Tests such as the bulbocavernosus reflex test are used to determine if there is sufficient nerve sensation in the penis. The physician squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal. A physician measures the latency between squeeze and contraction by observing the anal sphincter or by feeling it with a gloved finger inserted past the anus.
Their treatment plan will include a great deal of information about ED. It is important you take the time to read it all. You will be better prepared to manage your condition as a partner—and not just a patient. Also, erectile dysfunction is often a symptom of a more serious underlying condition—like heart disease, diabetes, high blood pressure, or even depression. That’s why we want you to learn as much as you can. Nothing would be a sign of our success more so then if you could resolve the condition that causes your ED instead of needing to use the medications your doctor prescribes. We strongly recommend optional laboratory tests. You do not need to get them to receive treatment but it can be one of the best things you can do for your health in the long run.
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Erectile dysfunction (ED) is one of the most common conditions affecting middle-aged and older men. Nearly every primary care physician, internist and geriatrician will be called upon to manage this condition or to make referrals to urologists, endocrinologists and cardiologists who will assist in the treatment of ED. This article will briefly discuss the diagnosis and management of ED. In addition, emerging concepts in ED management will be discussed, such as the use of testosterone to treat ED, the role of the endothelium in men with ED and treating the partner of the man with ED. Finally, future potential therapies for ED will be discussed.
The venous constriction device is a device designed to compress the veins that drain blood flow out of the penis to keep blood in the penis. These devices may help individuals who have a "venous leak." In these individuals, although blood flow is coming into the penis, it is draining out at the same time and this persistent drainage prevents a fully rigid erection. These devices may be used with other forms of medical therapy, such as medications, injection therapy, or the vacuum device.
Iatrogenic hypotension can occur in men in neurodegenerative disease using sildenafil (49). Hussain et al. placed men with PD and MSA on sildenafil and recorded blood pressure before and after. Half of the 12 MSA patients developed postural hypotension, while none of the twelve PD patients did. Since MSA can be difficult to distinguished diagnostically from PD, baseline blood pressure measurements prior to prescribing the medication and seeking medical assistance if symptomatic hypotension occurred was recommended for all patients with PD, and MSA. Of note, none of the men with MSA who developed hypotension discontinued sildenafil use due to its effectiveness at improving their erections.

Erectile dysfunction is the inability to develop or maintain an erection that is rigid enough to allow penetration of the vagina, and therefore functional sexual intercourse. Generally, the term erectile dysfunction is applied if this occurs frequently (75% of the time) over a significant period if time (several weeks to months). If this is the case, the term impotence may also be used.


Impotence, also known as erectile dysfunction or ED, is a condition in which a man is unable to get or hold an erection long enough to have a satisfactory sex life. Impotence is a common problem, affecting up to half of Australian men between the ages of 40 and 70 years. The risk of developing erectile dysfunction increases as you get older.In the past, doctors considered impotence to be a mainly psychological problem, caused by performance anxiety or stress. Now, doctors know that many cases of impotence have a physical cause, which usually can be treated. Often, a combination of physical and psychological factors contributes to erectile dysfunction.Physical causes of impotencePhysical causes of impotence can include:problems with blood to flow into and out of the penis;damage to the nerves that send signals from the body’s central nervous system to the penis; and, more rarely,a deficiency in testosterone or other hormones.Some medicines can contribute to impotence, as can some types of surgery and radiotherapy treatments.Blocked blood vessels to the penisA very common cause of impotence is when blood flow into the penis is reduced. This can be due to atherosclerosis, also known as hardening of the arteries. In atherosclerosis, the arteries are clogged and narrowed, resulting in reduced blood flow.Risk factors for atherosclerosis include:high cholesterol;high blood pressure;obesity;sleep apnoea;diabetes; andsmoking.If your erection problems are caused by atherosclerosis, there is a