors that make the problem worse and make treatment more
complicated.
Many doctors take a stepwise approach to treating
erection problems, using the least invasive treatments first. These steps
are:
- Discovering and then eliminating
medicines that may be causing your condition. In
some cases, a different medicine can be tried.
- Trying testosterone or another treatment to fix a hormone problem if tests show you have one.
- Trying an oral
medicine. Medicines used for erection problems include
phosphodiesterase-5 inhibitors such as sildenafil
(Viagra), tadalafil (Cialis), and vardenafil (Levitra). One of these medicines
may be tried unless an easily treated cause—such as a medicine side effect or
testosterone deficiency—has been
identified.
- Getting counseling if a psychological cause is
suspected.
- Trying medicines that are injected or inserted into the
penis.
- Trying a vacuum device.
- Trying penile implant
surgery.
Counseling (also called psychotherapy) or behavioral
therapy may be appropriate even if your erection problem has a physical cause.
It may be offered if your health professional suspects psychological issues
play a role in your erection problems.
For more information on
treatment options, see:
-
Erection Problems: Should I Take Medicine?
-
Erection Problems: Should I Try Injection Treatments?
What to Think About
It is important to involve your
partner in your decision regardless of the treatment you choose.
Oral medicines have revolutionized the treatment of erection problems. And they are commonly tried first before other medicine or surgery.
Although phosphodiesterase-5 inhibitors have relatively few side effects,
they can be dangerous in certain men. If you are taking
nitrate-containing medicines, such as nitroglycerin,
you cannot use sildenafil (Viagra), tadalafil (Cialis), or vardenafil
(Levitra). You also should not take certain alpha-blockers—used to lower blood
pressure and to treat an enlarged
prostate gland—with these medicines because of the
risk of a dangerous drop in blood pressure. Check with your doctor
to see whether you can take sildenafil (Viagra), tadalafil (Cialis), or
vardenafil (Levitra) with your alpha-blocker.
Many men
overestimate how important being able to have erections is to their
relationships. Some men find that when they are able to have erections again,
the hassle of using the treatment is not worth the effort. Other men may find
that being able to have erections doesn't change their relationship as much as
they or their partners had expected.
Prevention
You may be able to avoid
erection problems (erectile dysfunction) related to
anxiety and stress by taking a more relaxed approach to sex. Talk to
your partner about your problems and concerns. Sexual intimacy is a form of
communication. If you and your partner talk about sex, it will help
reduce your stress and anxiety, and you may become more relaxed.
Erections may gradually become more difficult to get and maintain as you
get older. But foreplay—erotic stimulation before intercourse—and the right
environment can help increase your ability to have an erection, regardless of
your age.
Other things you can do that may reduce your risk for having an erection problem include:
- Quitting smoking.
- Avoiding use of
alcohol and illegal drugs.
- Keeping your
cholesterol level low to reduce the risk of hardening
of the arteries (atherosclerosis).
- Treating
high blood pressure.
- Keeping your blood
sugar in your target range if you have
diabetes.
- Exercising
regularly.
- Losing weight, especially if you are obese.
- Lowering stress in your life.
Home Treatment
In some cases you can treat occasional
episodes of
erection problems (erectile dysfunction) at home,
without a doctor's help. But do involve your partner in the
process, and don't be embarrassed about seeking professional help if erection
problems are consistent and troublesome. You may be able to help yourself
by:
Some men may try methods available in health food stores or
through magazine advertisements. Most of these methods have never been
medically proved to work, may be unsafe, and are often expensive. They are not
recommended.
Medications
Medicines that can help produce an
erection may be used to treat
erection problems (erectile dysfunction) that are
caused by blood vessel (vascular), hormonal, nervous system, or psychological
problems. They also may be used along with counseling to treat erection
problems that have psychological causes.
Medication Choices
Commonly used oral medicines include:
Other medicines that may be used include:
Hormones and other medicines may be prescribed for men
who have low
testosterone or high
prolactin levels.
For more information on
medicine choices, see:
-
Erection Problems: Should I Take Medicine?
-
Erection Problems: Should I Try Injection Treatments?
