Erectile dysfunction (impotence) is the inability to get and keep an erection firm enough for sex. Having erection trouble from time to time isn't necessarily a cause for concern. But if erectile dysfunction is an ongoing problem, it may cause stress, cause relationship problems or affect your self-confidence. Even though it may seem awkward to talk with your doctor about erectile dysfunction, go in for an evaluation. Problems getting or keeping an erection can be a sign of a health condition that needs treatment, such as heart disease or poorly controlled diabetes. Treating an underlying problem may be enough to reverse your erectile dysfunction. If treating an underlying condition doesn't help your erectile dysfunction, medications or other direct treatments may work.

Complications of Erectile Dysfunction

Complications resulting from erectile dysfunction can include:

• An unsatisfactory sex life
• Stress or anxiety
• Low self-esteem
• Marital or relationship problems
• The inability to get your partner pregnant

Causes of Erectile Dysfunction

Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles and blood vessels. Erectile dysfunction can result from a problem with any of these. Likewise, stress and mental health problems can cause or worsen erectile dysfunction. Sometimes a combination of physical and psychological issues cause erectile dysfunction. For instance, a minor physical problem that slows your sexual response may cause anxiety about maintaining an erection. The resulting anxiety can lead to or worsen erectile dysfunction.

Physical causes of erectile dysfunction

In most cases, erectile dysfunction is caused by something physical. Common causes include:

• Heart disease
• Clogged blood vessels (atherosclerosis)
• High blood pressure
• Diabetes
• Obesity
• Metabolic syndrome, a condition involving increased blood pressure, high insulin levels, body fat around the waist and high cholesterol
• Parkinson's disease
• Multiple sclerosis
• Low testosterone
• Peyronie's disease, development of scar tissue inside the penis
• Certain prescription medications
• Tobacco use
• Alcoholism and other forms of substance abuse
• Treatments for prostate cancer or enlarged prostate
• Surgeries or injuries that affect the pelvic area or spinal cord

Psychological causes of erectile dysfunction

The brain plays a key role in triggering the series of physical events that cause an erection, starting with feelings of sexual excitement. A number of things can interfere with sexual feelings and cause or worsen erectile dysfunction. These include:

• Depression, anxiety or other mental health conditions
• Stress
• Fatigue
• Relationship problems due to stress, poor communication or other concerns

Signs & Symptoms of Erectile Dysfunction

Erectile dysfunction is the inability to maintain an erection firm enough for sex, on an ongoing basis. Symptoms related to erectile dysfunction may include:

• Trouble getting an erection
• Trouble keeping an erection
• Reduced sexual desire

Diagnosis of Erectile Dysfunction

For many men, a physical exam and answering questions (medical history) are all that's needed before a doctor is ready to recommend a treatment. If your doctor suspects that underlying problems may be involved, or you have chronic health problems, you may need further tests or you may need to see a specialist.

Tests for underlying problems may include:

• Physical exam. This may include careful examination of your penis and testicles and checking your nerves for feeling.
• Blood tests. A sample of your blood may be sent to a lab to check for signs of heart disease, diabetes, low testosterone levels and other health problems.
• Urine tests (urinalysis). Like blood tests, urine tests are used to look for signs of diabetes and other underlying health conditions.
• Ultrasound. This test can check blood flow to your penis. It involves using a wand-like device (transducer) held over the blood vessels that supply the penis. It creates a video image to let your doctor see if you have blood flow problems. This test is sometimes done in combination with an injection of medications into the penis to determine if blood flow increases normally.
• Overnight erection test. Most men have erections during sleep without remembering them. This simple test involves wrapping special tape around your penis before you go to bed. If the tape is separated in the morning, your penis was erect at some time during the night. This indicates the cause is of your erectile dysfunction is most likely psychological and not physical.

Treatments of Erectile Dysfunction

The first thing your doctor will do is to make sure you're getting the right treatment for any health problems that could be causing or worsening your erectile dysfunction. A variety of options exist for treating erectile dysfunction. The cause and severity of your condition, and underlying health problems, are important factors in your doctor's recommending the best treatment or treatments for you. Your doctor can explain the risks and benefits of each treatment, and will consider your preferences. Your partner's preferences also may play a role in treatment choices.

