Erection Problems (Erectile Dysfunction)

Condition Basics

What are erection problems?

You have erection problems if you can't get or keep an erection that is firm enough for you to have sex. Erection problems are also called erectile dysfunction or impotence. They are more common as you get older. But there are treatments that can help.

What causes them?

Erection problems may be caused by physical problems or mental health issues. Examples include injury to the nerves or loss of blood supply to the penis, side effects of some medicines, and some surgeries. Depression, stress, and anxiety can also cause the problem.

How are they diagnosed?

Your doctor can find out if you have an erection problem by asking questions about your health and doing a physical exam. Your doctor will want to know how often the problem happens. Lab tests, and sometimes mental health tests, can also help find out the cause of the problem.

How are they treated?

Treatment for an erection problem depends on the cause of the problem. The cause may be mental, physical, or a combination. Treatment can include talking about the issue with your partner, taking pills that can help you get an erection, and finding and then stopping medicines that may be causing the problem.

How can you prevent erection problems?

To reduce your risk of having erection problems, lead a healthy lifestyle—eat healthy foods; be active; and don't smoke, drink too much alcohol, or use illegal drugs. You may be able to avoid erection problems related to anxiety and stress by talking with your partner about your concerns. This may help you relax.

Cause

Erection problems may be caused by physical problems related to the blood vessels, nerves, and hormones. Or they may be caused by mental health issues.

Normally, an erection occurs when your imagination or senses (vision, hearing, touch, smell, taste) are stimulated. You then get aroused. Your central nervous system sends nerve impulses that increase blood flow to your penis.

Causes of erection problems may include:

• Problems with the blood vessels. These problems may prevent blood from filling the penis or from staying there long enough to keep an erection.
• Problems with the nerves. These may prevent arousal signals from traveling from the brain and spinal cord to the penis.
• Other health problems, such as low testosterone levels, diabetes, or high blood pressure.
• Side effects of certain medicines.
• Drinking too much alcohol or smoking.
• Surgery, such as for prostate cancer.
• Mental health issues, such as depression, anxiety, stress, or grief.

Prevention

You may be able to avoid erection problems related to anxiety and stress by taking a more relaxed approach to sex. Talk to your partner about your problems and concerns. Sexual intimacy is a form of communication. If you and your partner talk about sex, it will help reduce your stress and anxiety. And you may become more relaxed.

Erections may gradually become more difficult to get and keep as you get older. But foreplay—erotic stimulation before intercourse—and the right environment can help increase your ability to have an erection, regardless of your age.

Here are some other things you can do that may reduce your risk for erection problems.

• Quit smoking.
• Avoid using illegal drugs.
• Limit alcohol. Even small amounts of alcohol can cause erection problems.
• Manage high blood pressure and high cholesterol. This can help lower your risk of hardening of the arteries (atherosclerosis).
• Keep your blood sugar in your target range if you have diabetes.
• Exercise regularly.
• Lose weight, especially if you are obese.
• Lower stress in your life.

Symptoms

The only symptom of an erection problem is being unable to get and keep an erection that is firm enough or lasts long enough to have sex. But even with an erection problem, you may still have sexual desire and be able to have an orgasm and to ejaculate.

What Happens

It's common to have erection problems at times. When you have them often, "performance anxiety" can make the problem worse. If you can't keep an erection that's firm enough for intercourse, or if you have an orgasm right after entering your partner, you may feel frustrated. Many causes of erection problems can be treated.

When to Call

Call your doctor now or seek medical care right away if:

• You have an erection that lasts longer than 3 hours.
• You have taken a pill to help you get an erection within the past 24 hours (or within 72 hours for long-acting tadalafil) and you have chest pain. Do not take nitroglycerin. Make sure all the doctors you see know that you took this medicine.
• You have erection problems that occur along with pain or difficulty with urination, a fever, or pain in the lower belly.

Call a doctor if erection problems occur:

• With any type of injury to the back, legs, buttocks, groin, penis, or testicles.
• With other symptoms such as loss of hair, enlargement of the breasts, or backache.
• With any change to the medicine you take.

If your erection problem happens just now and then, there's no reason to call your doctor. If it happens often and upsets you or your partner, it's okay to call your doctor. If an erection problem doesn't bother you or your partner, you may choose not to call your doctor.

Watchful waiting

Watchful waiting is a wait-and-see approach. A single episode of an erection problem is often a temporary problem that is easy to reverse. Don't assume it will happen again. Try to forget about it, and expect a more successful experience the next time. If you or your partner is concerned about it, talk about the problem. Openly discuss your fears and anxieties.

If self-care has not helped after 2 weeks and you are concerned about your erection problem, see a doctor who has experience in dealing with these problems.

Exams and Tests

To diagnose an erection problem, your doctor may:

• Review your risk factors. This includes things like any medicines you take and how much you drink.
• Ask questions about your sexual function, including how often you have erection problems.
• Do a complete physical exam of the belly, penis, prostate, rectum, and testicles.
• Do lab tests for testosterone and other hormones and for blood sugar.

