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Wikipedia

Erectile dysfunction

December 02, 2023

Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a penile erection with sufficient rigidity and duration for satisfactory sexual activity. It is the most common sexual problem in males and can cause psychological distress due to its impact on self-image and sexual relationships. Majority of ED cases are attributed to physical risk factors and predictive factors. These factors can be categorized as vascular, neurological, local penile, hormonal, and drug-induced. Notable predictors of ED include aging, cardiovascular disease, diabetes mellitus, high blood pressure, obesity, abnormal lipid levels in the blood, hypogonadism, smoking, depression, and medication use. Approximately 10% of cases are linked to psychosocial factors, encompassing conditions like depression, stress, and problems within relationships.[14]

Erectile dysfunction
Other namesImpotence
SpecialtyUrology, sexual medicine, andrology
SymptomsInability to gain or maintain an erection
CausesLow testosterone levels,[1][2] certain prescription drugs,[3][4] neurogenic disorders[3][4][5][2]
Risk factorsCardiovascular disease, diabetes, smoking, stress,[6] mental disorders,[6] ageing,[1] high saturated fat diet,[7][8] kidney disease[9]
Diagnostic methodDepends if psychological or physiological; absence of involuntary erections suggests physiological[4]
Differential diagnosisHypogonadism,[4] prolactinoma[4]
PreventionAdequate exercise[10]
TreatmentPenis pump,[11] counseling (psychological treatment)[12]
MedicationSildenafil[13]

It is worth noting that the term erectile dysfunction does not encompass other erection-related disorders, such as priapism.

Treatment of ED encompasses addressing the underlying causes, lifestyle modification, and addressing psychosocial issues.[4] In many instances, medication-based therapies are used, specifically PDE5 inhibitors like sildenafil.[13] These drugs function by dilating blood vessels, facilitating increased blood flow into the spongy tissue of the penis, analogous to opening a valve wider to enhance water flow in a fire hose. Less frequently employed treatments encompass prostaglandin pellets inserted into the urethra, the injection of smooth-muscle relaxants and vasodilators directly into the penis, penile implants, the use of penis pumps, and vascular surgery.[4][15]

ED is reported in 18% of males aged 50 to 59 years, and 37% in males aged 70 to 75.[14]

Signs and symptoms

ED is characterized by the persistent or recurring inability to achieve or maintain an erection of the penis with sufficient rigidity and duration for satisfactory sexual activity.[14] It is defined as the "persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity for at least 3 months."[4]

Psychological impact

ED often has an impact on the emotional well-being of both males and their partners.[14] Many males do not seek treatment due to feelings of embarrassment. About 75% of diagnosed cases of ED go untreated.[16]

Causes

Causes of or contributors to ED include the following:

Surgical intervention for a number of conditions may remove anatomical structures necessary to erection, damage nerves, or impair blood supply.[25] ED is a common complication of treatments for prostate cancer, including prostatectomy and destruction of the prostate by external beam radiation, although the prostate gland itself is not necessary to achieve an erection. As far as inguinal hernia surgery is concerned, in most cases, and in the absence of postoperative complications, the operative repair can lead to a recovery of the sexual life of people with preoperative sexual dysfunction, while, in most cases, it does not affect people with a preoperative normal sexual life.[33]

ED can also be associated with bicycling due to both neurological and vascular problems due to compression.[34] The increased risk appears to be about 1.7-fold.[35]

Concerns that use of pornography can cause ED[36] have little support[37][38] in epidemiological studies, according to a 2015 literature review.[39] According to Gunter de Win, a Belgian professor and sex researcher, "Put simply, respondents who watch 60 minutes a week and think they're addicted were more likely to report sexual dysfunction than those who watch a care-free 160 minutes weekly."[40][41]

In seemingly rare cases, medications such as SSRIs, isotretinoin (Accutane) and finasteride (Propecia) are reported to induce long-lasting iatrogenic disorders characterized by sexual dysfunction symptoms, including erectile dysfunction in males; these disorders are known as post-SSRI sexual dysfunction (PSSD), post-retinoid sexual dysfunction/post-Accutane syndrome (PRSD/PAS), and post-finasteride syndrome (PFS). These conditions remain poorly understood and lack effective treatments, although they have been suggested to share a common etiology.[42]