chance that the arteries in other parts of your body (e.g. the coronary arteries that supply your heart) are also affected by atherosclerosis. In fact, erection problems may be the first sign that you are at risk of coronary heart disease.Because the arteries to the penis are narrower than those to the heart, you may develop symptoms of erectile dysfunction before you experience any symptoms of heart disease, such as angina. So seeing your doctor about erection problems may be important for your overall physical health.Impotence can also be caused by a blood clot that prevents enough blood from flowing into the penis to cause an erection.Venous leakageIn some men, blood can flow in to the penis easily, but the problem is that it leaks out again, so an erection cannot be sustained. This is called venous leakage. Doctors aren’t certain of the cause of venous leakage, but they can perform surgery to help repair it.Medicines that can cause impotenceMany medicines can cause erection problems as a side effect, including:diuretics (sometimes known as ‘water tablets’ - often used for high blood pressure);high blood pressure medications;cholesterol-lowering medicines (including statins);some types of antipsychotics;antidepressants;cancer treatments;some medicines used to treat heartburn and stomach ulcers;antihistamines;some pain medicines; andcertain epilepsy medications.If you experience impotence after starting a new medication, tell your doctor, who may be able to prescribe a different medicine for you. Don’t stop taking a medicine without first consulting your doctor. You should also tell your doctor about any over-the-counter medicines or complementary remedies you may be taking.The following table contains a list of specific medicines that may cause or contribute to erectile dysfunction. This list may not cover all types of medicines that can cause erectile dysfunction, so always ask your doctor if you are in doubt. Also, for some of these medicines ED is a very rare side effect. Most men taking these medicines do not experience erectile dysfunction.Medicines that may cause erectile dysfunctionType of medicineExamplesACE inhibitorscaptopril (Capoten), enalapril (Renitec), perindopril (Perindo), ramipril (Tritace), and othersAntidepressantsamitriptyline (Endep), clomipramine (Anafranil), desvenlafaxine (Pristiq), fluoxetine (Prozac), paroxetine (Aropax), sertraline (Zoloft), venlafaxine (Altven, Efexor), and othersAnti-epilepticsclonazepam (Rivotril), pregabalin (Lyrica)Antifungalsitraconazole (Sporanox)Anti-ulcer drugscimetidine (Magicul), nizatidine (Tazac), ranitidine (Zantac), and othersBeta-blockerspropranolol (Inderal), metoprolol (Betaloc, Lopresor), and othersOther blood pressure-lowering medicinesclonidine (Catapres), lercanidipine/enalapril (Zan-Extra), losartan (Cozaar), perindopril/amlodipine (Coveram), olmesartan/amlodipine (Sevikar), telmisartan/amlodipine (Twynsta), valsartan/hydrochlorothiazide (Co-Diovan)Calcium-channel blockersdiltiazem (Cardizem), felodipine (Plendil), nifedipine (Adalat)Cholesterol-lowering drugsatorvastatin (Lipitor), ezetimibe/simvastatin (Vytorin), fluvastatin (Lescol, Vastin), gemfibrozil (Ausgem), pravastatin (Pravachol), simvastatin (APO-simvastatin, Lipex, Zocor), and othersDiuretics ('water tablets')bumetanide (Burinex), chlorthalidone (Hygroton), spironolactone (Aldactone), and othersSchizophrenia drugsamisulpride (Solian, Sulprix), haloperidol (Haldol, Serenace), olanzapine (Lanzek, Ozin, Zypine, Zyprexa), paliperidone (Invega), risperidone (Rispa, Risperdal), ziprasidone (Zeldox)Combination cholesterol-lowering and anti-hypertensiveamlodipine/atorvastatin (Caduet, Cadatin)Pain medicinesfentanyl (Denpax, Durogesic), hydromorphone (Jurnista), morphine (Momex SR, MS Contin), oxycodone (OxyContin, OxyNorm, Targin), tramadolMiscellaneousoestrogens, antiandrogens, anticancer drugs and some chemotherapy treatments, baclofen (Clofen, Lioresal); cyproterone (Androcur, Cyprohexal, Cyprostat), degarelix (Firmagon), etoricoxib (Arcoxia), finasteride (Proscar and Propecia), flutamide (Flutamin), rotigotine (Neupro), triptorelin (Diphereline)*The names in brackets are just some examples of the trade names each specific medicine is marketed under in Australia. The medicine may also be known by other trade names.Diabetes and erectile dysfunctionMen who have diabetes have a higher risk of developing impotence than other men. Diabetes contributes to impotence because it can damage blood vessels and cause a type of nerve damage known as peripheral neuropathy.Hormones and impotenceLow levels of the male hormone, testosterone, are more commonly linked to a lowered sex drive, rather than impotence itself. Only a small percentage of cases of impotence are caused by hormone deficiency.Low testosterone levels may be the result of a condition called hypogonadism, in which the testicles don’t produce enough