What Is Erectile Dysfunction?
The term "erectile dysfunction" or "impotence," has traditionally been used to signify the inability of the male to attain and maintain erection of the penis sufficient to permit satisfactory sexual intercourse. The personal nature of this problem can lead to poor self-esteem, feelings of inadequacy and a negative impact towards one's relationships. The following paragraphs will briefly outline the prevalence, causes, diagnoses and treatment of erectile dysfunction.

Prevalence
Erectile dysfunction affects millions of men. More recent estimates suggest that the number of U.S. men with erectile dysfunction may likely be near 10-20 million. Inclusion of individuals with partial erectile dysfunction increases the estimate to about 30 million. The majority of these individuals will be older than 65 years of age. The prevalence of erectile dysfunction has been found to be associated with age. A prevalence as high as 40 percent is observed at age 40, increasing as much as 65 percent at age 65 and older.

Although for some patients, erectile function may not be the best or most important measure of sexual satisfaction, for many men erectile dysfunction creates mental stress that affects their interactions with family and associates. Many advances have occurred in both diagnosis and treatment of erectile dysfunction and patients should be aware of these changes.

Causation
Whatever the causal factors, discomfort of patients and even some health care providers in discussing sexual issues becomes a barrier to pursuing treatment. The multifactorial nature of erectile dysfunction, comprising both organic and psychologic aspects, may often require a multidisciplinary approach to its assessment and treatment. Erectile dysfunction is often assumed to be a natural concomitant of the aging process, and is often tolerated along with other conditions associated with aging. This assumption may not be entirely correct. For the elderly and for others, erectile dysfunction may occur as a consequence of specific illnesses or of medical treatment for certain illnesses, resulting in fear, loss of image and self-confidence, and depression. For ease of discussion, causes contributing to erectile dysfunction can be broadly classified into two categories: organic and psychologic. In reality, while the majority of patients with erectile dysfunction are thought to demonstrate an organic component, psychological aspects of self-confidence, performance anxiety, and partner communication and conflict are often important contributing factors.

Erectile dysfunction is clearly a symptom of many conditions, and certain risk factors have been identified, some of which may be amenable to prevention strategies. Diabetes mellitus, hypertension, vascular disease, high levels of blood cholesterol, low levels of high density lipoprotein, drugs, neurogenic disorders, hypogonadism in association with a number of endocrinologic conditions, Peyronie's disease, priapism, depression, alcohol ingestion, lack of sexual knowledge, poor sexual techniques, inadequate interpersonal relationships, and many chronic diseases, especially renal failure and dialysis, have been demonstrated as risk factors. For example, many men with diabetes mellitus may develop erectile dysfunction during their young and middle adult years, even before being diagnosed as a diabetic.

As stated earlier, age appears to be a strong indirect risk factor in that it is associated with an increased likelihood of direct risk factors. Smoking has an adverse effect on erectile function by accentuating the effects of other risk factors such as vascular disease or hypertension. To date, vasectomy has not been associated with an increased risk of erectile dysfunction other than causing anxiety that could then have a temporary negative influence.

When To Call Your Doctor
If you have experienced erectile dysfunction, you should ask for an evaluation by your doctor. The treatment for this widespread problem may be as simple as changing your medication. The first step is to arrange an appointment with your doctor and to have an appropriate evaluation.

Diagnosis of Erectile Dysfunction
The appropriate evaluation of all patients with erectile dysfunction should include a medical and detailed sexual history (including practices and techniques), a physical examination, a psycho-social evaluation, and basic laboratory studies.

The general medical history is important in identifying specific risk factors that may account for or contribute to the patient's erectile dysfunction. These include vascular risk factors such as hypertension, diabetes, smoking, coronary artery disease, peripheral vascular disorders, pelvic trauma or surgery, and blood lipid abnormalities. Decreased sexual desire or history suggesting a hypogonadal state could indicate a primary endocrine disorder. Neurologic causes may include a history of diabetes mellitus or alcoholism with associated peripheral neuropathy. Neurologic disorders such as multiple sclerosis, spinal injury, or cerebrovascular accidents are often obvious or well defined prior to presentation. It is essential to provide a detailed medication and illicit drug history since an estimated 25 percent of cases of erectile dysfunction may be attributable to medications for other conditions.

