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Erection problems

Definition

An erection problem is when a man cannot get or keep an erection that is firm enough to have intercourse. You may be unable to get an erection at all. Or, you may lose the erection during intercourse before you are ready.

If the condition continues, it is called erectile dysfunction.

Alternative Names

Erectile dysfunction; Impotence; Sexual dysfunction - male

Considerations

Erection problems are common in adult men. Almost all men sometimes have trouble getting or keeping an erection.

In many cases, the problem goes away with little or no treatment. In other cases, it can be an ongoing problem. If you have trouble getting or keeping an erection more than 25% of the time, it is a problem.

An erection problem that does not go away can damage your self-esteem and harm your relationship with your partner. It needs to be treated.

In the past, erection problems were thought to be "all in the man's mind." Men often were given unhelpful advice such as, "don't worry," or "just relax and it will take care of itself." Today, doctors believe that physical factors often cause erection problems.

One way to know if the cause is physical is whether you have nighttime erections. Normally, men have 3 to 5 erections per night. Each erection lasts for up to 30 minutes. Your doctor can tell you how to find out whether you are having the normal number of nighttime erections. If you have erections in the morning, this can also mean that there is not a physical cause.

Erection problems usually do not affect a man's sex drive.

Having an orgasm too quickly (premature ejaculation) is not the same as impotence. Get counseling with your partner for this problem.

Male infertility is also different from impotence. A man who cannot keep an erection may be able to produce sperm that can fertilize an egg. A man who is infertile can usually keep an erection, but he may not be able to father a child due to problems with sperm.

Causes

An erection involves your brain, nerves, hormones, and blood vessels. Anything that interferes with these normal functions can lead to problems getting an erection.

Common causes of erection problems include:

  • Diseases such as diabetes, high blood pressure, heart or thyroid conditions, poor blood flow, depression, or nervous system disorders (such as multiple sclerosis or Parkinson's disease)
  • Medicines, including blood pressure medications (especially beta-blockers), heart medications (such as digoxin), some peptic ulcer medications, sleeping pills, and antidepressants
  • Nerve damage from prostate surgery
  • Nicotine, alcohol, or cocaine use
  • Poor communication with your partner
  • Repeated feelings of doubt and failure
  • Spinal cord injury
  • Stress, fear, anxiety, or anger
  • Unrealistic sexual expectations, which make sex a task instead of a pleasure

Erection problems become more common with age. However, they can affect men at any age. Physical causes are more common in older men. Emotional causes are more common in younger men.

Low levels of testosterone can lead to erection problems. They may also reduce a man's sex drive.

Home Care

For many men, lifestyle changes can help:

  • Cut down on smoking, alcohol, and illegal drug use.
  • Get plenty of rest and take time to relax.
  • Exercise and eat a healthy diet to keep good blood circulation.
  • Use safe sex practices to prevent HIV and STDs.
  • Talk openly to your partner about sex and your relationship. If you cannot do this, counseling can help.

Couples who cannot talk to each other are likely to have problems with sexual intimacy. Men who have trouble talking about their feelings may find it hard to share their anxiety about sexual performance. Counseling can help both you and your partner.

When to Contact a Medical Professional

Call your doctor if:

  • The problem does not go away with lifestyle changes
  • The problem begins after an injury or prostate surgery
  • You have other symptoms, such as low back pain, abdominal pain, or a change in urination

If erection problems seem to be caused by a medication you are taking, talk to your health care provider. You may need to lower the dose or change to another drug. Do NOT change or stop taking any medications without first talking to your health care provider.

Talk to your health care provider if your erection problems have to do with a fear of heart problems. Sexual intercourse is usually safe for men with heart problems.

Call your doctor right away or go to an emergency room if the medication you are taking for erection problems gives you an erection that lasts for more than 4 hours.

What to Expect at Your Office Visit

Your doctor will perform a physical exam, which may include:

  • Checking your blood flow (circulation)
  • An exam of your penis and rectum
  • An exam of your nervous system

To help find the cause of the problem, your doctor will ask medical history questions such as:

  • Have you been able to get and keep erections in the past?
  • Are you having trouble getting an erection, or keeping erections?
  • Do you have erections during sleep?
  • How long have you had trouble with erections?
  • What medications are you taking (including prescription medications, over-the-counter medications, and recreational drugs)?
  • Do you smoke? How much each day?
  • Do you use alcohol? How much?
  • Have you recently had surgery?
  • Have you ever had surgery or other treatments for your blood vessels?
  • Are you depressed?
  • Are you afraid or worried about something?
  • Are you experiencing a lot of stress?
  • Has your energy level decreased?
  • Are you sleeping well each night?
  • Are you afraid of sexual activity because of physical problems?
  • Have there been any recent changes in your life?
  • What other symptoms do you have?
  • Have you noticed changes in feeling to your penis?
  • Do you have any problems with urination?

Tests that may be done include:

  • Blood tests, including:
  • Nerve testing
  • Nocturnal penile tumescence (NPT) to check for normal nighttime erections
  • Penile ultrasound to check for blood vessel or blood flow problems
  • Psychometric testing
  • Rigidity monitoring
  • Urine analysis

TREATMENT

The treatment may depend on the cause of the problem. Talk to your health care provider about the best way to treat your erection problem.

There are many treatment options today, including:

  • Injections into the penis
  • Medicines inserted into the urethra
  • Medicines taken by mouth
  • Surgery
  • Vacuum devices

Ask your health care provider about the possible side effects and complications of each treatment.

Sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are medicines called phosphodiesterase-5 (PDE5) inhibitors. They work only when you are sexually aroused. They usually start to work in 15 to 45 minutes.

These drugs can have side effects, which can range from muscle pain and flushing to heart attack. Do not use these drugs with medications such as nitroglycerin. The combination can cause your blood pressure to drop. Some men have died after taking these drugs with nitroglycerin.

Use PDE5 inhibitors with caution if you have any of the following conditions:

  • Recent stroke or heart attack
  • Severe heart disease, such as unstable angina or irregular heartbeat (arrhythmia)
  • Severe heart failure
  • Uncontrolled high blood pressure
  • Uncontrolled diabetes
  • Very low blood pressure

If pills do not work, other treatment options include:

  • Testosterone replacement using skin patches, gel, or injections into the muscle -- if your testosterone level is low.
  • A medicine called alprostadil, injected into the penis or inserted into the urethra, improves blood flow to the penis. This usually works better than medications taken by mouth.
  • A vacuum device can be used to pull blood into the penis. A special rubber band is then used to keep the erection during intercourse.
  • Some men may need a penis implant (prosthesis).

Many herbs and dietary supplements are marketed to help sexual performance or desire. However, none of these supplements have been proven effective for treating erectile dysfunction, and they may not always be safe.

References

Heidelbaugh JJ. Management of erectile dysfunction. Am Fam Physician. 2010;81:305-312.

Qaseem A, Snow V, Denberg TD, et al. Hormonal testing and pharmacologic treatment of erectile dysfunction: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2009;151:639-649.


Review Date: 9/19/2011
Reviewed By: Louis S. Liou, MD, PhD, Chief of Urology, Cambridge Health Alliance, Visiting Assistant Professor of Surgery, Harvard Medical School. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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