Pathophysiology

Penile erection is managed by two mechanisms: the reflex erection, which is achieved by directly touching the penile shaft, and the psychogenic erection, which is achieved by erotic or emotional stimuli. The former involves the peripheral nerves and the lower parts of the spinal cord, whereas the latter involves the limbic system of the brain. In both cases, an intact neural system is required for a successful and complete erection. Stimulation of the penile shaft by the nervous system leads to the secretion of nitric oxide (NO), which causes the relaxation of the smooth muscles of the corpora cavernosa (the main erectile tissue of the 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 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.[2] Spinal cord injury causes sexual dysfunction, including ED. Restriction of blood flow can arise from impaired endothelial function due to the usual causes associated with coronary artery disease, but can also be caused by prolonged exposure to bright light.[citation needed]

Diagnosis

In many cases, the diagnosis can be made based on the person's history of symptoms. In other cases, a physical examination and laboratory investigations are done to rule out more serious causes such as hypogonadism or prolactinoma.[4]

One of the first steps is to distinguish between physiological and psychological ED. Determining whether involuntary erections are present is important in eliminating the possibility of psychogenic causes for ED.[4] Obtaining full erections occasionally, such as nocturnal penile tumescence when asleep (that is, when the mind and psychological issues, if any, are less present), tends to suggest that the physical structures are functionally working.[43][44] Similarly, performance with manual stimulation, as well as any performance anxiety or acute situational ED, may indicate a psychogenic component to ED.[4]

Another factor leading to ED is diabetes mellitus, a well known cause of neuropathy.[4] ED 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.[4] Screening for cardiovascular risk factors, such as smoking, dyslipidemia, hypertension, and alcoholism, is helpful.[4]

In some cases, the simple search for a previously undetected groin hernia can prove useful since it can affect sexual functions in males and is relatively easily curable.[33]

The current diagnostic and statistical manual of mental diseases (DSM-IV) lists ED.

Ultrasonography

 
Transverse ultrasound image, ventral view of the penis. Image obtained after induction of an erection, 15 min after injection of prostaglandin E1, showing dilated sinusoids (arrows).[45]

Penile ultrasonography with doppler can be used to examine the erect penis. Most cases of ED of organic causes are related to changes in blood flow in the corpora cavernosa, represented by occlusive artery disease (in which less blood is allowed to enter the penis), most often of atherosclerotic origin, or due to failure of the veno-occlusive mechanism (in which too much blood circulates back out of the penis). Before the Doppler sonogram, the penis should be examined in B mode, in order to identify possible tumors, fibrotic plaques, calcifications, or hematomas, and to evaluate the appearance of the cavernous arteries, which can be tortuous or atheromatous.[45]

Erection can be induced by injecting 10–20 µg of prostaglandin E1, with evaluations of the arterial flow every five minutes for 25–30 min (see image). The use of prostaglandin E1 is contraindicated in patients with predisposition to priapism (e.g., those with sickle cell anemia), anatomical deformity of the penis, or penile implants. Phentolamine (2 mg) is often added. Visual and tactile stimulation produces better results. Some authors recommend the use of sildenafil by mouth to replace the injectable drugs in cases of contraindications, although the efficacy of such medication is controversial.[45]

Before the injection of the chosen drug, the flow pattern is monophasic, with low systolic velocities and an absence of diastolic flow. After injection, systolic and diastolic peak velocities should increase, decreasing progressively with vein occlusion and becoming negative when the penis becomes rigid (see image below). The reference values vary across studies, ranging from > 25 cm/s to > 35 cm/s. Values above 35 cm/s indicate the absence of arterial disease, values below 25 cm/s indicate arterial insufficiency, and values of 25–35 cm/s are indeterminate because they are less specific (see image below). The data obtained should be correlated with the degree of erection observed. If the peak systolic velocities are normal, the final diastolic velocities should be evaluated, those above 5 cm/s being associated with venogenic ED.[45]

