Erectile Dysfunction: Causes and Treatment

Erectile dysfunction (ED) affects as many as 30 million men in the US, and more and more of them are seeking help as old taboos about openly discussing sex-related conditions have fallen away and treatment options hold greater promise for a return to sexual activity.

Due in general terms to insufficient blood flow to the penis, erectile dysfunction is the inability to get an erection, or a firm enough erection, or to maintain one long enough for intercourse. As with many other medical problems, several underlying causes can lead to ED.

But waiting for those issues to be resolved or for lifestyle changes to take hold, instead of treating the ED directly, is rarely successful and no longer standard practice, according to Peter Langenstroer, MD, MS, FACS, Medical College of Wisconsin Assistant Professor of Surgery (Urology) and a specialist in ED treatment.

"Of the known major causes of erectile dysfunction, cardiovascular disease and diabetes are the most common causes I see in my patients," said Dr. Langenstroer. "Under cardiovascular disease can come a number of subcategories such as high blood pressure and coronary artery disease. Psychosocial causes are also important in what we call psychogenic ED. And then there is drug-induced ED, either from medications or from illicit drug use."

Historical Evaluation
Because ED problems vary, Dr. Langenstroer asks each patient a series of questions before discussing treatment options. He looks for ED manifestations specific to the individual and tries to get a sense of the impact the dysfunction is having on his patients' relationships.

"When a patient comes in, I want to know a number of things," said Dr. Langenstroer. "When was the last time you had a normal erection? What is the quality of your erections now? Can you get an erection at all or is your penis always flaccid? Or, do you get a partial erection that just isn't firm enough for penetration?

"Do you get an erection that's firm up front but then falls away before you can complete intercourse? How often do you experience difficulty with loss of erections? And finally, what things have you tried to manage your problem with your erection? I would say that 90% of the evaluation is historical.

"Based on how those questions are answered, it will sometimes help me understand the dynamics. The other issues that are always important to ask about relate to how that all affects the individual's relationship with his partner. It's often that aspect that ultimately brings the patient in - concern about the negative impact on the relationship."

Non-Judgmental Approach
In the majority of cases, erectile dysfunction is not related primarily to what a person 'does', said Dr. Langenstroer, but to factors that are truly out of the patients' control. Smoking cigarettes or marijuana, abusing alcohol, and other lifestyle factors do contribute to ED in some men, but the condition is still largely attributable to other major medical problems.

"A person can't control if they get diabetes," said Dr. Langenstroer. "A person can't necessarily control if they develop high blood pressure. There are many issues of predisposition that go along with these diseases, cardiovascular diseases and the like. To suggest that 'if you live an indulgent life you're going to pay for that down the road (with ED) is very negative, presumptuous, and not helpful in establishing a relationship with the patient."

Most patients cannot successfully address their ED without oral drug therapy (the brand names Viagra, Cialis, and Levitra are used) or other interventions. "Certainly, I have seen a number of individuals who have significant health issues, like diabetes or high blood pressure, who have managed significant alterations in their lifestyle with a resultant improvement in their erectile dysfunction," he said. "However, those patients are hard to find.

"If people don't manage their blood sugars and general health as well as they should they are more likely to have trouble with ED. Conversely, other patients can have very tight diabetes control, eat right and exercise well, and still have trouble with erectile dysfunction."

ED Pills
Oral therapy using one of the three ED drugs now on the market is the 'first line' treatment for erectile dysfunction, Dr. Langenstroer said, adding that primary care physicians most often prescribe these drugs. "Viagra, Levitra, and Cialis are all in the same class of drugs called phosphodiesterase inhibitors," he said. "What they do in simple terms is block an enzyme and prolong erections by a process that is driven by nitric oxide."

At about $10 a pill each, the drugs are expensive for most patients and can reduce the spontaneity of sexual activity to varying degrees, Dr. Langenstroer said. Yet they are very safe when used under a physician's direction, he added, and have allowed millions of men and their partners to resume sexual intimacy.

Reports that a small number of men who use ED drugs have experienced permanent blindness are not based on any real evidence of cause and effect, said Dr. Langenstroer. "There are a few people at risk for a disease called non-arterial ischemic optic neuritis (NAION). These patients developed a disease that leads to blindness, while taking these drugs. Since the patients were at risk, no true cause and effect has been established. "In large study populations of Viagra users there has been no increase in incidence compared to general population. Only a handful of cases have been reported."

Other Treatment Options
When oral therapy does not work, Dr. Langenstroer said, the most viable 'second line' treatment options are a vacuum erection device or injection therapy. "A vacuum erection device will allow most men to have an erection," he said. "It's a cylinder that goes over the penis. The cylinder is used to draw blood into the penis by suction. A ring is placed at the base of the penis once it is erect. After intercourse, the patient removes the ring.

"Injection therapy is a direct injection of a drug into the penis. A number of products have been used over the years, and these drugs increase blood flow to the penis. This can be a very effective treatment. As I explain it to my patients, it gets the right drug to the right place at the right time. About 75% of oral therapy failures can get an erection with injection therapy, and most can get an erection with a vacuum device. However, not everyone likes those options for a variety of reasons."

The 'third line' erectile dysfunction treatment used by Dr. Langenstroer is a penile implant. "This is a surgical implant called a penile prosthesis. It is placed inside the penis and allows the penis to be rigid and erect for intercourse," he said. "For patients under my care, I make sure that they tried or at least considered the other options before having a surgical intervention. The patient satisfaction rate is extremely high with the implants."

Implants are either malleable rods that can be bent into an erect position and then back again, or a system that uses an implanted pump to send fluid to the penis and then draw it back after intercourse. Penile implants are very expensive, Dr. Langenstroer said, but like the other treatments they may be covered by health insurance plans including Medicare.

While there are pros and cons to all of the ED treatments, said Dr. Langenstroer, the overall success rate is high and the impact on patients' lives can be immeasurable. "Usually, if someone makes it to my clinic, the problem is significant enough that they're interested in having it addressed. It is not easy for men to address this issue. They're usually too proud to admit that they have a problem. I tell my patients that if they're motivated to return to intimacy with their partner, I have enough options to allow them to get there. Most any man who wishes to return to intimacy and intercourse can do so with appropriate treatment."

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.