Erectile dysfunction, sometimes called “impotence,” is the repeated inability to get or keep an erection firm enough for sexual intercourse. The word “impotence” may also be used to describe other problems that interfere with sexual intercourse and reproduction, such as lack of sexual desire and problems with ejaculation or orgasm. Using the term erectile dysfunction makes it clear that those other problems are not involved.
Erectile dysfunction, or ED, can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections. These variations make defining ED and estimating its incidence difficult. Estimates range from 15 million to 30 million, depending on the definition used. According to the National Ambulatory Medical Care Survey (NAMCS), for every 1,000 men in the United States, 7.7 physician office visits were made for ED in 1985. By 1999, that rate had nearly tripled to 22.3. The increase happened gradually, presumably as treatments such as vacuum devices and injectable drugs became more widely available and discussing erectile function became accepted. Perhaps the most publicized advance was the introduction of the oral drug sildenafil citrate (Viagra) in March 1998. NAMCS data on new drugs show an estimated 2.6 million mentions of Viagra at physician office visits in 1999, and one-third of those mentions occurred during visits for a diagnosis other than ED.
In older men, ED usually has a physical cause, such as disease, injury, or side effects of drugs. Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED. Incidence increases with age: About 5 percent of 40-year-old men and between 15 and 25 percent of 65-year-old men experience ED. But it is not an inevitable part of aging.
ED is treatable at any age, and awareness of this fact has been growing. More men have been seeking help and returning to normal sexual activity because of improved, successful treatments for ED. Urologists, who specialize in problems of the urinary tract, have traditionally treated ED; however, urologists accounted for only 25 percent of Viagra mentions in 1999.

Overview and symptoms

Erectile dysfunction is characterized by the regular or repeated inability to obtain or maintain an erection. There are several ways that erectile dysfunction is analyzed:

Obtaining full erections at some times, such as when asleep (when the mind and psychological issues if any are less present), tends to suggest the physical structures are functionally working. However the opposite case, a lack of nocturnal erections, does not imply the opposite, since a significant proportion of sexually functional men do not routinely get nocturnal erections or wet dreams.
Obtaining erections which are either not rigid or full (lazy erection), or are lost more rapidly than would be expected (often before or during penetration), can be a sign of a failure of the mechanism which keeps blood held in the penis, and may signify an underlying clinical condition, often cardiovascular in origin.
Other factors leading to erectile dysfunction are diabetes mellitus (causing neuropathy) or hypogonadism (decreased testosterone levels due to disease affecting the testicles or the pituitary gland).

Erection problems are very common. The Sexual Dysfunction Association estimates that 1 in 10 men in the UK have recurring problems with their erections at some point in their life.

How does an erection occur?

The penis contains two chambers called the corpora cavernosa, which run the length of the organ. A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum.
Erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed.