  •  

    Graphs representing the color Doppler spectrum of the flow pattern of the cavernous arteries during the erection phases. A: Single-phase flow with minimal or absent diastole when the penis is flaccid. B: Increased systolic flow and reverse diastole 25 min after injection of prostaglandin.[45]

  •  

    Longitudinal, ventral ultrasound of the penis, with pulsed mode and color Doppler. Flow of the cavernous arteries at 5, 15, and 25 min after prostaglandin injection (A, B, and C, respectively). The cavernous artery flow remains below the expected levels (at least 25–35 cm/s), which indicates ED due to arterial insufficiency.[45]

Other workup methods

Penile nerves function
Tests such as the bulbocavernosus reflex test are used to ascertain whether there is enough 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 in the anus.[46]
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. A significant proportion[quantify] of males who have no sexual dysfunction nonetheless do not have regular nocturnal erections.[citation needed]
Penile biothesiometry
This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glans and shaft of the penis.[47]
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.[citation needed]
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 visualized by infusing a mixture of saline and x-ray contrast medium and performing a cavernosogram.[48] In Digital Subtraction Angiography (DSA), the images are acquired digitally.[citation needed]
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. The doctor may inject into the patient's bloodstream a contrast agent, which causes vascular tissues to stand out against other tissues, so that information about blood supply and vascular anomalies is easier to gather.[citation needed]

Treatment

 
One ad from 1897 claims to restore "perfect manhood. Failure is impossible with our method".[49] Another "will quickly cure you of all nervous or diseases of the generative organs, such as Lost Manhood, Insomnia, Pains in the Back, Seminal Emissions, Nervous Debility, Pimples, Unfitness to Marry, Exhausting Drains, Varicocele and Constipation".[49] The U.S. Federal Trade Commission warns that "phony cures" exist even today.[50]

Treatment depends on the underlying cause. In general, exercise, particularly of the aerobic type, is effective for preventing ED during midlife.[10] Counseling can be used if the underlying cause is psychological, including how to lower stress or anxiety related to sex.[12] Medications by mouth and vacuum erection devices are first-line treatments,[10]: 20, 24  followed by injections of drugs into the penis, as well as penile implants.[10]: 25–26  Vascular reconstructive surgeries are beneficial in certain groups.[51] Treatments, other than surgery, do not fix the underlying physiological problem, but are used as needed before sex.[52]

Medications

The PDE5 inhibitors sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) are prescription drugs which are taken by mouth.[10]: 20–21  As of 2018, sildenafil is available in the UK without a prescription.[53] Additionally, a cream combining alprostadil with the permeation enhancer DDAIP has been approved in Canada as a first line treatment for ED.[54] Penile injections, on the other hand, can involve one of the following medications: papaverine, phentolamine, and prostaglandin E1, also known as alprostadil.[10] In addition to injections, there is an alprostadil suppository that can be inserted into the urethra. Once inserted, an erection can begin within 10 minutes and last up to an hour.[12] Medications to treat ED may cause a side effect called priapism.[12]

Prevalence of medical diagnosis

In a study published in 2016, based on US health insurance claims data, out of 19,833,939 US males aged ≥18 years, only 1,108,842 (5.6%), were medically diagnosed with erectile dysfunction or on a PDE5I prescription (μ age 55.2 years, σ 11.2 years). Prevalence of diagnosis or prescription was the highest for age group 60–69 at 11.5%, lowest for age group 18–29 at 0.4%, and 2.1% for 30–39, 5.7% for 40–49, 10% for 50–59, 11% for 70–79, 4.6% for 80–89, 0.9% for ≥90, respectively.[55]

Focused shockwave therapy

Focused shockwave therapy involves passing short, high frequency acoustic pulses through the skin and into the penis. These waves break down any plaques within the blood vessels, encourage the formation of new vessels, and stimulate repair and tissue regeneration.[56][57]

Focused shockwave therapy appears to work best for males with vasculogenic ED, which is a blood vessel disorder that affects blood flow to tissue in the penis. The treatment is painless and has no known side effects. Treatment with shockwave therapy can lead to a significant improvement of the IIEF (International Index of Erectile Function).[58][59][60]