Your doctor may start treatment with pills. But you may get more tests if pills don't work or your doctor thinks that testing is needed.

Tests can help your doctor find out whether physical factors are causing your erection problem. These may include lab tests for:

• Testosterone. A low level may reduce sexual desire.
• Thyroid hormone.
• Blood sugar. A high level may indicate diabetes. This can cause erection problems.

If your doctor thinks you have a mental health issue, a mental health evaluation may be recommended.

Treatment Overview

Treatment for an erection problem depends on the cause. Treatment can include having you:

• Avoid tobacco and drugs and limit alcohol.
• Talk with a counselor about the problem.
• Ask your doctor about changing any medicines that may be causing the problem. In some cases, you may be able to use a different medicine.
• Take testosterone or another treatment to fix a hormone problem, such as low testosterone, if tests show that you have one.
• Take pills that help you get an erection. These pills are called PDE-5 inhibitors. They include sildenafil (such as Viagra), tadalafil (such as Cialis), and vardenafil (such as Levitra). Check with your doctor to see if it's safe for you to take one of these medicines with your other medicines. These pills can be dangerous if you take nitroglycerin or other medicines that contain nitrates (for heart disease).
• Use medicines that are injected or inserted into the penis.
• Use vacuum devices. These devices have a tube that you place around the penis. You pump the device to create a vacuum that leads to an erection.
• Have surgery to place an implant in the penis.

You can talk to your partner or partners before you choose a treatment.

Self-Care

Lifestyle

• Limit alcohol. Have no more than 2 drinks a day.
• Do not smoke. Smoking makes it harder for the blood vessels in the penis to relax and let blood flow in. If you need help quitting, talk to your doctor about stop-smoking programs and medicines. These can increase your chances of quitting for good.
• Do not use cocaine, heroin, or other illegal drugs.
• Try to reduce stress.
• Give yourself time to adjust to change. Changes in your job, family, relationships, home life, and other areas can cause stress. And stress can cause erection problems.

Work with your partner

• Talk with your partner about what time of day works best for having sex. Mornings may be a good time since you are both rested. Also, some medicines that help with erections need to be taken on an empty stomach.
• If either of you are too tired or have a lot on your mind, wait until another time to have sex.
• Ask what your partner likes when it comes to sex. Talk about what each of you does and does not enjoy.
• Make time outside of the bedroom to talk about your sex life. If you avoid sex because you are afraid of having erection problems, your partner may worry that you are no longer interested.
• If you and your partner have trouble talking about sex, see a therapist. They may help you talk about it. Reading books with your partner about sexual health may also help.
• Relax. Take time for more foreplay. Worrying about your erections may only make things worse.

Medicines

• Tell your doctor about all the medicines that you take.
  • Some medicines can cause erection problems.
  • Some medicines can have dangerous interactions with medicines that are prescribed for erection problems. These include over-the-counter medicines and herbal products.
• Be safe with medicines. Take your medicines exactly as prescribed. Call your doctor if you think you are having a problem with your medicine.
• Talk to your doctor about trying a medicine to help you keep an erection. This could be a medicine like sildenafil (such as Viagra), tadalafil (such as Cialis), or vardenafil (such as Levitra). If you have a heart problem, ask your doctor if these are safe for you. Do not take these medicines if you take nitroglycerin or other nitrate medicine.

Medicines

Medicines that can help produce an erection may be used to treat erection problems that are caused by vascular (blood vessel), hormonal, nervous system, or psychological problems. The medicines also may be used with counseling. Together, they can treat erection problems that have psychological causes.

Commonly used oral medicines include:

• PDE-5 inhibitors. These medicines work by helping to relax the blood vessels in your penis, allowing more blood to flow into your penis when you get sexually excited. This can help you have an erection. Examples are sildenafil (such as Viagra), tadalafil (such as Cialis), and vardenafil (such as Levitra).

PDE-5 inhibitors should never be used if you may need to take a nitrate-containing medicine, such as nitroglycerin. Taking nitroglycerin and a PDE-5 inhibitor within 24 hours (or 72 hours for long-acting tadalafil) of each other may greatly lower your blood pressure. This could lead to a heart attack, stroke, or death.

Talk with your doctor about whether oral medicines for erection problems are safe if you:

• Have heart disease.
• Have heart failure or low blood pressure.
• Are taking drugs for high blood pressure.

If you cannot take these oral medicines or they don't work for you, your doctor might recommend other medicines. They include:

• Inserted medicine. A thin tube contains a small pellet of medicine. You insert the tube into the opening in the end of your penis. When you press a button on the applicator, the pellet is released into the penis. The erection that follows usually lasts at least 30 minutes, depending on how much medicine you use.
• Injected medicine. You inject medicine, using a tiny needle, into the side of the penis. The erection that follows usually lasts 30 minutes or longer, depending on how much medicine you use.

An erection that does not go away after 3 to 4 hours when using any of these medicines (oral, inserted, or injected) is an emergency. Call your doctor right away or go to the nearest emergency room.

Hormones and other medicines may be prescribed if you have low testosterone or high prolactin levels.