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Erectile Dysfunction
 Erectile dysfunction or ED is the inability to achieve or sustain an erection suitable for sexual intercourse. Problems with erections may stem from medications, chronic illnesses, poor blood flow to the penis, drinking too much alcohol, or being too tired. Lifestyle changes, medications, and other treatments are often used to treat ED.
According to the National Institutes of Health, approximately 5 percent of 40-year-old men and between 15 and 25 percent of 65-year-old men experience ED on a long-term basis.

A much more common problem that affects the majority of men at some point in their life is the occasional failure to achieve an erection, which can occur for a variety of reasons, such as from drinking too much alcohol or from being extremely tired.

Failure to achieve an erection less than 20% of the time is not unusual and treatment is rarely needed. Failure to achieve an erection more than 50% of the time, however, generally indicates there is a problem requiring treatment.

What Causes ED?
In order to achieve an erection three conditions must occur: The nerves to the penis must be functioning properly; the blood circulation to the penis must be adequate; there must be a stimulus from the brain. If there is something interfering with any or all of these conditions, a full erection will be prevented.

Common causes of ED include diseases that affect blood flow, such as atherosclerosis (hardening of the arteries); nerve diseases, psychological factors, such as stress, depression, and performance anxiety; and injury to the penis. Chronic illness, certain medications and a condition called Peyronie's disease (scar tissue in the penis) can also cause ED.

Can ED Be Prevented?
For people who are at risk of developing ED due to personal behavior, such as drinking too much alcohol, steps may be taken to prevent its occurrence. However, other causes of ED may not be preventable.

What Doctors Treat ED?
The type of medical specialist who treats ED will depend on the cause of the problem. Based on your family's medical history as well as your own medical history and current health, your doctor may treat you with oral medications such as Viagra or similar drugs. If this fails, he or she may refer you to a urologist or psychologist.

What Should I Do If I am Having Problems Achieving/Maintaining an Erection?
If you suspect you may have erectile dysfunction, see your doctor. He or she can perform a variety of tests to identify what is causing your problem and refer you to a specialist if needed. Once the cause is identified, there are several treatments to consider.

How Is Erectile Dysfunction Treated?
There are many different ways ED can be treated, including oral medications, sex therapy, penile injections, suppositories, vacuum pumps, and surgery. Each type of treatment has its own advantages and disadvantages. Talk to your doctor to determine the best treatment for you.

Does Insurance Cover ED Treatment?
Insurance coverage of ED depends upon the type of treatment prescribed. If there is a documented medical condition that is shown to be causing ED, insurance will usually cover at least some of it. Sex therapy and medications that have not yet been approved by the FDA, however, are generally not covered. Talk to your insurance provider to determine if the treatment you are considering will be covered

Physical Causes of Erectile Dysfunction
The process of achieving an erection is complex and problems may occur for a variety of reasons. These problems can be psychological, physical, or a combination of the two.

Physical causes of ED are related to a breakdown or damage to the sequence of events that lead to an erection. This sequence involves nerve impulses in the brain, spine, and penis as well as the subsequent response in the muscles, fibrous tissues, veins and arteries in and near the corpora cavernosa.

Often times the breakdown or damage in the sequence affects the arteries, muscles, and surrounding tissues of the penis, and this breakdown is most commonly the result of a disease. Diseases that commonly cause ED include:

Diabetes: Diabetes can cause nerve and artery damage that can make achieving an erection difficult. Between 35% and 50% of men with diabetes experience ED, according the National Institutes of Health. Some estimates are higher, stating that up to 75% of men with diabetes will experience at least some degree of ED during their lifetime and the risk increases with age.
Kidney disease: Kidney disease can cause chemical changes to occur in your body that affect hormones, circulation, nerve function, and energy level. Often times these changes will lower a person's libido (sex drive) or sexual ability. Drugs used to treat kidney disease may also cause ED.
Neurological (nerve and brain) diseases: The nervous system (the body's system of nerves) plays a vital part in achieving and maintaining an erection and it is common for men with diseases such as stroke, multiple sclerosis (MS), Alzheimer's disease, Parkinson's disease and spinal cord injuries to experience ED. This is due to an interruption in the transmission of nerve impulses between the brain and the penis.
Vascular disease: Vascular diseases are those that affect the blood vessels. These diseases include atherosclerosis (hardening of the arteries), hypertension, and high cholesterol. These diseases, which account for 70% of physically-related causes of ED, all restrict blood flow to the heart, the brain and, in the case of ED, the penis.
Prostate cancer: Prostate cancer doesn't cause ED on its own, but treatment (radiation, hormonal manipulation, or surgery to remove the cancer) can lead to erectile problems.
The physical causes of ED are not only disease-related. There are many other potential causes, including:

Surgery: Surgery performed to treat diseases such as prostate cancer and bladder cancer often require the removal of nerves and tissues around the affected area which can lead to ED. Some of these surgeries result in only temporary problems (lasting 6-18 months) while others result in permanent damage to the nerves and tissue around the penis and require treatment in order for an erection to be achieved.
Injury: Injuries to the pelvis, bladder, spinal cord, and penis that require surgery also commonly cause ED.
Hormonal imbalances: Imbalances of hormones, such as thyroid hormones, prolactin, and testosterone, can affect a man's response to sexual stimulation. These imbalances can be the result of a tumor of the pituitary gland, kidney disease, liver disease, or hormonal treatment of prostate cancer.
Venous leak: If the veins in the penis cannot prevent blood from leaving the penis during an erection, an erection cannot be maintained. This is known as a venous leak, and can be a result of injury or disease.
Tobacco, alcohol or drug use: All three of these substances can damage a person's blood vessels and/or restrict blood flow to the penis, causing ED. Smoking in particular plays a large role in causing ED in people with arteriosclerosis.
Prescription drugs: There are over 200 types of prescription drugs that may cause ED.
Prostate enlargement: Bladder neck obstruction due to prostate enlargement has recently been implicated in being associated with varying degrees of ED.
Erectile Dysfunction: Where to Start
Day One ... We're here to help.
The doctor says you have erectile dysfunction (ED). It sounds terrible, but it's not the end of your sex life. In fact, your sex life probably is about to get much better.

You may have a referral to a urologist, a doctor who specializes in treating this condition, for more tests. You may already have a trial prescription for Viagra or similar drugs. Whatever you're doing next, the most important thing to remember is that you aren't in this alone.

Your partner is affected by the problem, and is an important part of the solution. Nothing is going to help you more than talking with your partner about what works, and doesn't work, for both of you.

Of Drugs and Devices
An erection starts in the brain, where arousal signals trigger a chemical chain reaction. This process results in relaxation of the muscle in the blood vessel walls that keeps blood from flowing into the penis. Lots of different things can go wrong along the way, which is why there are so many different causes of ED.

If you have erectile dysfunction, Viagra or similar drugs like Cialis and Levitra may very well solve your problem. These drugs help the arousal signal from the brain do what it's supposed to do. They don't give you an erection, but they let you have one. You and your partner will have to adjust to using these medicines.

While these medications work for many people with erectile dysfunction, they don't work for everyone. It is also important to know that not everyone is a suitable candidate for these drugs. If these issues are true in your case, there are other options to consider.

To bypass roadblocks along the brain-to-penis highway, drugs can be injected or inserted directly into the penis. While some men find this painful to think about, many others find that it can restore a satisfying sex life and is highly effective.

One simple device now making a comeback is the penile pump. It's a vacuum pump that lets a man draw blood into the penis. A constriction ring placed at the base of the penis keeps the penis erect during intercourse.