testosterone. More rarely, low testosterone can be caused by the pituitary (a small gland at the base of the brain) not secreting sufficient hormones to stimulate the testes to produce testosterone. The pituitary is also sometimes affected by small benign (non-cancerous) tumours that secrete prolactin, another hormone that can cause impotence.Mildly decreased levels of testosterone are often not due to specific testicular or pituitary problems, but rather stress or depression. In this situation, testosterone replacement is rarely of any benefit.Other hormone problems, including thyroid disease, can also cause impotence.Prostate cancer and erectile dysfunctionThe advanced stages of prostate cancer can affect the nerves and arteries that are vital for an erection.Radiation treatment for prostate cancer can harm the erectile tissues of the penis, and prostate cancer surgery can cause nerve or artery damage to the penis.Treatment for advanced prostate cancer often includes medicines that counteract testosterone, and commonly cause erectile dysfunction as well as loss of sexual interest.Peyronie’s diseasePeyronie’s disease is an uncommon condition that affects a man’s sex life because his penis curves abnormally and causes pain when he has an erection. He might also be unable to have a hard erection. The curvature of the penis is caused by a scar, called a plaque, that forms in the penis.Other physical causes of impotenceSeveral other factors and conditions can contribute to erectile dysfunction, including the following.Depression. Many men find that when they’re suffering from depression, they lose interest in sex and can’t get or keep an erection. Asking your doctor for treatments for depression may help alleviate your erection problems as well.Smoking contributes to vascular disease (disease of the blood vessels), so it can contribute to erectile dysfunction by affecting blood flow to the penis. Giving up smoking often has a beneficial effect on erectile function.Excessive alcohol use. Alcoholism can cause permanent nerve damage, resulting in impotence. This nerve damage is called peripheral neuropathy. Long-term alcohol use can impair the liver’s ability to function, resulting in a hormone imbalance in which a man has too much of the female sex hormone, oestrogen. On a day-to-day level, alcohol dulls the central nervous system, adversely affecting sexual response.Illicit drug use. Illicit drugs such as marijuana, cocaine, heroin, barbiturates, and amphetamines act on the central nervous system, impairing the body’s ability to respond sexually.Certain exercises. Nerve and artery damage can be caused by prolonged cycling, rodeo riding, or use of a rowing machine, resulting in the inability to get an erection. Often, minimising the use of hard bicycle seats and exercise machine seats, as well as correct positioning of the seat, will help restore sexual function.Surgery to organs near the nerve pathways of the penis, such as the bladder, rectum and prostate, can cause nerve or artery damage to the penis, resulting in the inability to have an erection.Injuries. Impotence can be caused by spinal cord injury; injury to your sex organs; or a pelvic fracture, which can cause damage to the nerves of the penis, or damage the blood vessels, resulting in reduced blood flow to the penis.Conditions affecting the nervous system. Multiple sclerosis (MS) and other degenerative diseases of the nervous system, such as Parkinson’s disease, can damage the nerves involved in erections.Psychological causes of impotenceMost cases of impotence have physical causes, but, in some men, psychological factors are the main contributors to impotence.Impotence that’s triggered by psychological factors is more common in men who are sexually inexperienced. Psychological erectile dysfunction may only occur when you’re with just one particular person. You’re also more likely to have morning erections, and be able to have an erection when you masturbate, than men whose impotence has a physical cause.Here are some psychological factors that can have an impact on your erections.Stress and anxietyWhen you’re stressed and focusing on other issues apart from sex, you might find that you don’t want to have sex as often and there might be a drop in your ability to perform when you do try. You might find that tackling the source of your stress can have benefits in the bedroom as well.Fear of failureAnxiety about your sexual prowess (commonly called performance anxiety) can, in itself, contribute to failure. By putting pressure on yourself, you become too anxious to get an adequate erection.Most men experience isolated episodes of erectile failure. Even when the transient physical cause has passed, anxiety that it may recur is sufficient to prevent erection. Anxiety, whether about something specifically sexual or part of a wider anxiety syndrome, is never helpful to good sexual function.Problems