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admin | Category: What Cause Ed | 21.04.2014
Propecia’s link to sexual and erectile dysfunction has been well documented in the media recently. See related patient information handout on erectile dysfunction, written by the author of this article. Erectile dysfunction is defined as the persistent inability to attain or maintain penile erection sufficient for sexual intercourse. Erectile dysfunction is the inability to achieve and maintain an erection sufficient for satisfactory sexual intercourse. It may result from any one of the following factors: psychological, neurologic, hormonal, arterial, and venous. Penile erection is an event that has physiological, psychological and hormonal aspects to it. Hormonally, a low testosterone state results in a decrease in nighttime erections and decreases sex drive. The penis is essentially a complex blood vessel that fills and empties in response to nerve and hormonal signals. Erectile dysfunction can be the presenting symptom for a variety of diseases such as diabetes mellitus, heart disease, hyperlipidemia, high blood pressure, spinal-cord compression, and pituitary tumor. It is important to understand the goals and preferences of the patient when treating erectile dysfunction, as this issue largely drives therapy. Until other treatments became more popular in the 1980s and 1990s, psychotherapy was the mainstay of ED treatment. Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis.
Testosterone pills can reduce ED in some men with low natural testosterone levels, but it is often ineffective and may cause liver damage. Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Mechanical vacuum devices induce erections by creating a partial vacuum, which draws blood into the penis, engorging and expanding it. Surgical procedures to improve erections are performed for 3 reasons: to implant a device that can cause the penis to become erect, to reconstruct arteries and increase penile blood flow, and to occlude veins that allow blood to leak out of the penis and cause ED. Send Home Our method Usage examples Index Contact StatisticsWe do not evaluate or guarantee the accuracy of any content in this site.
What is erectile dysfunction (ED)?Erectile dysfunction (ED) occurs when a man has repeated problems achieving or sustaining an erection. To provide even greater transparency and choice, we are working on a number of other cookie-related enhancements.
For example, professors at George Washington University and Boston University linked Propecia to prolonged and possibly irreversible male erectile dysfunction and loss of sexual libido.
The majority of cases have an organic etiology, most commonly vascular disease that decreases blood flow into the penis. The corpora cavernosa are composed of a mesh-work of interconnected cavernosal spaces lined by vascular endothelium. Normal erectile function requires a complex set of dynamic neural and vascular interactions. Most causes of erectile dysfunction were once considered to be psychogenic, but current evidence suggests that up to 80 percent of cases have an organic cause.1 Organic causes are subdivided into vasculogenic, neurogenic and hormonal etiologies.
Aging is an independent risk factor, and although the incidence of erectile dysfunction increases steadily with age, it is not an inevitable consequence of aging. Information from references 7 and 8.Excessive and long-term use of a number of substances may also cause erectile dysfunction.
In all instances, medical conditions having an impact on erectile function should be corrected or their progression controlled.
Recently it has become quite clear that, in many cases, erection dysfunction can be a “silent marker” for the later development of cardiovascular disease. Upon sexual stimulation, nerve impulses from the cavernous nerves in the penis stimulate relaxing factors from cells inside the penis, resulting in relaxation of smooth muscle in the arteries of the penis with a 20 fold increase in blood flow into the penis. Within the muscle lining the cells inside the penis, nitric oxide causes higher levels of cyclic guanosine monophosphate (GMP). It is made up of the same cells that make up other blood vessels and is subject to the same changes with age and disease as are other blood vessels. As men age, the latency period between erections after ejaculation increases, erections are less firm, ejaculation is less forceful, and the semen volume decreases. Therefore, a thorough patient history, physical examination and appropriate lab tests aimed at detecting these diseases are undertaken.
Healthy lifestyle changes like quitting smoking, losing excess weight, gaining better control of diabetes and increasing physical activity may improve overall health and also help some men regain sexual function.
Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use these drugs because the combination can cause a sudden drop in blood pressure.
