Erectile dysfunction: causes, evaluation and treatment by video

According to the NIH, erectile dysfunction (ED, sometimes called impotence) is a condition that keeps you from getting or keeping an erection firm enough for sex. It may happen only some of the time, or you may not be able to get an erection at all.

It is very common. The NIH estimates that 30 to 50 million men in the United States have ED, and it becomes more frequent with age: about 40% of men have it at 40 and 70% by 70. But the NIH is clear that ED is not a routine part of aging: there is almost always a cause that can be looked for and treated.

According to the NIH, ED shows up as:

• Getting an erection only some of the time
• An erection that doesn’t last long enough for sex
• Not being able to get an erection

An erection depends on blood flow, nerves, hormones and your mind. That is why, according to the NIH, the most common causes are:

• Heart and blood vessel problems: clogged arteries (atherosclerosis), often from high cholesterol, high blood pressure and stroke.
• Diabetes: over time, high blood sugar damages nerves and blood vessels. Read type 2 diabetes.
• Hormones: low testosterone and thyroid problems.
• Medicines: some blood pressure medicines, diuretics, antidepressants, antihistamines, certain pain relievers, sedatives and ulcer medicines.
• Smoking, heavy drinking, drug use and not getting enough exercise.
• Stress, anxiety, depression, feeling lonely or low self-esteem.
• Other conditions, such as chronic kidney disease, obesity, nerve injuries or an enlarged prostate.

ED can be an early warning sign for your heart. The American Urological Association (AUA) guideline says ED is a risk marker for underlying cardiovascular disease. ED and heart disease share causes: inflammation, damage to blood vessel walls and clogged arteries. So the doctor does not only treat the erection: she also checks your blood pressure, blood sugar and cholesterol.

Lifestyle changes. The AUA guideline says changing your diet and getting more physical activity may improve erections in men whose health conditions affect them. The NIH also recommends quitting smoking, limiting alcohol, keeping a healthy weight and avoiding drugs.

A medicine review. If a medicine you take may be causing the problem, the doctor considers whether to adjust it. Don’t stop any medicine on your own.

ED medication. Phosphodiesterase-5 (PDE5) inhibitors such as sildenafil and tadalafil increase blood flow to the penis during sexual stimulation. The AUA guideline recommends telling men with ED about these pills unless they are contraindicated. If appropriate, the doctor prescribes and we send your prescription to your pharmacy. Read sildenafil and tadalafil: uses and risks.

Other treatments, in person. Penile injections, urethral suppositories, vacuum devices and implants are taught or done by a urologist. If you need them, the doctor refers you. If stress or your relationship is part of it, counseling helps, and the doctor can guide you.

The NIH warns against ordering ED medicine online without talking to a doctor, and against “natural” products without checking first: they can hide drugs that interact with yours.

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According to MedlinePlus, premature ejaculation is when a man ejaculates sooner than he wants during sex, anywhere from before penetration to shortly after. It can have emotional or physical causes, and it often gets better without treatment.

MedlinePlus says practice and relaxation help, and describes behavioral techniques such as stop-start (pausing stimulation for about 30 seconds when you feel close, then starting again) and squeeze (gently squeezing the tip of the penis for a few seconds). If it doesn’t improve with these, get checked. The doctor evaluates you by video, looks for causes such as anxiety or ED, and explains your options; if appropriate, she prescribes.

For your safety, go to the emergency room or call 911 if you have any of these signs. If you took an ED pill, tell the emergency staff: it changes which treatment they can give you. See when to go to the ER.

• An erection that lasts more than 4 hours, painful or not (priapism)
• Chest pain, shortness of breath or severe dizziness during or after sex
• Sudden loss of vision or hearing after taking an ED pill
• Sudden, severe pain in the testicles