with your relationship and impotenceImpotence may be a manifestation of a poor relationship, or a problematic time in a relationship. Sexual boredom, tension or anger among partners, and lack of intimacy and communication are all possible triggers of erectile dysfunction. In these cases, seeing a counsellor may help.It’s worth remembering that impotence is a complex medical condition, which may have more than one cause. For example, if impotence is the result of a side effect of medicine or an underlying disease, the anxiety caused by lack of performance may perpetuate the erectile dysfunction even after the physical cause has been dealt with.Almost any chronic (ongoing) physical or mental health disorder, including those with no direct effect on penile nerves or blood supply, can have a powerful effect on sexuality, sexual self-image and erectile function.If you’re worried about your sexual response or the quality of your erections, don’t be afraid to talk to your doctor, who has access to treatments that can help. Last Reviewed: 16 December 2016
Cavallini, G., Modenini, F., Vitali, G., & Koverech, A. (2005, November). Acetyl-L-carnitine plus propionyl-L-carnitine improve efficacy of sildenafil in treatment of erectile dysfunction after bilateral nerve-sparing radical retropubic prostatectomy. Urology, 66(5), 1080-5. Retrieved from http://www.sciencedirect.com/science/article/pii/S0090429505006515
There are many effective treatments for impotence. The most popular is a class of drugs called phosphodiesterase type 5 (PDE5) inhibitors. These include sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis) and avanafil (STENDRA). These drugs are taken in pill form. They work in most men. But they are less effective in men with neurological causes of impotence.
A vacuum erection device helps draw blood into the penis by applying negative pressure. This type of device is sometimes referred to as penis pump and may be used just prior to sexual intercourse. Several types of FDA approved vacuum therapy devices are available under prescription. When pharmacological methods fail, a purpose-designed external vacuum pump can be used to attain erection, with a separate compression ring fitted to the base of the penis to maintain it. These pumps should be distinguished from other penis pumps (supplied without compression rings) which, rather than being used for temporary treatment of impotence, are claimed to increase penis length if used frequently, or vibrate as an aid to masturbation. More drastically, inflatable or rigid penile implants may be fitted surgically.

The sympathetic pathway originates from the 11th thoracic to the 2nd lumbar spinal segments and goes via the white rami to enter the sympathetic chain ganglia. Subsequently nerves travel through the lumbar splanchnic to inferior mesenteric and superior hypogastric nerves to the pelvic plexus. The T10 through T12 segments are most often the origin of sympathetic fibers, and the sympathetic chain ganglia that innervate the penis are located in the sacral and caudal ganglia (3).
The development of an erection is a complex event involving integration of psychologic, neurologic, endocrine, vascular, and local anatomic systems. Positron emission tomography scanning studies have suggested that sexual arousal is activated in higher cortical centers that then stimulate the medial preoptic and paraventricular nuclei of the hypothalamus.5 These signals ultimately descend through a complex neural network involving the parasympathetic nervous system and eventually activate parasympathetic nerves in the sacral area (S2 to S4).
• Medications: About 25 percent of ED cases are caused by drugs. Many medications, including common medicines prescribed for diabetes and its complications, can cause ED. The most common offenders are blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug). In addition, over-the-counter medications, including certain eye drops and nose drops, have been associated with ED. That does not mean you should stop taking these medications! Rather, you should discuss them with your doctor to determine whether a different dosage, an alternate medicine, or additional treatments will resolve the ED.
I started meditating about three years ago. I jumped in at the deep end. After a month of goofing around with apps, I signed up for a Vipassana—a ten-day silent retreat, where you sit cross-legged and meditate for about ten hours a day and spend the remaining 14 questioning everything you've ever done. After the retreat all sorts of changes took place: My anxiety disappeared, and my decision-making improved; but one of the most pronounced changes was my sex life. For the first time, I could have sex while thinking about sex rather than how broke I was or how quickly my career was imploding. And I'm not alone; meditation forums are full of people who have had similar experiences.