Oral medications

Oral medications are a successful erectile dysfunction treatment for many men. They include:

• Sildenafil (Viagra)
• Tadalafil (Cialis)
• Vardenafil (Levitra)

All three medications work in much the same way. These drugs enhance the effects of nitric oxide; a natural chemical your body produces that relaxes muscles in the penis. This increases blood flow and allows you to get an erection in response to sexual stimulation. These medications vary in dosage, how long they work and their side effects. Your doctor will take into account your particular situation to determine which medication may work best. Don't expect these medications to fix your erectile dysfunction immediately. You may need to work with your doctor to find the right medication and dose for you. Before taking any prescription erectile dysfunction medication (including over-the-counter supplements or herbal remedies), get your doctor's OK. Although these medications can help many people, not all men should take them to treat erectile dysfunction. These medications may not work or may be dangerous for you if you:

• Take nitrate drugs for angina, such as nitroglycerin (Nitro-Bid, others), isosorbide mononitrate (Imdur) and isosorbide dinitrate (Isordil)
• Take a blood-thinning (anticoagulant) medication, alpha blockers for enlarged prostate (benign prostatic hyperplasia) or high blood pressure medications
• Have heart disease or heart failure
• Have had a stroke
• Have very low blood pressure (hypotension) or uncontrolled high blood pressure (hypertension)
• Have uncontrolled diabetes

Other medications

Other medications for erectile dysfunction include:

• Alprostadil self-injection. With this method, you use a fine needle to inject alprostadil (Alprostadil, Caverject Impulse, Edex) into the base or side of your penis. In some cases, medications generally used for other conditions are used for penile injections on their own or in combination. Examples include papaverine, alprostadil and phentolamine. Each injection generally produces an erection in five to 20 minutes that lasts about an hour. Because the needle used is very fine, pain from the injection site is usually minor. Side effects can include bleeding from the injection, prolonged erection and formation of fibrous tissue at the injection site.
• Alprostadil penis suppository. Alprostadil intraurethral (MUSE) therapy involves placing a tiny alprostadil suppository inside your penis. You use a special applicator to insert the suppository about two inches down into your penis. Side effects can include pain, minor bleeding in the urethra, dizziness and formation of fibrous tissue inside your penis.
• Testosterone replacement. Some men have erectile dysfunction caused by low levels of the hormone testosterone, and may need testosterone replacement therapy.

Penis pumps, surgery and implants

Medications may not work or may not be a good choice for you. If this is the case, your doctor may recommend a different treatment. Other treatments include:

• Penis pumps. A penis pump (vacuum constriction device) is a hollow tube with a hand-powered or battery-powered pump. The tube is placed over your penis, and then the pump is used to suck out the air inside the tube. This creates a vacuum that pulls blood into your penis. Once you get an erection, you slip a tension ring around the base of your penis to hold in the blood and keep it firm. You then remove the vacuum device. The erection typically lasts long enough for a couple to have sex. You remove the tension ring after intercourse.
• Penile implants. This treatment involves surgically placing devices into the two sides of the penis. These implants consist of either inflatable or semirigid rods made from silicone or polyurethane. The inflatable devices allow you to control when and how long you have an erection. The semirigid rods keep the penis firm but bendable. This treatment can be expensive and is usually not recommended until other methods have been tried first. As with any surgery, there is a risk of complications such as infection.
• Blood vessel surgery. In rare cases, a leaking blood vessel can cause erectile dysfunction and surgery is necessary to repair it.

Psychological counseling

If your erectile dysfunction is caused by stress, anxiety or depression, your doctor may suggest that you, or you and your partner, visit a psychologist or counselor. Even if it is caused by something physical, erectile dysfunction can create stress and relationship tension.

Prevention of Erectile Dysfunction

The best way to prevent erectile dysfunction is to make healthy lifestyle choices and to manage any existing health problems you have. Here are some things you can do:

• Work with your doctor to manage diabetes, heart disease or other chronic health problems.
• See your doctor for regular checkups and medical screening tests.
• Stop smoking, limit or avoid alcohol, and don't use street drugs.
• Exercise regularly.
• Take steps to reduce stress.
• Get help for anxiety or depression.

When to seek Medical Advice

A family doctor is a good place to start when you have erectile problems. See your doctor if:

• Erectile or other sexual problems are an issue for you or your partner
• You have diabetes, heart disease or another known health problem that may be linked to erectile dysfunction
• You have other symptoms along with erectile dysfunction that may not seem related