Pathophysiology

Penile erection is managed by two different mechanisms. The first one is the reflex erection, which is achieved by directly touching the penile shaft. The second is the psychogenic erection, which is achieved by erotic stimuli. The former uses the peripheral nerves and the lower parts of the spinal cord, whereas the latter uses the limbic system of the brain. In both conditions an intact neural system is required for a successful and complete erection. Stimulation of penile shaft by the nervous system leads to the secretion of nitric oxide (NO), which causes the relaxation of smooth muscles of corpora cavernosa (the main erectile tissue of penis), and subsequently penile erection. Additionally, adequate levels of testosterone (produced by the testes) and an intact pituitary gland are required for the development of a healthy male erectile system. As can be understood from the mechanisms of a normal erection, impotence may develop due to hormonal deficiency, disorders of the neural system, lack of adequate penile blood supply or psychological problems. Restriction of blood flow can arise from impaired endothelial function due to the usual causes associated with coronary artery disease, but can also include causation by prolonged exposure to bright light or chronic exposure to high noise levels.
A few causes of impotence may be iatrogenic (medically caused). Various antihypertensives (medications intended to control high blood pressure) and some drugs that modify central nervous system response may inhibit erection by denying blood supply or by altering nerve activity. Psychiatric medications, especially SSRIs have been shown to cause erectile dysfunction in patients, both males and females. Although usually reversible, these sexual side effects can, in rare cases, last for months or years or permanently after the drug has been completely withdrawn. This disorder is known as Post SSRI Sexual Dysfunction.
Surgical intervention for a number of different conditions may remove anatomical structures necessary to erection, damage nerves, or impair blood supply.Complete removal of the prostate gland or external beam radiotherapy of the gland are common causes of impotence; both are treatments for advanced prostate cancer. Some studies have shown that male circumcision may result in an increased risk of impotence, while others have found no such effect, and another found the opposite.
Excessive alcohol use has long been recognised as one cause of impotence, leading to the euphemism “brewer’s droop,” or “whiskey dick;” Shakespeare made light of this phenomenon in Macbeth.
A study in 2002 found that ED can also be associated with bicycling. The number of hours on a bike and/or the pressure on the penis from the saddle of an upright bicycle is directly related to erectile dysfunction.

How is Erectile dysfunction (impotence) diagnosed?

Medical diagnosis

There are no formal tests to diagnose erectile dysfunction. Some blood tests are generally done to exclude underlying disease, such as diabetes, hypogonadism and prolactinoma. Impotence is also related to generally poor physical health, poor dietary habits, obesity, and most specifically cardiovascular disease such as coronary artery disease and peripheral vascular disease.
A useful and simple way to distinguish between physiological and psychological impotence is to determine whether the patient ever has an erection. If never, the problem is likely to be physiological; if sometimes (however rarely), it could be physiological or psychological. The current diagnostic and statistical manual of mental diseases (DSM-IV) has included a listing for impotence.

Clinical Tests Used to Diagnose ED

Duplex ultrasound
Duplex ultrasound is used to evaluate blood flow, venous leak, signs of atherosclerosis, and scarring or calcification of erectile tissue. Injecting prostaglandin, a hormone-like stimulator produced in the body, induces erection. Ultrasound is then used to see vascular dilation and measure penile blood pressure. Measurements are compared to those taken when the penis is flaccid.

Penile nerves function
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. Specific nerve tests are used in patients with suspected nerve damage as a result of diabetes or nerve disease.

Nocturnal penile tumescence (NPT)
It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge. (It should be noted that a significant proportion of men who have no sexual dysfunction nonetheless do not have regular nocturnal erections.Thus presence of NPT tends to signify physically functional systems, but absence of NPT may be ambiguous and not rule out either cause.)

Penile biothesiometry
This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glans and shaft of the penis. A decreased perception of vibration may indicate nerve damage in the pelvic area, which can lead to impotence.

Penile Angiogram
Invasive test - allows visualization of the circulation in the penis and is used during the repair of a priapism.

Dynamic Infusion Cavernosometry (DICC)
Technique in which fluid is pumped into the penis at a known rate and pressure. It gives a measurement of the vascular pressure in the corpus cavernosum during an erection. To do this test, a vasodilator like prostaglandin E-1 is injected to measure the rate of infusion required to get a rigid erection and to help find how severe the venous leak is.

Corpus Cavernosometry
Cavernosography measurement of the vascular pressure in the corpus cavernosum. Saline is infused under pressure into the corpus cavernosum with a butterfly needle, and the flow rate needed to maintain an erection indicates the degree of venous leakage. The leaking veins responsible may be visualised by infusing a mixture of saline and x ray contrast medium and performing a cavernosogram.

Digital Subtration Angiography
In DSA, the images are acquired digitally. The computer creates a mask from lower-contrast x-rays of the same area and digitally isolates the blood vessels (this is done manually through darkroom masking with traditional angiography).