What To Think About
PDE-5 inhibitors and heart problems
PDE-5 inhibitors should never
be used if you may need to take a
nitrate-containing medicine, such as nitroglycerin.
Taking nitroglycerin and a PDE-5 inhibitor within 24 hours of each other may
greatly lower your blood pressure, which could lead to a heart attack,
stroke, or death.
Talk with your doctor about whether medicines for erection problems are safe for you if you:
Sexual activity is exercise. If you have a heart
condition and have not been sexually active for a while, talk with your doctor to make sure you can engage in sexual activity safely.
If you are taking a
PDE-5 inhibitor and are going to have a test for heart disease, be certain your
doctor knows you are taking it. You should not take sildenafil (Viagra) or
vardenafil (Levitra) for 24 hours before the test. Do not take tadalafil
(Cialis) for at least 48 hours before the test. Then if you develop a problem
during the test, it will be safe to use nitrate-containing medicines such as
nitroglycerin.
Although oral medicines for erection problems can
be purchased over the Internet, you should still talk with your doctor before using this medicine. This is especially important if you
have a heart problem.
If you are using a combination of drugs for
high blood pressure, PDE-5 inhibitors could result in low blood pressure
(hypotension). Also for this reason, you should not take alpha blockers—used to
lower blood pressure and to treat an enlarged prostate—with these medicines
without talking to your doctor. The combination could cause a
dangerous drop in blood pressure.
Surgery
In a few cases, surgery may be an option to
treat
erection problems (erectile dysfunction). Surgery will
rarely be recommended before nonsurgical treatment and counseling have been
tried.
Surgery on the pelvic area, such as prostate or bladder surgery, can
sometimes damage nerves there and cause erection problems. But this is much
less common than it used to be. For example, a surgeon now may do a
nerve-sparing radical prostatectomy as treatment for prostate cancer. Some
surgeons do nerve grafts as part of surgery for prostate cancer when the nerves
cannot be saved. In a nerve graft surgery, the surgeon takes nerves from
another part of your body and uses them to replace nerves damaged during
surgery.
Surgery Choices
-
Penile Implants
-
Surgery on Penile Blood Vessels
What to Think About
Think carefully about
nonsurgical options and about the possible risks of surgery. Include your partner
in your decision.
Doctors who specialize in conditions of the
urinary tract (urologists) perform most penile implants. Specially trained
urologic surgeons usually do blood vessel repair surgery.
Other Treatment
Other treatments for
erection problems (erectile dysfunction) include
vacuum devices and counseling (psychotherapy).
Other Treatment Choices
-
Vacuum devices are useful for all types
of erection problems—physical, psychological, or both. The device has a tube
you place around the penis. You pump the device to create a vacuum that leads
to an erection. Then you place a band around the base of the penis to maintain
the erection for up to 30 minutes.
- Counseling (psychotherapy) is recommended for men whose erection
problems are caused, at least in part, by psychological factors. Psychological
factors seem to be involved in many cases of erection problems. Treatment may
include
sex therapy, which focuses on methods to improve attitudes toward sex and
specific sexual techniques. Counseling also may be used with medicine treatment or vacuum devices for erection problems that have psychological and
physical causes. Evidence shows that group therapy helps with erection problems
in some men. Adding group therapy to treatment with sildenafil (Viagra) helped
more than Viagra alone. Men who were taking part in group therapy also were
more likely to keep taking their medicine.2
Although medicines are usually the main treatment for
erection problems, some men try
complementary therapies. If you don't want to use
medicine, or medicine doesn't work for you, you may want to talk with your
doctor about some of the following options. Most of these treatments need more
research before doctors can know if they work for sure.3
-
Acupuncture
may
work for some men with erection problems.
- Ginseng has been shown to
work for some men with erection problems. But because it is sold as a dietary
supplement, it is hard to know if you are getting the right
amount.
- Some men take the amino acid L-arginine as a dietary
supplement to try to treat erection problems. The amino acid increases the
amount of nitric oxide in the blood, which relaxes blood vessels. In theory,
L-arginine could improve erections. But L-arginine may be harmful.1
- Some
men who have low zinc levels in their body have had success using zinc
supplements to treat erection problems. But high doses of zinc can be
dangerous.