Other forms of testosterone may be safer than oral testosterone; however, only a small proportion of ED (estimated at 6%) is due to low testosterone. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (prostaglandin E2) dilate blood vessels by a mechanism slightly different than the phosphodiesterase inhibitors and can help induce and maintain erections.
The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra.
The best candidates for such surgery are young men with a well-defined blockage of an artery because of pelvis injury or fracture. It is intended for general information purposes only and does not address individual circumstances.
Both Men’s Health and Men’s Journal published articles in 2011on Propecia’s link to erectile dysfunction, and the articles contain numerous interviews with anonymous Propecia patients who experienced erectile dysfunction while taking Propecia, as well as after they quit taking Propecia. Regardless of the primary cause, erectile dysfunction can have a negative impact on self-esteem, quality of life and interpersonal relationships.
An estimated 10 to 20 million American men have some degree of erectile dysfunction.1,2Increased understanding of the male erectile process and the development of several agents to improve erectile function have generated great public interest among men and their sexual partners. Penile erection can be elicited by at least two distinct mechanisms, central psychogenic and reflexogenic,3 which interact during normal sexual activity. Vasculogenic etiologies represent the largest group, with arterial or inflow disorders being the most common. Several studies have indicated that patients and providers are reluctant to address sexual topics.
What follows is relaxation of the smooth muscle lined spaces within the penis and rapid filling and expansion of these spaces causing penile enlargement. Cyclic GMP results in a block in calcium influx, smooth muscle relaxation, and an erection. Organic causes include medication-related ED, or that due to medical, vascular or neurological disease. High prolactin levels are a medically important cause of both decreased sex drive and poor erections in young men and is medically treatable.
It is now clear that the same risk factors that occur for heart attacks and strokes, termed cardiovascular risks factors, are also important in the development of erectile dysfunction. A recent study in the Journal of the American Medical Association followed men age 55 and older for over 7 years and assessed them for both erectile dysfunction and cardiovascular disease, including heart attacks and strokes. There is also a decrease in serum testosterone concentration in men with age but it is not felt to be the major contributor to the changes in erections as men age. Standardized, validated survey instruments such as the SHIM-5 are now available to assess erectile dysfunction (Figure 1).
Since that time, vardenafil (Levitra), tadalafil (Cialis), and avanafil (Stendra) have also been approved. One of these medications may cause a sudden drop in blood pressure when taken with an alpha-blocker.
Other drugs (including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone) may be effective for ED, but studies to substantiate these claims are inconsistent.


These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Implants are devices, however and have complications that include mechanical breakdown, erosion and infection. The procedure is almost never successful in older men with diffuse vascular disease due to atherogenesis. It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health.
The initial step in evaluation is a detailed medical and social history, including a review of medication use. These advances are expanding the treatment options available to primary care physicians in the management of erectile dysfunction. 3 Blood flow is provided primarily by the cavernosal branches of the internal pudendal artery.
Psychogenic erections are initiated centrally in response to auditory, visual, olfactory or imaginary stimuli.
Consideration should be given to discontinuation of any medication suspected of contributing to the erectile problem or, if required, switching to an alternative medication less likely to interfere with erectile function. Due to this, the small veins that normally drain the penis become compressed thus stopping outflow of blood from the penis. Sildenafil, vardenafil tadalafil, and avanafil are drugs currently FDA approved to treat erection dysfunction and they work by blocking the breakdown of the energy molecule cyclic GMP.
These risk factors include: high blood pressure, elevated cholesterol and lipid levels, obesity, cigarette smoking and diabetes mellitus. In patients with new erectile dysfunction there was a 25% increased risk for heart attacks, strokes, chest pain, or mini-strokes, compared to men with no erectile dysfunction. Often, the characteristics of the erection problem can help with the diagnosis: with arterial problems, more stimulation may be needed to achieve an erection, whereas with venous leak, an erection is easily achieved but lost very quickly.