Magnetic resonance angiography (MRA)
This is similar to magnetic resonance imaging. Magnetic resonance angiography uses magnetic fields and radio waves to provide detailed images of the blood vessels. Doctors may inject a “contrast agent” into the patient’s bloodstream that causes vascular tissues to stand out against other tissues. The contrast agent provides for enhanced information regarding blood supply and vascular anomalies. Aside from the IV used to introduce the contrast material into the bloodstream, magnetic resonance angiography is noninvasive and painless.

How is ED treated?

Conventional treatment

Most physicians suggest that treatments proceed from least to most invasive. For some men, making a few healthy lifestyle changes may solve the problem. Quitting smoking, losing excess weight, and increasing physical activity may help some men regain sexual function.
Cutting back on any drugs with harmful side effects is considered next. For example, drugs for high blood pressure work in different ways. If you think a particular drug is causing problems with erection, tell your doctor and ask whether you can try a different class of blood pressure medicine.
Psychotherapy and behavior modifications in selected patients are considered next if indicated, followed by oral or locally injected drugs, vacuum devices, and surgically implanted devices. In rare cases, surgery involving veins or arteries may be considered.

Psychotherapy

Experts often treat psychologically based ED using techniques that decrease the anxiety associated with intercourse. The patient’s partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when ED from physical causes is being treated.

Erection-inducing drugs

Oral drugs which induce erection have revolutionised the treatment of ED over the last eight years. They don’t work for everybody, but they do work for the majority – even in diabetes. They can also help people with neurological and spinal problems.
Also, the choice of available drugs means that if one particular drug doesn’t suit you, it’s well worth trying one of the others.
There are three orally-administered drugs available in the UK. They all have side-effects, only a few of which we can list here. For more information, read the package insert leaflet, and if in doubt ask your doctor.
It is not safe for some people to use these drugs, and some medications interact dangerously with them. Therefore, before going on any of these pills you should always see a doctor, talk things over with him, and have a physical check-up.
Do not buy erection drugs by mail-order, or from chaps you meet in pubs! They may not be the right thing.

The oral drugs currently available are:

Viagra (sildenafil)

Widens the bloods vessels, so giving an erection - provided the penis is rubbed. In most men, works within an hour. Effect lasts for about four hours. Easily blocked by food in the stomach.
Viagra still remains the world’s most popular ED drug. At the Vienna International Sexology conference of December 2006 which we attended, it was claimed that its continuing popularity is due to the ‘hardness ‘ of the erections it produces.
The most common side-effects are headache, visual disturbances, blocked nose, flushed face, indigestion, palpitations - and dizziness after getting out of bed too quickly! Blue vision occurs at higher doses. Viagra is very dangerous with certain heart drugs. Interacts with many medications. Do not drink grapefruit juice on day of use.
At the beginning of April 2005, a report from the University of Minnesota suggested that a small group of men have suffered blindness as a result of Viagra use. It was claimed that the drug may rarely cause a serious eye condition called ‘non-arteritic ischaemic optic atrophy.’ In 2007, it became apparent that about half a dozen British men have suffered similar eye problems. If you are taking Viagra, you should ask your doctor to keep you informed of any further research on this development.

Cialis (tadalafil)

Works in the same way as Viagra. Now popular with a lot of men, because its effects last so long – at least 12 hours in most cases. Manufacturers claim it is not blocked by food.
Side-effects similar to those of Viagra, but also causes back pain and muscle pain. Interactions with other drugs and with grapefruit juice are similar to those of Viagra, but also clashes with the antibiotic clarithromycin and the sedative phenobarbitone. Cialis is very similar in structure to Viagra, but so far (2007) there have been no reports of blindness on Cialis.

Levitra (vardenafil)

Works in same way. Side-effects and interactions are similar to those of Viagra. Not as long-lasting as Cialis. So far, there have been no reports of blindness.

