Psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure cause 10-20 % of ED cases. Men with physical cause for ED frequently experience same sort of psychological reactions (stress, anxiety, guilt, depression). Other possible causes are smoking, which affects blood flow in blood vessels, and hormonal abnormalities, such as low testosterone.

Diagnosis

Patient History
Medical and sexual history helps to define the degree and nature of ED. Medical history can disclose the diseases that lead to ED, while a simple recounting of sexual activity might distinguish among the problems with sexual desire, erection, ejaculation, or orgasm. Using certain prescription or illegal drugs can suggest a chemical cause.

Physical Examination
Physical examination can give clues towards systemic problems. For example, if the penis is not sensitive to touch, a problem in the nervous system may be the cause. Abnormal secondary sex characteristics such as hair pattern or breast enlargement can point to hormonal problems, which would mean that the endocrine system is involved. The examiner might discover circulatory problem by observing decreased pulse in wrist or ankle. Unusual characteristics of the penis itself could suggest the source of the problem- for example, penis that bends or curves when erect could be due to Peyronie’s disease.

Laboratory Tests
Several laboratory tests can help diagnose ED. Tests for systemic diseases include blood count, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. Measuring the amount of free testosterone in the blood can yield information about problems with the endocrine system and is indicated especially in patients with decreased sexual desire.

Other Tests
Monitoring the erections that occur during sleep (nocturnal penile tumescence) can help rule out certain psychological causes of ED. Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then ED is likely to have a physical rather than psychological cause. Tests of nocturnal erections are not completely reliable.

Psychosocial Examination
Psychosocial examination comprising of an interview and a questionnaire reveals psychological factors. Patient’s sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.

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 their sexual function.

• Cutting back on the drugs having harmful side effects is considered the next step. 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
• locally injected drugs.
• vaccum devices
• Surgically implanted devices.
• In rare cases, surgery involving blood vessels may be considered.

Psychotherapy
Experts often treat psychological ED using techniques that decrease anxiety associated with intercourse. Patient’s partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques can also help to relieve anxiety when ED from physical cause is being treated.

Drug Therapy

• Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra from the tip of the penis. In March 1998, the Food and Drug Administration (FDA) approved Viagra, the first pill to treat ED.

Sildenafil

Tadalafil

Vardenafil

• Many men achieve strong erection by injecting drug into the penis causing it to become engorged with blood. Drugs such as Papaverine Hydrochloride, Phentolamine and Alprostadil (marketed as Caverject) widen the blood vessels. However, these drugs may create unwanted side effects including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed on the penis.

• A system for inserting a pellet of Alprostadil into the urethra is marketed as ‘Muse’. This system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection begins within 8-10 minutes and may last till 30 – 60 minutes. The most common side effects are aching in the penis, testicles, and area between penis and rectum; warmth or burning sensation in urethra; redness due to increased blood flow to the penis; and minor urethral bleeding or spotting.

Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances.

Vaccum Devices
Mechanical vaccum devices cause erection by creating a partial vacuum, which draws blood into the penis, engorging and expanding it. These devices have 3 components: plastic cylinder to place the penis, pump to draw air out of the cylinder, and an elastic band placed around the base of the penis to maintain the erection after the cylinder is removed and during intercourse by preventing blood from flowing back into the body.

Surgery

Surgery usually has 1 out of 3 goals:

• to implant a device that can make penis to become erect
• to reconstruct arteries to increase blood flow 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 adjusts the position of the penis manually 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 to some extent. They also leave the penis in a more natural state when not inflated.

Surgery to repair arteries can reduce ED caused by obstruction that blocks the blood flow. 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 of veins that allow blood to leave the penis usually involves an opposite procedure, intentional blockage. Blocking off the 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.