If an isolated low testosterone level is found, then testosterone replacement may be the treatment of choice. Surgery to tie off veins permitting blood to leak from the penis has the opposite goal: to reduce leakage of blood out of the penis that causes ED.
Never ignore professional medical advice in seeking treatment because of something you have read on the BootsWebMD Site.
Each branch divides into numerous terminal branches that open directly into the cavernous spaces.
Reflexogenic erections result from stimulation of sensory receptors on the penis which, through spinal interactions, cause somatic and parasympathetic efferent actions.3On arousal, parasympathetic activity triggers a series of events starting with the release of nitric oxide and ending with increased levels of the intracellular mediator cyclic guanosine monophosphate (cGMP). Regardless of the primary etiology, a psychologic component frequently coexists.5The severity of erectile dysfunction is often described as mild, moderate or complete, although these terms have not been precisely defined. These events effectively trap the blood within the penis and raise the penis from flaccid to erect position.
They are related to stress (emotional or physical), performance anxiety, strained relationship, lack of sexual arousability, and to depression and schizophrenia. Many of these symptoms have now been termed the “metabolic syndrome.” For this reason, men with otherwise unexplained erectile dysfunction and who harbor such risk factors should also be evaluated for cardiovascular risk.
In fact, ED is as important a cardiovascular disease risk factor as is smoking or a family history of heart disease.
Recommended lab tests include urinalysis, complete blood count, and measurement of fasting blood glucose, cholesterol and triglycerides, and testosterone. Taken an hour before sexual activity, they work by enhancing the effects of nitric oxide, which relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow. Given the complexity of the venous drainage patterns from the penis, this type or penile surgery is rarely done in men with mild to moderate ED. While the topic was once taboo, awareness has skyrocketed with recent advances in treatment for ED. Increases in cGMP cause penile vascular and trabecular smooth muscle relaxation.3,4 Blood flow into the corpora cavernosa increases dramatically. First, provide information about conditions that are commonly associated with sexual dysfunction, then follow with a question about the individual's concerns. Before ejaculation, a reflex is triggered (bulbocavernosus) which causes the muscles that surround the penis to forcefully compress the penis, such that the blood pressure within the penis reaches levels that exceed that found elsewhere in the body.
Essentially these drugs work by giving the same stimulatory effect that coffee has on the body, but to the penis instead. Indeed, it is also true that among patients who seek medical care for ED, nearly 20% have undiagnosed high blood pressure, 15% have diabetes, and 5% may have significant heart disease.
If cardiovascular risk factors exist, then patients should be recommended to undergo cardiac evaluation before treatment is considered.
While these drugs improve the response to sexual stimulation, they do not trigger an automatic erection.
Laboratory tests are useful to screen for common etiologic factors and, when indicated, to identify hypogonadal syndromes. The rapid filling of the cavernosal spaces compresses venules resulting in decreased venous outflow, a process often referred to as the corporeal veno-occlusive mechanism. The male sexual response cycle consists of four major phases: (1) desire, (2) arousal (erectile ability), (3) orgasm and (4) relaxation. Before the initiation of testosterone therapy, the patient should be evaluated for the possibility of an occult prostate malignancy, which may be stimulated by supplemental testosterone. The penis falls when there are no more energy molecules available, or due to nervous system discharge during ejaculation.
The majority of men with ED will respond to these drugs and for this reason, they are considered first line therapy for ED. Inflatable implants consist of paired cylinders that are surgically inserted inside the penis and then expanded using pressurized fluid from a co-implanted fluid reservoir and a pump. Appropriate evaluation of erectile dysfunction leads to accurate advice, management and referral of patients with erectile dysfunction. This discharge results in a latency period or “down time” during which it is difficult to achieve another erection. The cylinders are inflated by pressing on the scrotal pump and reproduce a more natural erection with expansion of both the width and length of the penis.