Endocrine evaluation consisting of a morning serum testosterone is generally indicated if hypogonadism is suspected. A low testosterone level merits repeat measurement together with assessment of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin levels. Other tests may be helpful in excluding unrecognized systemic disease and include a complete blood count, urinalysis, creatinine, lipid profile, fasting blood sugar, and thyroid function studies.

The number of patients who may benefit from more extensive vascular testing is small, but includes young men with a history of significant perineal or pelvic trauma, who may have anatomic arterial blockage (either alone or with a neurologic deficit) to account for erectile dysfunction.

Studies to further define vasculogenic disorders include pharmacologic duplex grey scale/color ultrasonography, pharmacologic dynamic infusion cavernosometry/ cavernosography, and pharmacologic pelvic/penile angiography.

Treatment
Treatment for erectile dysfunction is tailored to meet the patient's individual needs. Various forms of therapy are available and involve aspects of psychological, medical and surgical techniques.

Medical Therapy
An initial approach to medical therapy should consider reversible medical problems that may contribute to erectile dysfunction. Many drugs for treating impotence are now available. These therapies are designed to improve the blood flow regulation necessary for a normal erection.

Oral Agents
There are a number of new oral agents(pills) available for the treatment of erectile dysfunction. These are all similar in that they require sexual stimulatioin to work and all require at least 20 minutes to become effective.

Intra-urethral Therapy
Intra-urethral pellets (about the size of a grain of rice) can be placed inside the tip of the penis (inside the urethra). These contain medicine which is absorbed into the penis to cause an erection. Onset of action is only about five minutes and requires no sexual stimulation to be effective.

Intracavernosal Injection Therapy
Injection of vasodilator substances into the corpora (shaft) of the penis has provided a very effective technique for a variety of causes of erectile dysfunction. A very small needle is used so that there is very little if any discomfort. Onset of action is only about five minutes and requires no sexual stimulation to be effective.

Vacuum/Constrictive Devices
Vacuum constriction devices may be effective at generating and maintaining erections in many patients with erectile dysfunction and these appear to have a low incidence of side effects. A large cylinder is placed over the penis and a vacuum is created inside the cylinder drawing blood into the penis for an erection. A small rubber ring or band is then placed around the base of the penis to keep the penis erect.

Penile Prostheses
A surgical implant can be placed inside the penis to create an erection. Inflatable rods are placed inside the corporal bodies (the two structures inside the penis that normally fill up with blood to cause an erection). The main problems are mechanical failure, infection, and erosions

Psychotherapy and Behavioral Therapy
Psychosocial factors are important in all forms of erectile dysfunction. Should there be a significant component of erectile dysfunction resulting from psychosocial issues (such as performance anxiety or depression), an appropriate referral to a specialist in this area will be made.

Conclusions
The term "erectile dysfunction" is used to characterize the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance. Check with your doctor should you experience this problem. The first step towards treatment is your phone call.

The likelihood of erectile dysfunction increases progressively with age but is not an inevitable consequence of aging. Other age-related conditions increase the likelihood of its occurrence.

Erectile dysfunction may be a consequence of medications taken for other problems or a result of drug abuse. Many common medical conditions, such as diabetes, can also contribute to the problem.

Embarrassment of patients and the reluctance of both patients and some health care providers to discuss sexual matters candidly contribute to underdiagnosis of erectile dysfunction.

Many cases of erectile dysfunction can be successfully managed with appropriately selected therapy. There are several agents and techniques, which have proven successful in treating men with erectile dysfunction.

Patients with erectile dysfunction require diagnostic evaluations and treatments specific to their circumstances. Patient compliance as well as patient and partner desires and expectations are important considerations in the choice of a particular treatment approach. A multidisciplinary approach may be of great benefit in defining the problem and arriving at a solution.