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erectile dysfunction in young men

Erectile Dysfunction

The term Erectile Dysfunction covers a range of disorders, including curvature of the penis during erection (Peyronie’s disease), prolonged painful erection not associated with sexual desire (Priapism), and premature ejaculation. Typically, Erectile dysfunction (ED), also called impotence, is defined as man’s inability to have an erection hard enough to have sex or, to keep an erection long enough to finish having sex.

Erectile dysfunction affects the lives of 20 million to 30 million American men and their partners.

Although erectile dysfunction is more common in men over age 65, it can occur at any age. It is important to realize that an occasional episode of erectile dysfunction happens to most men and is perfectly normal. In fact, in most cases it’s nothing to worry about. As men age, it’s also normal for them to experience changes in erectile function. Erections may take longer to develop, may not be as rigid or may require more direct stimulation to be achieved. Men may also notice that orgasms are less intense, the volume of ejaculations is reduced and recovery time increases between erections.

When erectile dysfunction proves to be a pattern or a persistent problem, it can harm a man’s self-image as well as his sexual life. ED can also be a sign of a physical or emotional problems which may require treatment. A once taboo subject of discussion, attitudes are changing about Erectile dysfunction as more men are seeking help for the problem, and doctors are gaining a better understanding of what causes erectile dysfunction, while finding new and better ways to treat it.

Signs & Symptoms

Patterns of erectile dysfunction include:

  • Occasional inability to obtain a full erection
  • Inability to maintain an erection
  • Total inability to achieve an erection

Although it’s normal to experience erectile dysfunction on occasion, see your doctor if it lasts longer than 2 months or is recurring.

Causes

There are many factors that contribute to erection and ejaculation. Physical and mental stimulants, hormones, neural transmissions and feedback, muscle contractions and relaxations, and cardiovascular blood flow all work together to create and maintain an erection leading to ejaculation. When any of these processes are disrupted, it can cause erectile dysfunction (ED).

The causes of ED are generally divided into two major categories: Those that are psychological in nature and those that are physical (or organic) in nature.

Psychological causes are based on cultural expectations, mental distractions, personal desires and sometimes mental illness. Psychological causes of ED include:

  • Anxiety
  • Depression
  • Fatigue
  • Guilt
  • Stress
  • Marital discord
  • Performance anxiety
  • Excessive alcohol consumption

Physical causes of ED generally affect a particular step in the erection sequence. The most common physical causes for ED are:

Diabetes
Diabetes is one of the most common causes of ED. Nerves or blood vessels that control the flow of blood to the penis may become permanently damaged as a result of diabetes. Damage to either can lead to ED.

Cardiovascular Disease
Vascular problems, such as hardening of the arteries, can slow the blood flowing into the penis, making it difficult to get or keep an erection. (Since this affects the small vessels before it affects the bigger vessels, finding an ED problem could signal the presence of a cardiovascular disease.)

Sometimes, the veins that keep blood in the penis during an erection are damaged and don’t keep the erection long enough for sexual intercourse.

Drug Therapies
Drugs, including some prescriptions for high blood pressure, depression, and a number of other conditions, may cause ED by interfering with the nerve impulses or blood flow to the penis. The following drugs can cause ED.┬╣

  • Anti-psychotics
  • Anti-depressants
  • Anti-hypertensives
  • Anti-convulsants
  • Drugs for cardiovascular disease
  • Drugs for Parkinson’s disease
  • Psychotropic drugs
  • Amphetamines
  • Histamine antagonists
  • Hormones
  • Opiates

Important: Medications should never be changed without your doctor’s permission. Talk to your doctor about any concerns you have regarding the potential effects of medication on ED.

1. Nelson RP. Nonoperative management of impotence.J Urol. Jan 1988 v.139(1) p.2-5.

Alcoholism and Smoking
Alcoholism disrupts hormone levels and can lead to permanent nerve damage, causing impotence. Smoking may lead to vascular disease or other health problems, which may cause ED.

Hormone Problems
Certain diseases, such as kidney failure and liver disease can disrupt the balance of hormones, which control erections. Low levels of testosterone can also be a factor.