- Some men have tried yohimbine to treat erection problems, but
it is rarely used.
What to Think About
No matter what approach you use
to treat an erection problem, including your partner in the decision is helpful
and may improve results.
Other Places To Get Help
Organizations
|
American Association of Sexuality Educators, Counselors,
and Therapists (AASECT)
|
| P.O. Box 1960 |
| Ashland, VA 23005-1960 |
| Phone: |
(804) 752-0026 |
| Fax: |
(804) 752-0056 |
| Email: |
aasect@aasect.org |
| Web Address: |
www.aasect.org |
| |
|
The American Association of Sexuality Educators,
Counselors, and Therapists (AASECT) is a nonprofit professional organization
that promotes understanding of human sexuality and healthy sexual behavior.
AASECT offers certification of sexual health practitioners.
|
|
|
National Kidney and Urologic Diseases Information
Clearinghouse
|
| 3 Information Way |
| Bethesda, MD 20892-3580 |
| Phone: |
1-800-891-5390 |
| Fax: |
(703) 738-4929 |
| TDD: |
1–866–569–1162 toll-free |
| Email: |
nkudic@info.niddk.nih.gov |
| Web Address: |
http://kidney.niddk.nih.gov |
| |
|
The National Kidney and Urologic Diseases Information
Clearinghouse (NKUDIC), a federal agency, is a service of the National
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIDDK is part
of the National Institutes of Health under the U.S. Department of Health and
Human Services. The clearinghouse provides information about diseases of the
kidneys and urologic system to people with kidney and urologic disorders and to
their families, to health professionals, and to the public. NKUDIC answers
inquiries; develops, reviews, and distributes publications; and works closely
with professional and patient organizations and government agencies to
coordinate resources about kidney and urologic diseases.
|
|
|
UrologyHealth.org, American Urological
Association
|
| 1000 Corporate Boulevard |
| Linthicum, MD 21090 |
| Phone: |
1-866-RING AUA (1-866-746-4282) toll-free (U.S. only)
(410) 689-3700 |
| Fax: |
(410) 689-3800 |
| Email: |
auafoundation@auafoundation.org |
| Web Address: |
www.urologyhealth.org |
| |
|
UrologyHealth.org is a Web site written by urologists
for patients. Visitors can find specific topics by using the "search"
option.
The Web site provides information about adult and
pediatric urologic topics, including kidney, bladder, and prostate conditions.
You can find a urologist, sign up for a free quarterly newsletter, or click on
the Urology Resource Center to find materials about urologic problems.
|
|
References
Citations
-
Schulman SP, et al. (2006). L-arginine therapy in
acute myocardial infarction. JAMA, 295(1):
58–64.
-
Melnik T, et al. (2007). Psychosocial interventions
for erectile dysfunction. Cochrane Database of Systematic Reviews (3).
-
Lue TF, Broderick GA (2007). Evaluation and
nonsurgical management of erectile dysfunction and premature ejaculation. In AJ
Wein, ed., Campbell-Walsh Urology, 9th ed., vol. 1, pp.
750–787. Philadelphia: Saunders Elsevier.
Other Works Consulted
- American Urological Association (2005, reviewed and confirmed 2009).
Management of Erectile Dysfunction: An Update.
Baltimore: American Urological Association. Also available online: http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=ed.
- Cheitlin MD, et al. (1999). Use of sildenafil (Viagra) in patients with cardiovascular
disease. ACC/AHA expert consensus
document. Circulation, 99(1): 168–177.
- Esposito K, et al. (2004). Effect of lifestyle changes
on erectile dysfunction in obese men. JAMA, 291(24):
2978–2984.
- Lewis RW, Munarriz R (2007). Vascular surgery for
erectile dysfunction. In AJ Wein, ed., Campbell-Walsh Urology, 9th ed., vol. 1, pp. 802–817. Philadelphia: Saunders
Elsevier.
Credits
|
By
|
Healthwise Staff |
|
Primary Medical Reviewer
|
E. Gregory Thompson, MD - Internal Medicine |
|
Specialist Medical Reviewer
|
Christopher G. Wood, MD, FACS - Urology, Oncology |
|
Last Revised
|
May 12, 2010 |