The above three drugs are supposed to be ‘prescription-only’ in the UK and most other countries. However, in Manchester during early 2007, Boots the chemists opened three centres where men can obtain Viagra (for a fee) after careful counselling from a pharmacist. There is back-up from a group of private doctors. If this scheme turns out to be a success, then Viagra and similar drugs may become more widely available over the counter.

Uprima

There is another oral anti-ED drug called ‘Uprima’, but it was withdrawn from sale in Britain during 2006 – probably for commercial reasons.

What other drug treatments for ED are there?

It’s also possible to give erection-inducing agents by:

injections into the penis.
pellets inserted down the urinary pipe.

These methods have become less popular since the increasing availability of oral drugs, but they suit a minority of men. You have to be quite brave to give yourself a jab in the penis. For details of side-effects, consult your GP.

Vacuum pump

An external vacuum pump will produce an engorged penis with success approaching 90%; a penis ring will maintain this state, although it should be removed after not more than 30 minutes. The erection is not as rigid or hard as a natural erection; drugs or injections, when they work, may be preferable. Various studies show the degree of satisfaction of users and their partners to be vary variable, even when drugs and injections do not work; in one study, about 20% of men who tried a (high-priced) pump decided to proceed to purchase one. Other studies show higher percentages of satisfied users.
In some cases frequent use of a vacuum pump can eventually improve the degree of erection attainable without use of the pump. Claims of cheap “penis pumps” to permanently increase maximum penis size should be viewed with caution, however.
Some vacuum pumps, such as Osbon ErecAid, are sold at a higher price with 100% refund within 90 days to dissatisfied users, with a somewhat lower price with 50% refund guarantee.This pump is supported by medical insurance schemes, including the UK’s NHS and US Medicare and private insurers. The better-known pumps sell for prices of around 200 GBP/400 USD (2006). There is at least one vacuum pump with rings which sells for around one-fifth of this price.

Surgery

Surgery usually has one of three goals:

to implant a device that can cause the penis to become erect
to reconstruct arteries to increase flow of blood to the penis
to block off veins that allow blood to leak from the penile tissues

Implanted devices, known as prostheses, can restore erection in many men with ED. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have diminished in recent years because of technological advances.
Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa. The user manually adjusts the position of the penis and, therefore, the rods. Adjustment does not affect the width or length of the penis.
Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid. Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis somewhat. They also leave the penis in a more natural state when not inflated.
Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to the crotch or fracture of the pelvis. The procedure is almost never successful in older men with widespread blockage.
Surgery to veins that allow blood to leave the penis usually involves an opposite procedure—intentional blockage. Blocking off veins (ligation) can reduce the leakage of blood that diminishes the rigidity of the penis during erection. However, experts have raised questions about the long-term effectiveness of this procedure, and it is rarely done.

Natural Treatment

Nutritional and lifestyle choices that can contribute to difficulties achieving and maintaining an erection include long-term alcohol and/or tobacco use, chronic recreational drug use, and poor nutritional choices (i.e., diet of processed foods, fast foods, and refined foods). Poor dietary choices may lead to vascular disease (the most common cause of ED), which interferes with the erection process by restricting blood flow to the penis.
Natural treatment can support erectile function by improving overall health. Erectile dysfunction due to vascular disease may readily respond to nutritional changes and herbal support.

Nutrition

Good nutrition may help improve erectile dysfunction.

Eat whole, fresh, unrefined, and unprocessed foods. Include fruits (lots of richly pigmented berries to support vascular integrity), vegetables, whole grains, soy, beans, seeds, nuts, olive oil, and cold-water fish (salmon, tuna, sardines, halibut, and mackerel).
Avoid sugar, dairy products, refined foods, fried foods, junk foods, and caffeine.
Eliminate food sensitivities. Use an elimination and challenge diet elimination and challenge diet to determine food sensitivities.
Drink 50% of your body weight in ounces of water daily (e.g., if you weigh 150 lbs, drink 75 oz of water daily).