Body Trauma
Traumas to the body can result in ED. Some of these traumas include:

  • Pelvic fractures
  • Spinal cord injuries
  • Perineal injuries
  • Brain injuries

Neurological Trauma
Neurological traumas can cause ED. These types of traumas include:

  • Back surgery
  • Spinal cord injuries
  • Some birth defects such as spina bifida and myelomeningocele
  • Stroke
  • Brain tumors and/or increased intracranial pressure
  • Muscular disease such as multiple sclerosis (MS)

Priapism
Priapism is an erection that lasts longer than normal and is caused by reasons other than sexual desire. If an erection lasts longer than four hours, it can cause tissue injury, which will result in ED. Causes of priapism include:

  • Sickle cell anemia
  • Injection therapy for ED that is improperly prescribed or used
  • Misuse of medications such as Viagra┬«
  • Illegal drug use

Surgery
Surgery that interrupts blood flow or inhibits nerve innervations may result in ED. Some of these surgeries include:

  • Radical prostatectomy
  • Transurethral resection of the prostate (TURP)
  • Bowel surgeries that involve the rectum and perineum
  • Bladder or urethral surgeries
  • Surgeries on or near the neurovascular bundle, such as surgery for Peyronie’s disease
  • Spinal surgeries

Effects of Aging
It is estimated that 65 percent of men over age 65 have some type of ED. Statistically, the number of men experiencing ED rises as their age increases. However, age alone does not cause ED. It is simply that older men are more likely to have the illnesses and treatments (such as prostate surgery) that can cause ED.

Risk Factors

A wide variety of physical and emotional risk factors can contribute to erectile dysfunction.
They include:

Physical diseases and disorders:

Chronic diseases of the lungs, liver, kidneys, heart, nerves, arteries or veins can lead to impotence, including endocrine system disorders such as diabetes. The accumulation of deposits (plaques) in your arteries (atherosclerosis) can prevent adequate blood from entering the penis. In some men, erectile dysfunction may be caused by low levels of the hormone testosterone (male hypogonadism).

Surgery or trauma:

Erectile dysfunction may result from an injury to the pelvic area or spinal cord. Surgery to treat bladder, rectal or prostate cancer also can result in erectile dysfunction. Prolonged bicycle riding can cause a temporary problem.

Medications:

A wide range of drugs – including antidepressants, antihistamines and medications to treat high blood pressure, pain and prostate cancer – can cause erectile dysfunction by interfering with nerve impulses or blood flow to the penis. Tranquilizers and sleeping aids also may pose a problem.

Substance abuse:

Chronic use of alcohol, marijuana or other drugs often causes erectile dysfunction and decreased sexual drive. Excessive tobacco use may damage penile arteries.

Stress, anxiety or depression:

Psychological causes account for about 10 percent to 15 percent of erectile dysfunction cases.

When to seek medical advice

IF ERECTILE DYSFUNCTION LASTS LONGER THAN 2 MONTHS OR IS A RECURRING PROBLEM, SEE YOUR DOCTOR FOR A PHYSICAL EXAM OR FOR A REFERRAL TO A DOCTOR WHO SPECIALIZES IN ERECTILE PROBLEMS. YOUR OWN DOCTOR OR A SPECIALIST CAN HELP YOU DETERMINE THE UNDERLYING CAUSE OR CAUSES OF ERECTILE DYSFUNCTION, HELPING YOU FIND THE RIGHT TYPE OF TREATMENT.

Although you might view erectile dysfunction as a personal or embarrassing problem, it’s important to seek treatment, especially if a physical cause might be developing. In many cases, erectile dysfunction can be successfully treated. Also, see your doctor if the therapy or medication prescribed to treat erectile dysfunction isn’t working for you. Don’t try to combine medications or therapies on your own or deviate from prescribed doses.

Screening & Diagnosis

Should you chose to visit a doctor because of a problem with erectile dysfunction, he or she will generally ask questions about how and when the problem developed, the medications you may be taking, and any physical conditions you may have. Your doctor will also want to discuss recent developments in physical or emotional changes.

If your doctor suspects that physical causes are involved, he or she will often request blood tests to check your level of male hormones, as well, rule out other potential medical problems, such as diabetes. Your doctor may suggest eliminating or replacing certain prescription drugs you’re taking one at a time to see whether any are responsible for erectile dysfunction.

More specialized tests may include:

ULTRASONOGRAPHY: This test can determine the adequacy of arterial circulation in your genital organs. Ultrasonography involves using a wand like device (transducer) held over the blood vessels that supply blood to the penis. The transducer emits sound waves which pass through body tissues and reflect back; producing an image, allowing your doctor to see if your blood flow is impaired. The test often is done before and after injection of medication to see if there’s an improvement in blood flow.

