Erectile Dysfunction

Erectile dysfunction (ED) is the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity. Occasional difficulty is normal; ED is diagnosed when it occurs consistently over at least 3 months. It affects about 50% of men over 40 to some degree.

Vascular causes are most common (atherosclerosis, hypertension, diabetes reducing blood flow). Other causes: low testosterone, nerve damage (post-prostate surgery, diabetes neuropathy), medications (antidepressants, antihypertensives), and psychological factors (anxiety, depression, relationship issues).

History and validated questionnaires (IIEF score), physical exam, morning erection assessment, blood tests (testosterone, blood glucose, lipids, prolactin), and penile duplex Doppler ultrasound to evaluate arterial blood flow. Nocturnal penile tumescence testing distinguishes vascular from psychological causes.

Smoking damages penile blood vessels directly. Obesity reduces testosterone and increases cardiovascular risk. Sedentary lifestyle, excess alcohol, and poor diet all contribute. Quitting smoking and 30 minutes of exercise 5 days/week can improve ED significantly without medications.

PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) work by increasing blood flow to the penis. They are effective in 70-80% of patients. Tadalafil (Cialis) can be taken daily for spontaneous activity. They require sexual stimulation to work and are contraindicated with nitrates.

Intracavernosal injections (alprostadil) produce reliable erections in over 85% of cases. Vacuum erection devices are a non-pharmacological option. Intraurethral alprostadil pellets. Low-intensity shockwave therapy can improve vascular ED. These options work even in patients who fail oral medications.

A penile prosthesis (implant) is a permanent surgical solution for ED that has failed all other treatments. Inflatable 3-piece devices mimic natural erections. Patient satisfaction rates exceed 90%. It does not affect sensation, orgasm, or urination. Surgery takes about 60-90 minutes.

Psychological factors contribute to ED in up to 20% of cases and worsen it in most. Cognitive-behavioral therapy (CBT), sex therapy, and couples counseling address performance anxiety, relationship issues, and depression. Combined treatment (psychological + medical) gives better results than either alone.

ED affects both partners and open communication is essential. Share that it is a medical condition, not a reflection of attraction. Involve your partner in consultations when possible. Treatment success improves when both partners are engaged. Avoid self-blame — ED is highly treatable.

ED shares the same risk factors as heart disease. Preventing cardiovascular disease prevents ED: control blood pressure, blood sugar, and cholesterol; exercise regularly; quit smoking; maintain healthy weight; limit alcohol; manage stress. ED can be the first symptom of undiagnosed heart disease.