by J. François Eid, MD

Erectile dysfunction is also called male impotence. It is defined as the persistent inability to maintain or to achieve an erection of sufficient rigidity to have satisfying sexual activity. It is one of the most commonly untreated medical disorders in the world. It is estimated that 30 million men in the U.S. have problems achieving or maintaining an erection. The frequency of ED increases with age. For example, only five percent of 40-year-old men experience erectile dysfunction. The incidence of ED may be as high as 35 percent in 70-year-old men.

Erectile dysfunction largely goes untreated because only one out of 20 seeks medical help. Men are often embarrassed about being impotent and most of the time, they prefer to avoid sex rather than seek treatment. This is unfortunate because consistent loss of erection is not normal at any age. In addition, loss of erection can be a symptom of a serious medical illness such as coronary disease or advanced vascular disease. Finally, many effective treatments are now available, which means that erectile dysfunction can always be treated successfully.

More than 90 percent of all ED can be traced to a physical (organic) cause. This cause is usually due to insufficient blood flow to the penis and or insufficient blood trapping in the penis after it becomes erect.

As was mentioned earlier, difficulty in getting or maintaining an erection is often a predictor of vascular problems elsewhere in the body, including heart disease. Other factors that can affect your erection include:

• High cholesterol
• Cigarette smoking (which constricts the blood vessels leading to the penis)
• Excessive alcohol
• Diabetes (as many as 60 percent of diabetic men have erection problems at some point)
• Certain prescription drugs, particularly blood pressure and cardiovascular medications, plus some
• tranquilizers and antidepressants
• Radiation therapy
• Pelvic surgery (bladder, colon)
• Following radical prostate cancer surgery (60 percent of men, after all types of radical prostatectomy, have impotence)
• Stroke or neurological disease, including Parkinson’s, Alzheimer’s, and multiple sclerosis

A much smaller percentage of cases of ED are psychological in origin. These patients tend to be younger and usually report no erection at all with a partner, although they may be able to become erect when they are alone, watching an erotic movie, or during sleep.

Men who suffer from ED due to a physical problem, often have a psychological reaction to the ED such as depression, anxiety, or loss of self-esteem. This is a normal reaction and should not be confused with psychological impotence. Men with ED just do not feel normal or as a patient once put it: “I do not feel like myself.”

While its incidence is highest among older men, difficulty maintaining an erection is not a normal part of aging. A healthy male with a willing partner can expect to have one or two usable erections a week well into his 80s.

Most chronic erection problems are not in a man’s head, but in the blood vessels and muscle cells of the penis. Ninety percent of physical ED occurs because the penis loses flexibility and elasticity over time until its ability to trap and store blood becomes impaired. No matter how much blood flows into the penis, it leaks back out.

This leakage occurs because the muscle cells in the penis become thinner (atrophy) with age, while their supporting network of collagen (connective tissue) is no longer renewed as quickly as it was in youth and becomes less elastic (stiff or less compliant). As a result, the muscles in the penis are unable to fully expand, which is a necessary condition for blood to remain in the penis and erection to occur.

An occasional loss of erection is nothing to worry about. But if it happens consistently, you should see a physician specialist in this area, either an internist specializing in erectile dysfunction or a urologist. Only a urologist can treat all forms of ED.

Oral Medications
Currently there is only one oral medication approved by the FDA to treat erectile dysfunction. Sildenafil (Viagra) was approved by the FDA in 1998 and represents a milestone in the field of erectile dysfunction. Viagra works by increasing blood flow to the penis, as well as causing penile muscles to relax. It does not initiate an erection however, rather it helps to store penile blood flow in response to sexual stimulation by counteracting the chemical Phosphodiesterase V that takes away an erection.

This is very important to understand because it means that for Viagra to be effective one must be able to initiate a partial erection in response to sexual stimulation. In the absence of this partial erection or without sexual, tactile stimulation, Viagra will be ineffective. A high-fat meal will delay absorption and if the stomach is empty Viagra will be fully absorbed in a little less than an hour. If an erection occurs before it is fully absorbed, the chemical that takes away erections will not be fully counteracted and will begin to take away the erection. One must be patient. Fatigue, anxiety, a heavy meal, and large amount of alcohol intake will diminish the erectile response to Viagra. Viagra will remain in the body four to eight hours and the higher the dose (100 milligrams) the broader the window of sexual opportunity becomes. Most men (80 percent) require the 100-milligram dose. Finally, Viagra is effective regardless of the cause of the erectile dysfunction, including hypertension, coronary disease, prostate cancer, diabetes, depression, or age of the patient.