NEUROLOGIC EVALUATION: Your doctor usually assesses possible nerve damage by conducting a physical examination to test for normal touch sensation in your genital area.

CAVERNOSOMETRY AND CAVERNOSOGRAPHY: Cavernosometry is a test that measures penile vascular pressure. Cavernosography involves injecting a dye into your blood vessels, permitting your doctor to view any possible abnormalities in blood flow into and out of your penis.

If your doctor suspects nonphysical causes are the primary factor for erectile dysfunction, he or she may ask whether you obtain erections during masturbation, with a partner, or while you sleep. Most men experience many erections without remembering them during sleep. A simple test which involves wrapping a special perforated tape around your penis before going to sleep can confirm whether you have nocturnal erections. If the tape is separated in the morning, the test will indicate the penis was erect at some time during the night. Tests of this type confirm nonphysical causes.

Treatment

A wide variety of options exist for treating erectile dysfunction. Treatment options include everything from medications, simple mechanical devices, surgery, and psychological counseling. The cause and severity for each Individual’s condition are important factors in determining the best treatment, or combination of treatments available. It is wise to consider with your doctor how much money you’re willing to spend, and the personal preferences of you and your partner. Should erectile dysfunction be a result of a medical condition, the cost of treatment may be covered by insurance.

Sildenafil (Viagra)

Sildenafil (Viagra) was approved by the Food and Drug Administration (FDA) in 1998, becoming the first oral medication for erectile dysfunction on the market. Since then, doctors have written millions of prescriptions for the blue, diamond-shaped tablets. Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis. In August 2003, the FDA gave approval to a second oral medicine, vardenafil hydrochloride (Levitra). Presently, additional oral medicines are being tested for safety and effectiveness.

Taken an hour before sexual activity, Viagra and Levitra work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.

While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. The recommended dose for Viagra is 50 mg, a physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for Levitra is 10 mg, a physician may adjust this dose to 20 mg if 10 mg is insufficient. Lower doses of 5 mg and 2.5 mg are available for patients who take other medicines or have conditions that may decrease the body’s ability to use Levitra.

Neither Viagra nor Levitra should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use either drug, as the combination can cause a sudden drop in blood pressure. Levitra should not be taken with any of the drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure.

Oral testosterone can reduce ED in some men with low levels of natural testosterone, but it is often ineffective and may cause liver damage. Patients also have claimed other oral drugs–including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone–are effective. The results of scientific studies to substantiate these claims have been inconsistent. Improvements observed by the use of the drugs may be examples of the placebo effect; a change that results simply from the patient’s believing that an improvement will occur.

Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects such as a persistent erection (known as priapism) and/ or scarring. Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed on the penis.

A system for inserting a pellet of alprostadil into the urethra is marketed as Muse. The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, and area between the penis and rectum, warmth or burning sensation in the urethra, redness from increased blood flow to the penis, and minor urethral bleeding or spotting.

Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances.

Prostaglandin E (alprostadil)

Alternatives to sildenafil exist. Two treatments involve the use of a drug called alprostadil (al-PROS-tuh-dil). Alprostadil is a synthetic version of the hormone prostaglandin E. The hormone helps relax the smooth muscle tissue in the penis, which enhances the blood flow needed for an erection. There are two ways to use alprostadil:

Needle-injection therapy.With this method, a fine needle is used to inject alprostadil (Caverject, Edex) into the base or side of the penis. This generally produces an erection within 5 to 20 minutes, which lasts about an hour. As the injection goes directly into the spongy cylinders that fill with blood, alprostadil is an effective treatment for many men. The needle used for injection is generally small, and pain from the injection site is usually minor. Other side effects may include bleeding from the injection, prolonged erection, and formation of fibrous tissue at the injection site. The cost per injection can be expensive. Injecting a mixture of alprostadil and other prescribed drugs may be a less expensive and more effective option. These other drugs may include papaverine and phentolamine (Regitine).

Self-administered intraurethral therapy. This method’s trade name is Medicated Urethral System for Erection (Muse). It involves using a disposable applicator to insert a tiny suppository, about half the size of a grain of rice, into the tip of your penis. The suppository, placed about 2 inches into your urethra, and is absorbed by erectile tissue in your penis, increasing the blood flow that causes an erection. Although needles aren’t involved, you may still find this method painful or uncomfortable. Side effects may include pain, minor bleeding in the urethra, dizziness and formation of fibrous tissue.