Testosterone

 
Testosterone Supplementation - Content 88 g Gel

Men with low levels of testosterone can experience ED. Taking testosterone may help maintain an erection.[61] males with type 2 diabetes are twice as likely to have lower levels of testosterone, and are three times more likely to experience ED than non-diabetic men.[61]

Pumps

Main article: penis pump

A vacuum erection device helps draw blood into the penis by applying negative pressure. This type of device is sometimes referred to as penis pump and may be used just prior to sexual intercourse. Several types of FDA approved vacuum therapy devices are available under prescription. When pharmacological methods fail, a purpose-designed external vacuum pump can be used to attain erection, with a separate compression ring fitted to the base of the penis to maintain it. These pumps should be distinguished from other penis pumps (supplied without compression rings) which, rather than being used for temporary treatment of impotence, are claimed to increase penis length if used frequently, or vibrate as an aid to masturbation. More drastically, inflatable or rigid penile implants may be fitted surgically.[11]

Vibrators

Main article: Vibrator (sex toy)

The vibrator was invented in the late 19th century as a medical instrument for pain relief and the treatment of various ailments. Sometimes described as a massager, the vibrator is used on the body to produce sexual stimulation. Several clinical studies have found vibrators to be an effective solution for Erectile Dysfunction.[62][63] Examples of FDA registered vibrators for erectile dysfunction include MysteryVibe's Tenuto[64] and Reflexonic's Viberect.[65]

Surgery

Main article: Penile implant

Often, as a last resort, if other treatments have failed, the most common procedure is prosthetic implants which involves the insertion of artificial rods into the penis.[10]: 26  Some sources show that vascular reconstructive surgeries are viable options for some people.[51]

Alternative medicine

The Food and Drug Administration (FDA) does not recommend alternative therapies to treat sexual dysfunction.[66] Many products are advertised as "herbal viagra" or "natural" sexual enhancement products, but no clinical trials or scientific studies support the effectiveness of these products for the treatment of ED, and synthetic chemical compounds similar to sildenafil have been found as adulterants in many of these products.[67][68][69][70][71] The FDA has warned consumers that any sexual enhancement product that claims to work as well as prescription products is likely to contain such a contaminant.[72] A 2021 review indicated that ginseng had "only trivial effects on erectile function or satisfaction with intercourse compared to placebo".[73]

History

 
An unhappy wife is complaining to the qadi about her husband's impotence. Ottoman miniature.

Attempts to treat ED date back well over 1,000 years. In the 8th century, males of Ancient Rome and Greece wore talismans of rooster and goat genitalia, believing these talismans would serve as an aphrodisiac and promote sexual function.[74] In the 13th century Albertus Magnus recommended ingesting roasted wolf penis as a remedy for impotence.[74]

During the late 16th and 17th centuries in France, male impotence was considered a crime, as well as legal grounds for a divorce. The practice, which involved inspection of the complainants by court experts, was declared obscene in 1677.[75][76]

The first successful vacuum erection device, or penis pump, was developed by Vincent Marie Mondat in the early 1800s.[74] A more advanced device, based on a bicycle pump, was developed by Geddings Osbon, a Pentecostal preacher, in the 1970s. In 1982, he received FDA approval to market the product as the ErecAid®.[77]

John R. Brinkley initiated a boom in male impotence cures in the U.S. in the 1920s and 1930s. His radio programs recommended expensive goat gland implants and "mercurochrome" injections as the path to restored male virility, including operations by surgeon Serge Voronoff.

Modern drug therapy for ED made a significant advance in 1983, when British physiologist Giles Brindley dropped his trousers and demonstrated to a shocked Urodynamics Society audience his papaverine-induced erection.[78] The drug Brindley injected into his penis was a non-specific vasodilator, an alpha-blocking agent, and the mechanism of action was clearly corporal smooth muscle relaxation. The effect that Brindley discovered established the fundamentals for the later development of specific, safe, and orally effective drug therapies.[79][better source needed][80][better source needed]

The current first-line treatment for ED, the oral PDE5 inhibitor, was introduced by Pfizer in 1999.[81]

