by Janet Casperson, BS, MSN, ANP-C
How can I tell if I have erectile dysfunction (ED)?
Erectile dysfunction is defined as the inability to achieve or maintain an erection satisfactory for penetration. It's the old question "How do I know I have something?" and the response "You'll know it when you have it." This is a good way to judge: if you're not having as rigid an erection as you believe you should have, then you have erectile dysfunction. If you are unable to maintain an erection until the completion of intercourse then you probably should be checked out. Rapid or premature ejaculation is another form of sexual dysfunction. Ejaculating before you want to or just after you penetrate your partner can be considered sexual dysfunction but this condition is very treatable with medications. There are medications in clinical testing that can have a dramatic improvement on sexual functioning and the ability to maintain control over ejaculation for enough time to satisfy your partner.
How should I approach my partner about seeking treatment for ED?
This is often a difficult and uncomfortable subject for both men and women. Many men complain that their partner is not interested in sexual activity, but this may be related to the man's difficulty in achieving or maintaining an erection which is satisfactory for penetration. The man may fear failure and may avoid the lovemaking process entirely.
The partner's participation enhances communication, history taking and reduces stress at the time of visit. Additionally, it allows the clinician to give specific instructions to the both partners in the couple rather than just to one partner. Some important tips for couples:
- Communication is extremely important. Pick a time and place that is calm and quiet with no interruptions to initiate conversation about sexual activities with your partner.
- A great way to initiate a conversation is to print out our article on communication for couples and talk about it together. Read passages aloud together and leave it available so when there is a question about communication, you can refer to it frequently.
- Express yourself to your partner in a supportive and loving manner. You might say "Sex is important to me and we want to handle the problem together as a couple."
- Do not blame or criticize your partner.
- Go to doctor's appointments together when appropriate.
- Do not remain silent when going to the clinician's office; ask questions.
Remember that sexual dysfunction is a medical condition that can be treated. We have a range of treatments available, from pills to surgical procedures and we will work with couples to find the best successful treatment option.
How safe are the treatments for erectile dysfunction?
As we have discussed all through this Center, erectile dysfunction treatments are safe and reliable when you understand the indications and contraindications.
The PDE-5 inhibitors are very safe as long as one avoids concomitant treatment with nitroglycerin, long-acting nitrates, or alpha blocker drugs that are used for prostate disease or hypertension such as Flomax®, Cardura®, Hytrin®, Uroxatral®. There was a recent flurry of news regarding sudden onset of blindness from Viagra® and Cialis®. This condition, known as NAION, is a relatively rare condition in men with diabetes. A large study actually found that this probably had no relationship to the drug use.
Since Viagra® was first released, the news reports about all the effects that Viagra® was reported to have mostly disappeared as people become more comfortable with open discussion of intimate sexual topics. One needs only to watch the evening news or programming to see the impact that PDE-5 inhibitors has had on America.
A vacuum erection device has virtually no long-term damage or side effects. Penile injections may have a rare but significant side effect of a condition called priapism. This can be a medical emergency but most clinicians instruct patients on how to avoid or treat priapism.
The risks and benefits of a surgical implant can vary according to the patient's general health and well-being. Certainly, infection is a rare risk factor that can be catastrophic if not avoided or recognized early and treated appropriately. That's why it is so important to pick a surgeon who has extensive experience in implanting these prosthetic devices.
What about testosterone treatment?
Testosterone treatment has been discussed extensively in an article on testosterone. For more information, refer to the Androgen Deficiency in the Aging Male (ADAM) questionnaire on this website. If you score positively in the ADAM questionnaire you could certainly have testosterone deficiency and should discuss this with your health care professional. Remember, testosterone is a cornerstone for sexual functioning. A low testosterone level not only decreases the libido but also can adversely affect the rigidity of the erection. Testosterone is required for the production of nitric oxide (NO) which is crucial for Viagra® and the PDE-5 inhibitors to work.
What if my penis is bent?
Peyronie's disease is a common disease which has been estimated to affect up to 4% of men. The average age of diagnosis is the mid 50's; the vast majority of men have Peyronie's disease as a result of subclinical penile trauma. This may occur when the female partner is in the superior position ("on top"). Because of positioning, the penis gets bent, suddenly causing leakage of blood from the corporal body and causing a subsequent bend or scar in the penis. Peyronie's disease is considered a form of sexual dysfunction and is very treatable. There are a number of new innovative medical treatments for Peyronie's that involve injection of medications into the plaque or scarred area of the penis with dramatic results. Additionally, penile straightening can straighten the penis to allow adequate penetration. Our recommendation is to undergo straightening of the penis when the penis is so bent that it causes your partner pain and makes sexual intercourse an unpleasurable experience.
