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Erectile dysfunction is often called impotence. Some experts object to the term "impotence" because of its negative implications and lack of precise meaning. The term "erectile dysfunction" is now used. Erectile dysfunction is defined as the inability to achieve or maintain an erection as part of the overall multifaceted process of sexual function. This definition deemphasizes intercourse as the essential or only aspect of sexual life and gives equal importance to other aspects of male sexual behavior.
At some time in their life, all men experience erectile problems. But for 30 million men in the United States, erectile dysfunction is a chronic, persistent problem. This number includes about 10 percent of the entire male population and 35 percent of men over 60. Fewer than 5 percent of men with erectile dysfunction seek treatment for this condition.
There are different levels of erectile dysfunction:
- A total inability to achieve erection
- The occasional ability to achieve erection
- An inability to maintain erections
- The ability to achieve erection, but inability to control ejaculation
The following conditions can cause erectile dysfunction
- Diabetes. High levels of blood sugar associated with diabetes can damage small blood vessels and nerves throughout the body, including those in and around the penis. Diabetes can interfere with the nerve impulses and the blood flow necessary to produce an erection. About 60 percent of men with diabetes experience erectile dysfunction.
- Heart disease. Atherosclerosis, which cases hardening and narrowing of the arteries, increases with age. Over time it can reduce blood flow to the penis and lead to erectile dysfunction. It accounts for most cases in men over 60 years of age.
- Leaking veins. When veins in the penis are not compressed during an erection, a vein can leak, leading to erectile dysfunction. A leak can be the result of injury, disease, or damage to the veins of the penis.
- Neurological injuries or disorders. Spinal cord and brain injuries, including paraplegia and stroke, can cause erectile dysfunction when they interrupt the transfer of nerve impulses from the brain to the penis. Other nerve disorders, such as multiple sclerosis, Parkinson's disease, and Alzheimer's disease, may also result in erectile dysfunction.
- Drugs. More than 200 prescription medications may directly cause or contribute to erectile dysfunction. Among these are drugs for high blood pressure, antidepressants, tranquilizers, sedatives, and a number of over-the-counter medications. Long-term, excessive consumption of alcohol and use of illegal drugs such as heroin and cocaine also can cause erectile dysfunction.
- Hormonal imbalances. Hormonal disorders account for fewer than 5 percent of cases of erectile dysfunction. Testosterone deficiency, which is rare, can result in the loss of libido (sexual desire). An excess of the hormone prolactin, produced by tumors in the pituitary gland, reduces levels of testosterone. Kidney and liver disease also may lead to hormonal imbalances that contribute to erectile dysfunction.
- Peyronie's disease. This is a relatively rare, inflammatory condition that causes scarring of the erectile tissue in the penis. The scarring produces a curvature of the penis that can interfere with sexual function. In addition, it may cause erections to be painful.
- Pelvic surgery. With surgery of the colon, prostate, or bladder, the nerves that control the flow of blood into and out of the penis may be cut or removed. These nerves can be permanently damaged in men who have undergone radiation therapy for prostate or bladder cancer. Although these nerves do not control sensation in the penis and, therefore, are not responsible for orgasms, they influence the firmness of the penis during erection.
Some surgeons may try to spare nerve function during these procedures, with the hope that any sexual function problem will be temporary. Usually it takes six to 18 months for erections to return. Partial erections may return sooner. If they do, it could be a sign that complete erectile function will eventually return.
- Pelvic injury. A minor injury to the pelvic area, including a fall or blow to the hip while playing sports, or a very long bike ride, can sometimes numb the nerves around the penis and block their normal functioning. A day of rest is usually enough time for the nerves to recuperate.
- Psychological causes. Even though most cases of erectile dysfunction are the result of physical factors, psychological factors should not be overlooked. The most common psychological cause of erectile dysfunction is performance anxiety, a man's fear that he will not be able to perform sexually. Anxiety may lead to an initial failure, which increases the anxiety, resulting in a cycle that leads to future failures to achieve an erection.
Stress, tension, depression, worry, guilt, and anger can also inhibit sexual performance. These psychological factors may occur secondary to and possibly as a result of the physical causes. They may magnify the impact of erectile dysfunction resulting from physical causes.
Many cases of sexual dissatisfaction are related to problems in the control of ejaculation or in the loss of sexual desire unrelated to achieving or maintaining an erection.
Premature Ejaculation
Premature ejaculation is ejaculation that occurs too early, usually before, upon, or shortly after penetration. This condition, also called rapid ejaculation, is the most common sexual dysfunction. As many as 30 percent to 40 percent of men may have this problem. Even when rapid ejaculation is not defined by a man as a problem, it limits the sexual satisfaction of his partner.
Premature ejaculation is common among adolescent boys who fear being caught having intercourse or making their partner pregnant, or who have anxiety about their sexual performance. Some boys may find the excitement of seeing a nude body or touching a female to be so overwhelming and so stimulating that they may ejaculate even before they get their pants unzipped. In most men, ejaculatory control increases with sexual experience.
When premature ejaculation persists into adulthood, it often signals a problem in the relationship. One consequence of premature ejaculation is that the man begins to feel inadequate in meeting his partner's sexual needs since he may not maintain an erection long enough for his partner to achieve orgasm. He often tries to distract himself mentally during the sexual experience or reduce his thrusting in an effort to slow ejaculation. Some men may concentrate so heavily on not ejaculating that they lose all sense of pleasure in sexual intercourse.