Other men prefer to undergo surgery for the insertion of a penile implant. The simplest and most durable of these is a flexible rod that allows the penis to be folded away when not in use. Other men prefer a fluid-filled implant that lets them pump the penis erect.

Sexuality
Learning to overcome ED is like learning any sexual skill; it takes patience, practice, and a partner. Solving erection problems is only a part of regaining a satisfying sex life. You and your partner have a whole world of erotic possibilities to explore. Remember the sexiest word in the language: communication.

Erectile Dysfunction: Diagnosing Erectile Dysfunction
Because there are a variety of causes for ED, there are several different tests your doctor may use to diagnose the condition and determine its cause. Only after the cause of ED is determined can it be effectively treated.

Before ordering any tests, your doctor will review your medical history and perform a thorough physical examination. The doctor will also "interview" you about your personal and sexual history. Some of these questions will be very personal and may feel intrusive. However, it is important that you answer these questions honestly. The questions asked may include:

What medications or drugs are you currently using? This includes prescription drugs, over-the-counter drugs, herbal supplements, dietary supplements, and illegal drugs or alcohol.
Have you had any psychological problems such as stress, anxiety and depression?
When did you first notice symptoms of ED?
What are the frequency, quality, and duration of any erections you have had?
What are the specifics of the circumstances under which ED first occurred?
Do/did you experience erections at night or during the morning?
What sexual techniques do you use?
Are there problems in your current relationship?
Do you have more than one sexual partner?
If you have more than one partner, do you experience ED with one or both?
The doctor may also wish to interview your sexual partner since your partner may be able to offer in sight about the underlying causes.

After your physical examination and interview, your doctor may then order any one of the following tests:

Complete blood count (CBC): This is a set of blood tests that, among other things, can detect the presence of anemia. Anemia is caused by a low red blood cell count and can cause fatigue, which in turn can cause ED.
Liver and kidney function tests: These blood tests may indicate whether ED may be due to your kidneys or liver functioning improperly.
Lipid profile: This blood test measures the level of lipids (fats), like cholesterol. High levels may indicate atherosclerosis (hardening of the arteries), which can affect blood circulation in the penis.
Thyroid function test: One of the thyroid hormones' functions is to regulate the production of sex hormones, and a deficiency in these hormones may contribute to or cause ED.
Blood hormone studies: Testosterone and/or prolactin levels in the blood may be measured to see if abnormalities in either of these sex hormones are present.
Urinalysis: Analysis of urine can provide a wealth of information, including information on protein, sugar, and testosterone levels. Abnormal measurements of these substances can indicate diabetes, kidney disease, or a testosterone deficiency, all of which can cause ED.
Duplex ultrasound: This is perhaps the best test for evaluating ED. An ultrasound uses high-frequency sound waves to take "pictures" of the body's tissues. For people with ED, an ultrasound may be used to evaluate blood flow and check for signs of a venous leak, artherosclerosis or tissue scarring. This test is performed both while the penis is erect (usually induced by an injection of a drug that stimulates erection) and also while it is soft.