Hormone replacement therapy
For the small number of men who have a testosterone deficiency, testosterone replacement therapy may be recommended.

Vacuum devices

This treatment involves the use of an external vacuum and one, or more, rubber bands (tension rings). To begin, a hollow plastic tube is placed, (available by prescription), over the penis. A hand pump is then used to create a vacuum in the tube, pulling blood into the penis. Once an adequate erection achieved, a tension ring is placed around the base of the penis to maintain the erection. The vacuum device is then removed. Erection achieved by this method typically lasts long enough for a couple to have adequate sexual relations.

Vascular surgery

This treatment is usually reserved for men whose blood flow has been blocked by an injury to the penis or pelvic area. Surgery may also be used to correct erectile dysfunction caused by vascular blockages. The goal of this treatment is to correct a blockage of blood flow to the penis, allowing erections to occur naturally. It is important to note, the long-term success of this surgery is unclear.

Penile implants

This treatment involves surgically placing a device into the two sides of the penis, allowing an erection to occur as often, and for as long as desired. These implants consist of an inflatable device or semirigid rods made from silicone or polyurethane. Surgical implants are often expensive and is usually not recommended until other methods have been considered or have been unsuccessful. As with any surgery, there is a small risk of complications such as infection.

Psychological counseling

Should stress, anxiety or depression be the cause of your erectile dysfunction, your doctor may suggest that you, or you and your partner, visit a psychologist or psychiatrist with experience in treating sexual problems.

Prevantions

Although most men will experience episodes of erectile dysfunction from time to time, these steps may decrease the likelihood of ED occurrences:

  • LIMIT OR AVOID THE USE OF ALCOHOL AND OTHER SIMILAR DRUGS
  • STOP SMOKING
  • EXERCISE REGULARLY
  • REDUCE STRESS
  • GET ENOUGH SLEEP
  • DEAL WITH ANXIETY OR DEPATENTS & PRESSION
  • SEE YOUR DOCTOR FOR REGULAR CHECKUPS AND MEDICAL SCREENING TESTS

Coping Skills

Whether erectile dysfunction is caused by physical or psychological factors, or a combination of both, it can become a source of mental and emotional stress for a man – and his partner. If you experience erectile dysfunction on occasion, try not to assume that you have a permanent problem or expect it to happen again during your next sexual encounter. One episode of erectile dysfunction should not be seen as a lasting comment on your health, virility or masculinity.

It’s also important for a man who experiences occasional or persistent erectile dysfunction to remember his sexual partner. Your partner may see your inability to have an erection as a sign of diminished sexual desire. Be mindful of the importance of communication, reassuring your partner may prevent undue stress and emotional distress between you both.

To appropriately treat erectile dysfunction and strengthen your relationship with your partner, try to communicate openly and honestly about your condition. Couples may also want to seek counseling to confront any concerns they may have about erectile dysfunction and to learn how to discuss their feelings. Couples should try to maintain this communication throughout the diagnosis and treatment process. In fact, treatment is often more successful if couples work together as a team.

Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis. In March 1998, the Food and Drug Administration (FDA) approved Viagra, the first pill to treat ED. In August 2003, the FDA gave approval to a second oral medicine, vardenafil hydrochloride (Levitra). Additional oral medicines are being tested for safety and effectiveness.

Taken an hour before sexual activity, Viagra and Levitra work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.

While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. The recommended dose for Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for Levitra is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is insufficient. Lower doses of 5 mg and 2.5 mg are available for patients who take other medicines or have conditions that may decrease the body’s ability to use Levitra.

Neither Viagra nor Levitra should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use either drug because the combination can cause a sudden drop in blood pressure. Also, Levitra should not be taken with any of the drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure.

Oral testosterone can reduce ED in some men with low levels of natural testosterone, however it is often ineffective and may cause liver damage. Patients have made claims in which other oral drugs–including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone–are effective, yet the results of scientific studies to substantiate these claims have been inconsistent. Improvements observed from the use of these drugs may be examples of the placebo effect, that is, a change that results simply from the patient’s believing that an improvement will occur.

Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects, including persistent erection (known as priapism) and/ or scarring. Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed on the penis.

A system for inserting a pellet of alprostadil into the urethra is marketed as Muse. The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, and area between the penis and rectum; warmth or burning sensation in the urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting.

Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances. (www.cure-ed.org )

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