About Male Impotence (Erectile Dysfunction)

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.

Side effects of Viagra include headaches, redness of the face, nasal stuffiness, and heartburn. Three percent of men may experience visual disturbance in the form of an increased sensitivity to light or seeing a bluish tint to everything. All side effects are very mild, well-tolerated, transient, and actually very few patients discontinue use because of them.

Viagra is contraindicated for men who take medications that contain nitrates of any form or schedule. Viagra should never be taken by a patient who is on nitrates.

The FDA could possibly approve apomorphine SL (Uprima) as early as July 1, 2000. This drug works on the brain centers that control erections and helps men obtain and/or maintain an erection. Although effective in clinical trials, the medication is currently not available for clinical use. Side effects are very infrequent and mild and include nausea and dizziness to the point of passing out (syncope). With correct use these side effects may be prevented.

Yohimbine is a popular oral medication, but its effectiveness has been disappointing. In men who suffer from physical ED, it is as effective as a sugar pill (placebo).

Phentolamine (Vasomax) was found to cause liver abnormalities in study animals, prompting the company (Nonagon) to withdraw the new drug application from the FDA. This medication most likely will never be available clinically.

The antidepressant drug Trazodone, taken one hour before sexual activity, has been found to prolong erections in men who are able to obtain, but not maintain an erection during intercourse. Trazodone, however, is much less effective than Viagra.

Finally, several Phosphodiesterase Inhibitors (Viagra-like) are currently being developed (ICOS, Bayer). It is unlikely, however, that efficacy or profile of side effects will be much different than Viagra.

Internal Penile Pump™
The Internal Penile Pump (IPP) is a soft-fluid-filled (saline) device that can expand and contract without losing elasticity. It consists of three small components: very thin tubes, pump, and reservoir. The reservoir contains the saline, which is transferred by the pump into the penis, causing the penis to expand and become rigid. There are more than 250,000 men who have the Internal Penile Pump.

Once inserted, the pump is invisible and the penis and scrotal sac look normal both in the flaccid and erect position. The entire IPP can be placed through a very small (two- to three-centimeter) opening in the skin of the scrotum in less than an hour. This is a breakthrough when compared to previous techniques, which made much larger openings that required a longer and more painful healing process. The beauty of this technique is that the skin on the penis itself is never opened so that there are no visible scars and normal sensation is preserved. In my hands, this is a safe procedure with an infection rate of less than 0.3 percent. It can even be done with a local anesthetic and on an outpatient basis. Again, the penis looks and feels normal. The internal pump does not interfere with normal sensation or ejaculation.

Men also report additional benefits from the IPP that include: opportunity for spontaneous sexual activity, restoration of normal penile anatomy (many patients after radical prostate cancer surgery lose penile length and girth), larger looking flaccid penis, and the ability to maintain an erection after orgasm. Use of the Internal Penile Pump has resulted in documented high satisfaction rates for both patient and partner, and doesn’t require additional treatments, such as injection or vacuum.

The Internal Penile Pump is an excellent alternative for men who do not respond to Viagra. For most men, it represents a cure. Excellent candidates are men between the ages of 50 and 90 years old, sexually motivated and active; men who have had prostate, bladder, or colon cancer treatment, and who have penile deformity and/or atrophy (shrinkage). (The Internal Penile Pump is also referred to as penile implant or prosthesis.)

Topical Creams
MUSE (Medicated Urethral System for Erection) contains a prostaglandin pellet that can be applied one-and-a-half inches deep into the opening of the urethra just prior to intercourse. The pellet acts by widening the penile blood vessels, causing blood flow to go to the penis. Since its FDA approval in 1996, patient response to MUSE has been very disappointing. This method is less effective and more painful than penile injection therapy. Also since FDA approval of Viagra, MUSE has become much less popular. Finally, Topiglans is a paste of Alprostadil (it is currently under investigation), which is applied to the head of the penis and may cause enlargement of the glans penis. This method, however, also causes penile ache and does not improve the rigidity of the erection.

Injection treatments
Prior to the FDA approval of Viagra, injection therapy was the most effective medical treatment available. Injection therapy works by injecting a type of medication through a very small hypodermic needle at the base of the penis five minutes before intercourse. The medication injected dilates the blood vessels to produce an erection. In the 1980s, the injection consisted of a mixture of papaverine and phentolamine. Side effects from the injections of these two drugs have led to scarring (from repeated injections) and sometimes painfully prolonged erections (solved by reducing the drug dosage).

Prostaglandin E-1 (Alprostadil) (Caverject or Edex) has been the drug used for injections since 1995. Alprostadil is a naturally occurring substance in the penile tissue. It can be self-injected safely at home with few side effects. A dull penile ache is experienced by 40 percent of patients using prostaglandin E-1. This is transient and well-tolerated in the majority of patients. Tests show that scarring from prostaglandin E-1 injections are minimal (occurring in only five percent of cases) and the satisfaction rate is high. This is currently the only FDA approved medication for penile injection. Off-label use of Trimix (Papaverine, Phentolamine, and Alprostadil) is very successful and safe, and is currently the preferred penile injection method. The instance of long-term use, however, is poor; more than 50 percent of men stop using the injection method after two months and less than 30 percent use this technique for more than two years.

This vacuum device doesn’t involve medications or surgery. A tube is placed over the end of the penis and the device is activated, creating a vacuum that encourages blood to flow into the penis to create an erection. A rubber ring is then snapped over the base of the penis to help maintain the erection. A semi-hard erection is obtained. While the initial success rate is high with vacuum devices, less than one-third of the men who buy them end up using the vacuum pump long-term. Many of the men who no longer use the external penile pumps say that they are too cumbersome and the erection that results can be somewhat painful and not quite normal. This is definitely not the preferred treatment option for couples who enjoy spontaneous, normal, and frequent sexual activity.

If the dysfunction has a psychological cause, then you will be referred to a certified sex therapist. If the problem turns out to be a simple issue of communication with your partner, a therapist could help you resolve it relatively quickly.

When the dysfunction involves more deeply ingrained issues—for example, inhibition or performance anxiety related to upbringing, religion, and social background, it tends to be more difficult and time consuming to treat.

The bottom line is that ED is debilitating for most men, and I believe that for many couples, a supportive partner is the most important factor in regaining a full, healthy sex life.

Dr. Francois Eid is the Director of Advanced Urological Care, and Clinical Associate Professor of Urology at Weill/Cornell Medical College in New York City.

Copyright © J. François Eid, MD. Permission to republish granted to Pregnancy.org, LLC