Nocturnal penile tumescence (NPT): This test measures a man's erectile function while he is sleeping. Normally, a man will have five or six erections while asleep. A lack of these erections may indicate there is a problem with nerve function or circulation to the penis. The test uses two methods, the snap gauge method and the strain gauge method. The snap gauge method is performed by wrapping three plastic bands of varying strength around the penis. Erectile function is then measured based on which of the three bands breaks. The strain gauge method works by placing elastic bands around the tip and base of the penis. If the penis becomes erect during the night, the bands stretch, measuring the changes in penile circumference.
Penile biothesiometry: This test involves the use of electromagnetic vibration to determine sensitivity and nerve function. A decreased sensitivity to these vibrations may indicate nerve damage.
Vasoactive injection: During this test, an erection is produced by injecting special solutions that cause the blood vessels to dilate (enlarge), allowing blood to enter the penis.
Dynamic infusion cavernosometry: This test is used for men with ED who have a venous leak. During this test, fluid is pumped into the penis at a predetermined rate. By measuring the rate at which fluid must be pumped to attain a rigid erection, doctors can determine the severity of the venous leak.
Cavernosography: Used in conjunction with the dynamic infusion cavernosometry, this test involves injecting a dye into the penis. The penis is then X-rayed so that the venous leak can be seen.
Arteriography: This test is given to people who are candidates for vascular reconstructive surgery. A dye is injected into the artery believed to be damaged and X-rays are taken.
Complete blood count (CBC): This is a set of blood tests that, among other things, can detect the presence of anemia. Anemia is caused by a low red blood cell count and can cause fatigue, which in turn can cause ED.
Liver and kidney function tests: These blood tests may indicate whether ED may be due to your kidneys or liver functioning improperly.
Lipid profile: This blood test measures the level of lipids (fats), like cholesterol. High levels may indicate atherosclerosis (hardening of the arteries), which can affect blood circulation in the penis.
Thyroid function test: One of the thyroid hormones' functions is to regulate the production of sex hormones, and a deficiency in these hormones may contribute to or cause ED.
Blood hormone studies: Testosterone and/or prolactin levels in the blood may be measured to see if abnormalities in either of these sex hormones are present.
Urinalysis: Analysis of urine can provide a wealth of information, including information on protein, sugar, and testosterone levels. Abnormal measurements of these substances can indicate diabetes, kidney disease, or a testosterone deficiency, all of which can cause ED.
Duplex ultrasound: This is perhaps the best test for evaluating ED. An ultrasound uses high-frequency sound waves to take "pictures" of the body's tissues. For people with ED, an ultrasound may be used to evaluate blood flow and check for signs of a venous leak, artherosclerosis or tissue scarring. This test is performed both while the penis is erect (usually induced by an injection of a drug that stimulates erection) and also while it is soft.
Bulbocavernosus reflex: This test evaluates nerve sensation in the penis. During the test, your doctor will squeeze the head of your penis, which should immediately cause your rectum to contract. If nerve function is abnormal, there will be a delay in response time or absence of rectal contraction.
Nocturnal penile tumescence (NPT): This test measures a man's erectile function while he is sleeping. Normally, a man will have five or six erections while asleep. A lack of these erections may indicate there is a problem with nerve function or circulation to the penis. The test uses two methods, the snap gauge method and the strain gauge method. The snap gauge method is performed by wrapping three plastic bands of varying strength around the penis. Erectile function is then measured based on which of the three bands breaks. The strain gauge method works by placing elastic bands around the tip and base of the penis. If the penis becomes erect during the night, the bands stretch, measuring the changes in penile circumference.
Penile biothesiometry: This test involves the use of electromagnetic vibration to determine sensitivity and nerve function. A decreased sensitivity to these vibrations may indicate nerve damage.
Vasoactive injection: During this test, an erection is produced by injecting special solutions that cause the blood vessels to dilate (enlarge), allowing blood to enter the penis.
Dynamic infusion cavernosometry: This test is used for men with ED who have a venous leak. During this test, fluid is pumped into the penis at a predetermined rate. By measuring the rate at which fluid must be pumped to attain a rigid erection, doctors can determine the severity of the venous leak.
Cavernosography: Used in conjunction with the dynamic infusion cavernosometry, this test involves injecting a dye into the penis. The penis is then X-rayed so that the venous leak can be seen.
Arteriography: This test is given to people who are candidates for vascular reconstructive surgery. A dye is injected into the artery believed to be damaged and X-rays are taken.
PSA: This test may be abnormal due to prostate enlargement or infection, which may complicate ED.