This information may help assess the patient's sexual problems as well as identify high-risk behaviors and other concerns affecting the patient's overall health.Once a concern with the patient's sexual function is identified, the next step is to differentiate erectile dysfunction from other sexual problems, such as loss of libido or ejaculatory problems. The physician should use appropriate vocabulary, avoiding slang or excessively technical terminology.
Patients with suspected vasculogenic or neurogenic causes can be considered for a trial of therapy in the primary care setting. Having the patient define the terms in his own words will help the physician and patient communicate more effectively.13 The International Index of Erectile Function (IIEF)14 is a valuable tool for defining the area of sexual dysfunction (Figure 4). Patients with a suspected psychogenic etiology should be considered for sexual counseling or psychiatric referral as well.Patients requesting a more comprehensive evaluation or those not responding to initial therapy should be referred for further evaluation and treatment.
The IIEF is designed to be a self-administered measure of erectile dysfunction, but it also assesses a patient's function in other phases of sexual function. As such, it should be viewed as an adjunct to, rather than a detailed sexual history.Reprinted with permission from Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A.
The international index of erectile dysfunction (IIEF): a multidimensional scale for assessment of erectile dysfunction. The mechanics of EDAn erection occurs when blood fills two chambers known as the corpora cavernosa. This causes the penis to expand and stiffen, much like a balloon as it is filled with water. Causes of ED: Chronic diseaseThe link between chronic disease and ED is most striking for diabetes (depicted here by a blood sugar test).
Because erectile dysfunction is frequently caused by medication, a review of the patient's drug therapy is essential and should include prescription and over-the-counter medications.


Other conditions that may cause ED include hypertension, cardiovascular disease (atherosclerosis – narrowing of the arteries), Parkinson's disease and multiple sclerosis.
Causes of ED: LifestyleLifestyle choices that impair blood circulation can contribute to ED. Life stressors such as change in social status, divorce, death of spouse, loss of job, or family problems may have an effect on erectile function. Smoking, excessive drinking and recreational drug use may damage the blood vessels and reduce blood flow to the penis. Difficulty in erectile function affects the patient and his partner, so it is important to assess whether the erectile problem is troubling one partner more than the other, and if so, who and why.
Smoking is a major contributor to atherosclerosis, making men particularly vulnerable to ED. Finally, the physician should determine the patient's and the partner's level of understanding of sexual anatomy and function, as well as what expectations each has with regard to treatment outcome. Men with erectile dysfunction and their partners often lack a full understanding of sexual processes or have unrealistic expectations regarding sexual performance and satisfaction.5PHYSICAL EXAMINATIONThe physical examination should assess the patient's overall health.
Causes of ED: SurgerySurgery, including treatments for prostate or bladder cancer, can sometimes damage nerves and blood vessels near the penis. Particular attention should be given to the cardiovascular, neurologic and genitourinary systems, as these systems are directly involved with erectile function. In some cases, the nerve damage is permanent, and the patient will require treatment to achieve an erection. The cardiovascular examination should include assessment of vital signs (especially blood pressure and pulse) and signs of hypertensive or ischemic heart disease.
Abdominal or femoral artery bruits and asymmetric or absent lower extremity pulses are indicative of vascular disease. Causes of ED: MedicationED may be a side effect of medication, including certain blood pressure drugs, antidepressants, tranquilisers and antihistamines. Skin and hair pattern evidence of vascular insufficiency should be noted.The patient's demeanor, dress, speech and overall appearance should be noted for signs suggestive of anxiety or depressive disorders. Men should talk to their doctor if they suspect a prescription or over-the-counter medication may be causing erectile problems. Causes of ED: PsychologicalED usually has something physical behind it, particularly in older men.
The superficial anal reflex, indicative of normal somatic function of sacral cord levels S2–4, is assessed by touching the perianal skin and noting contraction of the external anal sphincter muscles.