There is no agreed-upon amount of time that has to pass before an ejaculation is no longer considered premature. Some experts have used the number of thrusts and the partner's achievement of orgasm as criteria. But there is no standard for how long the sex act should last. Some men may feel they are accomplished lovers if they can pull off a "quickie"; others may feel they demonstrate their masculinity by prolonging intercourse to satisfy their partner.
No one is sure what causes premature ejaculation. Some question whether premature ejaculation is abnormal and point out that in the animal kingdom rapid ejaculation is an evolutionary adaptation to ensure procreation of the species. For men, however, most experts think of it as a psychological or learned problem. Although the condition rarely has a physical cause, in some cases inflammation of the prostate gland or a nervous system disorder may be involved.
Three different approaches are used to treat premature ejaculation. Counseling by a psychologist, psychiatrist, or sex therapist may be recommended based on the assumption that the problem is psychological in origin. Success rates of counseling are difficult to evaluate, since therapists use a variety of methods to measure success.
The second approach to treating premature ejaculation is behavior modification. A popular technique is the "stop-start" exercise. The male works with his partner to stop sexual stimulation just short of reaching ejaculation. The erection is allowed to subside. Then stimulation is started over and the procedure is repeated. This gives the man confidence when the deliberately subsided erection returns. The aim is to improve the man's ability to maintain higher levels of sexual excitement without ejaculating.
The third and most recently introduced treatment method is medication. Low doses of some antidepressants seem to produce a delay in the ejaculation response. While the potential benefits of these medications may be significant, there are some concerns that treatment may be offered without first evaluating the man's health history, current health status, and actual need for the medication.
Retarded Ejaculation
Retarded ejaculation is the opposite of premature ejaculation — the inability to have an orgasm even with prolonged erection. This condition is rare. But as men get older, it normally takes longer to reach orgasm. Often, however, this condition is caused by blood pressure medications, tranquilizers, and antidepressants, as well as diabetes. Psychological causes include fear of vaginal penetration and fear of ejaculating in the partner's presence. Treatment usually involves undergoing behavioral therapy to reduce anxiety and learning techniques for timing ejaculation.
Retrograde Ejaculation
Retrograde ejaculation is a condition in which semen travels up the urethra toward the bladder instead of through the penis. This condition is seen with some spinal cord injuries, after removal of the prostate gland, or after bladder surgery. It does not have any negative effects on the man's health.
Loss of Libido (Sexual Desire)
Loss of libido is a decrease in sex drive that occurs in both men and women. Nearly half of those seeking sex therapy have low libido. Most often, this common condition develops after years of normal sexual desire and activity. It may be caused by boredom, stress, depression, conflict with a partner, or changes in hormone levels. Often it is related to the increased use of medications, particularly in middle age.
A loss of libido may occur as a consequence of erectile dysfunction or it may precede erectile dysfunction. There is no "normal" amount of sexual drive or desire. Having less sexual desire than your partner does not indicate that you have a problem, only that there is a difference in how much sex each of you wants. If loss of libido has become a problem in your relationship, it is important to seek a physician's help to rule out medical causes. If psychological factors are involved, sex education, counseling, or behavioral therapy may help you and your partner communicate better and achieve a more intimate sexual relationship.
Decreased Orgasmic Intensity
Decreased orgasmic intensity is another symptom in men who have problems with sexual function. It is not quite the same as loss of libido because the man still has the same level of sexual desire, but he experiences the loss of or diminished sensation of pleasure usually associated with ejaculation. Those who lose the sensation may lose interest in sex altogether. Others may become anxious, which often leads to erectile dysfunction.
The intensity of orgasm depends on many factors, including the setting in which sexual activity occurs, feelings toward the partner, the amount of fantasy and foreplay, the partner's physical response to stimulation, and the amount of time that has passed since the previous orgasm. Men with diabetes or with a neurological condition such as multiple sclerosis often experience decreased orgasmic intensity. With age, some loss of orgasmic intensity is normal.
Effects of Erectile Dysfunction
Erectile dysfunction, regardless of the cause, leads both sexual partners to experience a range of feelings and intense emotions, including a sense of hopelessness and low self-esteem. These feelings can reinforce a man's performance anxiety and create a cycle of repeated failures and increasingly negative feelings. To overcome these feelings, both partners have to acknowledge the problem and communicate openly and honestly with each other. Because sexual performance is linked so strongly to a man's self-esteem, erectile dysfunction can be devastating not only to his sex life but also to his sense of self. Men with erectile dysfunction often develop feelings of inadequacy, embarrassment, or guilt, and may consider themselves unattractive to their partner. These feelings might cause a man to avoid intimate situations, isolate himself from the relationship, or withdraw from his partner, which can increase tension within the relationship.
The psychological effects of erectile dysfunction can invade other areas of a man's life as well, such as social interactions and job performance. It is important for a man with erectile dysfunction to overcome the reluctance to talk with his partner and physician to determine effective treatment strategies.
Excerpted from: Complete Guide to Men's Health, American Medical Association, 2001.