Erectile Dysfunction: Lifestyle Changes to Improve ED
One way to improve erectile dysfunction is to make some simple lifestyle changes. For some men, adopting a healthier lifestyle, such as quitting smoking, exercising regularly, and reducing stress, may be all that is needed to find relief. For those who require more intensive treatment, adopting these

Quit Smoking
Quitting smoking can be very difficult and there is no single best way to quit that works for all people. Some approaches to try that might help you kick the habit include:

Pick a quitting date one to three weeks in the future. Prepare for the date by cutting down on smoking, staying away from your favorite places to smoke, and making a plan for how you will deal with stressful events without smoking.
On your quitting date, get rid of all cigarettes, keep busy, and stay in smoke-free places.
Talk to your doctor to see if you should try nicotine replacement therapy. The nicotine patch, nicotine gum, or other medication can be helpful but they will not take away your cravings to smoke.
Make a clean break. Do not allow yourself to smoke "now and then." An addiction to nicotine can be reactivated anytime, even years after quitting.
Take it one moment, one hour, one day at time. Cravings to smoke are usually short-lived and will go away whether or not you have a cigarette.
Get help with quitting if you need it. Choose a comprehensive smoking cessation program that does not rely on a single technique (such as hypnosis). Your doctor can point you in the right direction.
Exercise Regularly
Regular exercise can improve your health in many ways. Along with improving erectile function, exercise can:

Strengthen the heart.
Improve the flow of oxygen in the blood.
Build energy levels.
Lower blood pressure.
Improve muscle tone and strength.
Strengthen and build bones.
Help reduce body fat.
Help reduce stress, tension, anxiety and depression.
Boost self-image and self-esteem.
Improve sleep.
Make you feel more relaxed and rested.
Make you look fit and healthy.
To get the most benefit, you should exercise at least 20 to 30 minutes, preferably on most days of the week. Current studies suggest that at least five times a week is best. If you are a beginner, exercise for a few minutes each day and build up to 30 minutes.

When starting out, you should plan a routine that is easy to follow and stick with. As the program becomes more routine, you can vary your exercise times and activities. Here are some tips to get you started.

Choose an activity you enjoy. Exercising should be fun not a chore.
Schedule regular exercise into your daily routine. Add a variety of exercises so that you do not get bored. Look into scheduled exercise classes at your local community center.
Exercise does not have to put a strain on your wallet. Avoid buying expensive equipment or health club memberships unless you are certain you will use them regularly.
Stick with it. If you exercise regularly, it will soon become part of your lifestyle.
If you feel you need supervision or medical advice to begin an exercise program, ask your doctor to refer you to physical therapy. A physical therapist can evaluate your needs and start you on a safe and effective exercise program

Erectile Dysfunction: Lifestyle Changes to Improve ED
(continued)
Reduce Stress
Stress is common to everyone. Our bodies are designed to feel stress and react to it. It keeps us alert and ready to avoid danger. But it is not always possible to avoid or change events that may cause stress and it is easy to feel trapped and unable to cope. When stress persists, the body begins to break down and illnesses can occur. The key to coping with stress is to identify stressors in your life and learn ways to direct and reduce stress.

Learning an effective means of relaxation and using it regularly is a good first step. Allow yourself some "quiet time," even if it's just a few minutes. Examine and modify your thinking, particularly unrealistic expectations. Talking problems out with a friend or family member can help put things in proper perspective. Seeking professional assistance can help you gain a new perspective on how to manage some of the more difficult forms of stress. Other approaches to reducing stress include:

Keep a positive attitude. Believe in yourself.
Accept that there are events you cannot control.
Be assertive instead of aggressive. "Assert" your feelings, opinions or beliefs instead of becoming angry, combative or passive.
Learn to relax.
Exercise regularly. Your body can fight stress better when it is fit.
Eat well-balanced meals.
Stop smoking.
Limit or avoid use of alcohol and caffeine.
Set realistic goals and expectations.
Get enough rest and sleep. Your body needs time to recover from stressful events.
Don't rely on alcohol or drugs to reduce stress.
Learn to use stress management techniques and coping mechanisms, such as deep breathing or guided imagery.