Begot, I., Peixoto, T. C. A., Gonzaga, L. R. A., Bolzan, D. W., Papa, V., Carvalho, A. C. C., ... & Guizilini, S. (2015, March 1). A Home-Based Walking Program Improves Erectile Dysfunction in Men With an Acute Myocardial Infarction. The American Journal of Cardiology, 115(5), 5741-575. Retrieved from http://www.ajconline.org/article/S0002-9149(14)02270-X/abstract
Penile implants - are generally used if physical damage (like an accident) makes the anatomical parts needed for an erection not work. These are inserted by surgery and can provide a permanent treatment choice if others fail to work. The implants can be semi-rigid or inflatable. They can be pretty expensive and are not usually available on the NHS.

ED can also occur as a side effect of some medications, for example some high blood pressure medications such as certain diuretics and beta blockers. If you think that a medication you are taking has a negative effect on your sex life, you should discuss this with your prescribing doctor. Your doctor may be able to recommend an alternative treatment.
In fact, one common reason many younger men visit their doctor is to get erectile dysfunction medication. Often, men with erectile dysfunction suffer with diabetes or heart disease, or may be sedentary or obese, but they don’t realize the impact of these health conditions on sexual function. Along with erectile dysfunction treatment, the doctor may recommend managing the illness, being more physically active, or losing weight.
Of particularly concern are antihypertensive medications for CVD (eg, digoxin, disopyramide [Norpace], gemfibrozil [Lopid]), anxiety, depression (eg, lithium, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants), or psychosis (eg, chlorpromazine, haloperidol, pimozide [Orap], thioridazine, thiothixene). Antihypertensive drugs, such as diuretics (eg, spironolactone, thiazides) and beta blockers, may be associated with ED. Discontinuation or switching to alternative drugs, such as angiotensin-converting enzyme inhibitors or calcium channel blockers (eg, diltiazem, nifedipine, amlodipine), may reduce ED. The newer angiotensin II receptor antagonists may be less problematic with respect to ED, but long-term data is needed to evaluate this.

Sexual dysfunction is highly prevalent in men and women. In the MMAS, 52% of the respondents reported some degree of erectile difficulty. Complete ED, defined as (1) the total inability to obtain or maintain an erection during sexual stimulation and (2) the absence of nocturnal erections, occurred in 10% of the respondents. Mild and moderate ED occurred in 17% and 25% of responders, respectively. [15]
However, in contrast, a recent systematic review of published studies, the authors concluded that overall, the addition of testosterone to PDE-5 inhibitors might benefit patients with ED associated with testosterone levels of less than 300 ng/dL (10.4 nmol/L) who failed monotherapy. [20] A limitation of existing studies are their heterogeneous nature and methodological drawbacks.
Stanley A Brosman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Advancement of Science, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Urological Association, Society for Basic Urologic Research, Society of Surgical Oncology, Society of Urologic Oncology, Western Section of the American Urological Association, Association of Clinical Research Professionals, American Society of Clinical Oncology, International Society of Urology, International Society of Urological Pathology
Some self-administered measures may be useful in the primary care setting to screen for and evaluate the degree of ED.12 The most commonly used instrument is the International Index of Erectile Function, a 15-item questionnaire that has been validated in many populations and is considered the gold standard to evaluate patients for ED.13 The Sexual Health Inventory for Men is a short-form, 5-item questionnaire developed to monitor treatment progress.12 It is important to recognize that short-form questionnaire does not evaluate specific areas of the sexual cycle, such as sexual desire, ejaculation, and orgasm; however, it may be useful in discussing ED with patients and evaluating treatment results over time.

Diabetes is an example of an endocrine disease that can cause a person to experience impotence. Diabetes affects the body’s ability to utilize the hormone insulin. One of the side effects associated with chronic diabetes is nerve damage. This affects penis sensations. Other complications associated with diabetes are impaired blood flow and hormone levels. Both of these factors can contribute to impotence.
Does drinking water improve erectile dysfunction? Erectile dysfunction or ED is a common concern for men. Everyday factors, such as hydration levels, may affect a person's ability to get or maintain an erection. Drinking water may, therefore, help some men with ED. In this article, learn about the link between hydration and ED, and other factors that can cause ED. Read now
Erections are more complicated than you think. Your brain, nerves, heart, blood vessels, and a whole lot of hormones have to work together perfectly or nothing happens. It’s a lot to ask, and sometimes things break down. And while ED happens to most guys at some point in their lives, erectile dysfunction isn’t something you can just ignore and hope it goes away.
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