Supplements

Supplements are intended to provide nutritional support. Because a supplement or a recommended dose may not be appropriate for all persons, a physician (i.e., a licensed naturopathic physician or holistic MD or DO) should be consulted before using any product. Recommended doses follow:

Bioflavonoids – Take 1000 mg daily.
Flaxseed meal – Grind 2-4 tablespoons daily. Flaxseed meal is a better choice due to its fiber, lignan, and vitamin content, but flaxseed oil (1 tbsp daily) can be substituted.
Inositol hexaniacinate – Take 1000-3000 mg daily to improve circulation and lower cholesterol. Diabetics should not take this supplement.
Selenium – Take 200 mcg daily.
Vitamin C – Take 1000 mg 3 times daily with meals.
Vitamin E – Take 400 IUs daily.
Zinc – Take 30 mg daily.

Acupressure

“Acupressure on the Sea of Vitality points, B 23 and B 47, can fortify the body and, with repeated usage over a long period of time, can make a man stronger sexually,” says Michael Reed Gach, Ph.D., director of the Acupressure Institute in Berkeley, California, and author of Acupressure’s Potent Points. To find the B 47 points, measure four finger-widths away from the spine at waist level. The points are situated on the lower back on the left and right sides of the spine, in line with the navel. From B 47, you can move two finger-widths closer to the spine to find the B 23 points.
Dr. Gach says you can use your thumbs or fingers to work the points, pressing one or both B 47 points for one minute, then one or both B 23 points for one minute. He says to use this remedy three times daily. He adds that if you have a weak back, press these points lightly, and be sure not to press directly on the disks or vertebrae.

Aromatherapy

Jasmine is often inhaled for its aphrodisiac qualities, writes San Francisco herbalist Jeanne Rose, chairperson of the National Association for Holistic Aromatherapy, in her book Aromatherapy: Applications and Inhalations. Because the oil is expensive, Rose suggests using it in a candle diffuser to make it last longer. It can also be inhaled from a handkerchief or applied directly to the body.

Ayurveda

Here’s a treatment regimen recommended by Vasant Lad, B.A.M.S., M.A.Sc., director of the Ayurvedic Institute in Albuquerque, New Mexico: Mix one cup of fresh grape juice with one teaspoon of fresh onion juice and one teaspoon of honey. Drink this mixture daily, one hour before going to bed, for 45 days. Dr. Lad says it will help increase sexual energy and sperm count.

Herbal Medicine

Herbal medicines usually do not have significant side effects when used appropriately and at suggested doses. Occasionally, an herb at the prescribed dose causes stomach upset or a headache. This may reflect the purity of the preparation or added ingredients, such as synthetic binders or fillers. For this reason, it is recommended that only high-quality products be used. As with all medications, more is not better and overdosing can lead to serious illness and death.
These herbs may be used to treat erectile dysfunction:

Asian ginseng (Panax ginseng) – Traditionally used for male impotence, though no current studies support this usage.
Damiana (Turnera diffusa) – Traditionally used as an aphrodisiac and for various sexual disorders; however, there are no current studies to confirm its effectiveness.
Ginkgo biloba – Increases arterial blood flow, which may have a positive effect on male sexual function.
Muira puama (Ptychopetalum olacoides) – Used for erectile dysfunction and lack of libido.

Reflexology

Pay special attention to the diaphragm reflex as well as to the spine, reproductive system and pituitary, parathyroid, thyroid and adrenal gland reflexes on your feet, says St. Petersburg, Florida, reflexologist Dwight Byers, author of Better Health with Foot Reflexology.

Physical Medicine

Kegel exercises – Increase pelvic blood flow and muscle tone.
Exercise – Aerobic exercise and weight training support the cardiovascular system, increase overall energy, and promote relaxation while at rest.

Sources: wikipedia, mothernature, urologychannel, National Kidney and Urologic Diseases Information Clearinghouse

Impotence (Erectile dysfunction), Natural and Conventional Treatments