Anthropology

Anthropological research presents ED not as a disorder but, as a normal, and sometimes even welcome sign of healthy aging. Wentzell's study of 250 Mexican males in their 50s and 60s found that "most simply did not see decreasing erectile function as a biological pathology".[82] The males interviewed described the decrease in erectile function "as an aid for aging in socially appropriate ways".[82] A common theme amongst the interviewees showed that respectable older males shifted their focus toward the domestic sphere into a "second stage of life".[82] The Mexican males of this generation often pursued sex outside of marriage; decreasing erectile function acted as an aid to overcoming infidelity thus helping to attain the ideal "second stage" of life.[82] A 56-year-old about to retire from the public health service said he would now "dedicate myself to my wife, the house, gardening, caring for the grandchildren—the Mexican classic".[82] Wentzell found that treating ED as a pathology was antithetical to the social view these males held of themselves, and their purpose at this stage of their lives.

In the 20th and 21st centuries, anthropologists investigated how common treatments for ED are built upon assumptions of institutionalized social norms. In offering a range of clinical treatments to 'correct' a person's ability to produce an erection, biomedical institutions encourage the public to strive for prolonged sexual function. Anthropologists argue that a biomedical focus places emphasis on the biological processes of fixing the body thereby disregarding holistic ideals of health and aging.[83] By relying on a wholly medical approach, Western biomedicine can become blindsided by bodily dysfunctions which can be understood as appropriate functions of age, and not as a medical problem.[84] Anthropologists understand that a biosocial approach to ED considers a person's decision to undergo clinical treatment more likely a result of "society, political economy, history, and culture" than a matter of personal choice.[83] In rejecting biomedical treatment for ED, males can challenge common forms of medicalized social control by deviating from what is considered the normal approach to dysfunction.

Lexicology

The Latin term impotentia coeundi describes simple inability to insert the penis into the vagina; it is now mostly replaced by more precise terms, such as erectile dysfunction (ED). The study of ED within medicine is covered by andrology, a sub-field within urology. Research indicates that ED is common, and it is suggested that approximately 40% of males experience symptoms compatible with ED, at least occasionally.[85] The condition is also on occasion called phallic impotence.[86] Its antonym, or opposite condition, is priapism.[87][88]

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Further reading

  • Carson, Culley; Faria, Geraldo; Hellstrom, Wayne J. G.; Krishnamurti, Sudhakar; Minhas, Suks; Moncada, Ignacio; Montague, Drogo K. (1 January 2010). "Implants, Mechanical Devices, and Vascular Surgery for Erectile Dysfunction". Journal of Sexual Medicine. Wiley. 7 (1): 501–523. doi:10.1111/j.1743-6109.2009.01626.x. PMID 20092450.