Experts say stress, depression, poor self-esteem and performance anxiety can short-circuit the process that leads to an erection. It is performed by placing a finger in the rectum and noting contraction of the anal sphincter and bulbocavernosus muscle when the glans penis is squeezed. These factors can also make the problem worse in men whose ED stems from something physical.
External anal sphincter tone can be assessed during this maneuver as well.The genital evaluation should assess for local abnormalities, such as hypospadias or phimosis, and evidence of hypogonadism. Diagnosing ED: Physical examinationTo diagnose ED, your doctor will ask you questions about your symptoms and medical history.
The doctor will conduct a complete physical examination to uncover signs such as poor circulation or nerve trouble. Your doctor will also look for abnormalities of the genital area that could cause problems with erections. The penis should be palpated to determine the presence of local abnormalities such as fibrous plaques of the fascial covering (Peyronie's disease). The prostate gland should be assessed for size, consistency and symmetry.ADDITIONAL STUDIESIf not previously done, some basic studies should be considered to identify unrecognized systemic conditions that may predispose to erectile dysfunction. Measuring testosterone levels can determine whether there is a hormonal imbalance, which is often linked to decreased desire. Blood cell counts, glucose and cholesterol levels, and kidney and liver function tests can reveal medical conditions that may account for ED.
The specific testosterone assay to be obtained is debated.15,17 Testosterone is predominately protein-bound and is influenced by a variety of clinical conditions. A 2010 study suggests ED is a strong predictor of heart attack, stroke and death from cardiovascular disease.
The researchers say all men diagnosed with ED should be checked for cardiovascular disease. This does not mean every man with ED will develop heart disease, or that every man with heart disease has ED, but patients should be aware of the link. An age-adjusted, first-morning, free testosterone level is probably the most accurate measure.17 If the initial testosterone level is low, follow-up studies should include luteinizing hormone and follicle-stimulating hormone levels to differentiate testicular from hypothalamic-pituitary dysfunction. Treating ED: Lifestyle changesMany men with ED are able to improve sexual function by making a few lifestyle changes. Giving up smoking, losing weight and exercising more often can help by improving blood flow. These tests are not usually performed in the family physician's office and are not necessary before the initiation of therapy for most patients. If you suspect a medication could be contributing to ED, talk to your doctor about adjusting your dosage or switching to another treatment. Many of these tests are subject to significant variation in interpretations and are most appropriate for use in refractory cases. Treating ED: MedicationViagra (sildenafil), Cialis (tadalafil) and Levitra (vardenafil) are oral treatments for ED. They're generally taken up to an hour before sexual activity and should not be used more than once a day. It is given as an injection directly into the penis, as a pellet inserted into the urethra, or as a cream applied to the tip of the penis. Treating ED: Vacuum devices (pumps)Vacuum devices for ED, also called pumps, offer an alternative to medication. An elastic band worn around the base of the penis maintains the erection during intercourse. Treating ED: SurgeryIf ED is caused by a blockage in an artery leading to the penis, surgery can often restore blood flow. Good candidates are typically younger men whose blockage stems from an injury to the groin or pelvis. Treating ED: ImplantsIn men with persistent ED, a penile implant can restore sexual function.
When an erection is desired, the man uses a pump to fill the cylinders with pressurised fluid. Another option is a malleable implant, which creates an erection with a surgically implanted rod. Treating ED: PsychotherapyEven when ED has a known physical cause, psychotherapy can be beneficial. A therapist can teach the man and his partner techniques to reduce performance anxiety and improve intimacy. The UK regulator MHRA advises men to look for the Royal Pharmaceutical Society of Great Britain logo to show a website is linked to a registered pharmacy.
Discussing ED with your partnerIt's natural to feel angry or embarrassed when dealing with ED, but don't forget that your partner is also affected. Talking openly about ED will help your partner understand the diagnosis and treatment options.



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