Will the PDE-5 inhibitors make my partner want to have sex with me?
It's very important to remember that erectile dysfunction or any sexual dysfunction is a couple's problem. PDE-5 inhibitors, taken orally, work only with sexual stimulation. If your partner still finds you desirable, the pill will aid in sexual activity but it still takes a couple to have satisfactory intercourse.
Will my erections ever be spontaneous and natural?
The answer to this question is based on the degree of damage that has been done to the tissues of the penis. In men who have relatively new onset of organic erectile dysfunction and who are willing to modify the risk factors, the answer is absolutely Yes. However, for men who haven't had a good erection for many years and who have not responded to any of the treatment options, the answer is Probably Not. These men should consider a penile implant. Remember that a spontaneous natural erection is a barometer of your overall cardiovascular health.
How expensive is the treatment of erectile dysfunction or sexual dysfunction? Will my insurance cover it?
Treatment can be as expensive as you want it to be but typically, insurance pays for the vast majority of diagnostic and treatment options. But the cost of an erection is not cheap. One can guesstimate that a single erection episode can cost anywhere between $8.00 and $10.00 depending on the medication used.
Insurance plans do cover the treatment of erectile dysfunction but stop short at the multiple uses of PDE-5 inhibitors in a month. Most of the insurance plans in our area will get between six and ten tablets per month and will ration these according to this plan. Many insurance companies will actually pay for penile implant surgery when it's appropriately coded and when your doctor takes the time to write the appropriate letter.
If I lose weight and stop smoking, will my erectile dysfunction get better?
The answer is yes. Risk factor modification and lifestyle changes can dramatically improve and even cure many of the existing conditions that contribute to erectile dysfunction. A recent study from Italy showed that a significant loss (10% of body weight) can return erections to normal in about one-third of men. In the remaining men, the use of PDE-5 inhibitors can dramatically improve the situation. In our clinical experience, erections will begin to return and can actually return to normal in men with significant weight loss.
Should I see a specialist?
You should see who are comfortable with. A specialist has the most expertise in treating sexual dysfunction. If they sub-specialize in the treatment of erectile dysfunction and sexual disorders, they often have a much greater understanding of the nuances of the treatment options and modalities. However, a good primary care clinician with the appropriate training can diagnose and treat these disorders just as well. Additionally, if you are considering hormonal treatments or hormonal replacement you should be sure your clinician is experienced in this as well.
For more information, refer to the SHIM, Sexual Health Inventory for Men test. Take this test after you have finished reading all of the material in this Center. If you score a high number, indicating a fairly substantial or severe erectile dysfunction, then referral to a specialist is probably indicated early on in the treatment and the course of the disease. If you have had prior unsuccessful treatments, you may want to consider seeing a specialist early on in the treatment as well.
Laboratory testing for erectile dysfunction
We believe that the minimum workup for a man with erectile dysfunction is a testosterone level, which can give us a clue as to the basic sexual functioning of a man's body. Testosterone is responsible for nocturnal erections, which help to nourish the penis and maintain rigidity and length. Other lab tests that may be included include an estradiol test. Estradiol is a breakdown product of testosterone and is frequently elevated in older or obese men. Another test that we use in the management of erectile dysfunction is a prostate specific antigen (PSA). If a man has a high PSA and may have prostate cancer, this can impact treatment options for erectile dysfunction> especially if he's had treatment for prostate cancer such as a radical prostatectomy. A prostatectomy can also dramatically affect erections.
Doppler ultrasound of the penis
A special ultrasound known as a Doppler flow machine uses sound waves to show how blood flows through the vessels. The Doppler ultrasound of the penis is a very useful technique to definitively identify the cause of the erectile dysfunction. We strongly feel that we're not doing a patient any favors by trying ineffective treatments over prolonged periods of times. This does nothing but frustrate you and your partner and waste your money.
In ultrasound of the penile arteries, the blood flow into the penis is measured after application of a vasoactive drug. The Doppler exam reveals whether the penis adequately traps the blood to maintain the erection during intercourse. Additionally, Doppler is crucial in the diagnosis of Peyronie's disease.
A Doppler examination should be done by an experienced clinician. These are not simple tests that are ordered in an outpatient radiology department but rather are performed by highly trained healthcare professionals.
References: See Bibliography
August 2006
Posted August 2008
Updated December 2011