External links

  • Erectile dysfunction at Curlie

December 02, 2023
erectile, dysfunction, also, referred, impotence, form, sexual, dysfunction, males, characterized, persistent, recurring, inability, achieve, maintain, penile, erection, with, sufficient, rigidity, duration, satisfactory, sexual, activity, most, common, sexual. Erectile dysfunction ED also referred to as impotence is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a penile erection with sufficient rigidity and duration for satisfactory sexual activity It is the most common sexual problem in males and can cause psychological distress due to its impact on self image and sexual relationships Majority of ED cases are attributed to physical risk factors and predictive factors These factors can be categorized as vascular neurological local penile hormonal and drug induced Notable predictors of ED include aging cardiovascular disease diabetes mellitus high blood pressure obesity abnormal lipid levels in the blood hypogonadism smoking depression and medication use Approximately 10 of cases are linked to psychosocial factors encompassing conditions like depression stress and problems within relationships 14 Erectile dysfunctionOther namesImpotenceSpecialtyUrology sexual medicine andrologySymptomsInability to gain or maintain an erectionCausesLow testosterone levels 1 2 certain prescription drugs 3 4 neurogenic disorders 3 4 5 2 Risk factorsCardiovascular disease diabetes smoking stress 6 mental disorders 6 ageing 1 high saturated fat diet 7 8 kidney disease 9 Diagnostic methodDepends if psychological or physiological absence of involuntary erections suggests physiological 4 Differential diagnosisHypogonadism 4 prolactinoma 4 PreventionAdequate exercise 10 TreatmentPenis pump 11 counseling psychological treatment 12 MedicationSildenafil 13 It is worth noting that the term erectile dysfunction does not encompass other erection related disorders such as priapism Treatment of ED encompasses addressing the underlying causes lifestyle modification and addressing psychosocial issues 4 In many instances medication based therapies are used specifically PDE5 inhibitors like sildenafil 13 These drugs function by dilating blood vessels facilitating increased blood flow into the spongy tissue of the penis analogous to opening a valve wider to enhance water flow in a fire hose Less frequently employed treatments encompass prostaglandin pellets inserted into the urethra the injection of smooth muscle relaxants and vasodilators directly into the penis penile implants the use of penis pumps and vascular surgery 4 15 ED is reported in 18 of males aged 50 to 59 years and 37 in males aged 70 to 75 14 Contents 1 Signs and symptoms 1 1 Psychological impact 2 Causes 3 Pathophysiology 4 Diagnosis 4 1 Ultrasonography 4 2 Other workup methods 5 Treatment 5 1 Medications 5 1 1 Prevalence of medical diagnosis 5 2 Focused shockwave therapy 5 3 Testosterone 5 4 Pumps 5 5 Vibrators 5 6 Surgery 5 7 Alternative medicine 6 History 7 Anthropology 8 Lexicology 9 References 10 Further reading 11 External linksSigns and symptomsED is characterized by the persistent or recurring inability to achieve or maintain an erection of the penis with sufficient rigidity and duration for satisfactory sexual activity 14 It is defined as the persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity for at least 3 months 4 Psychological impact ED often has an impact on the emotional well being of both males and their partners 14 Many males do not seek treatment due to feelings of embarrassment About 75 of diagnosed cases of ED go untreated 16 CausesCauses of or contributors to ED include the following Diets high in saturated fat are linked to heart diseases and males with heart diseases are more likely to experience ED 7 8 By contrast plant based diets show a lower risk for ED 17 18 19 Prescription drugs e g SSRIs 20 beta blockers antihistamines 21 22 23 alpha 2 adrenergic receptor agonists thiazides hormone modulators and 5a reductase inhibitors 3 4 Neurogenic disorders e g diabetic neuropathy temporal lobe epilepsy multiple sclerosis Parkinson s disease multiple system atrophy 3 4 5 Cavernosal disorders e g Peyronie s disease 3 24 Hyperprolactinemia e g due to a prolactinoma 3 Psychological causes performance anxiety stress and mental disorders 6 Surgery e g radical prostatectomy 25 Ageing after age 40 years ageing itself is a risk factor for ED although numerous other pathologies that may occur with ageing such as testosterone deficiency cardiovascular diseases or diabetes among others appear to have interacting effects 1 26 Kidney disease ED and chronic kidney disease have pathological mechanisms in common including vascular and hormonal dysfunction and may share other comorbidities such as hypertension and diabetes mellitus that can contribute to ED 9 Lifestyle habits particularly smoking which is a key risk factor for ED as it promotes arterial narrowing 27 28 29 Due to its propensity for causing detumescence and erectile dysfunction some studies have described tobacco as an anaphrodisiacal substance 30 COVID 19 preliminary research indicates that COVID 19 viral infection may affect sexual and reproductive health 31 32 Surgical intervention for a number of conditions may remove anatomical structures necessary to erection damage nerves or impair blood supply 25 ED is a common complication of treatments for prostate cancer including prostatectomy and destruction of the prostate by external beam radiation although the prostate gland itself is not necessary to achieve an erection As far as inguinal hernia surgery is concerned in most cases and in the absence of postoperative complications the operative repair can lead to a recovery of the sexual life of people with preoperative sexual dysfunction while in most cases it does not affect people with a preoperative normal sexual life 33 ED can also be associated with bicycling due to both neurological and vascular problems due to compression 34 The increased risk appears to be about 1 7 fold 35 Concerns that use of pornography can cause ED 36 have little support 37 38 in epidemiological studies according to a 2015 literature review 39 According to Gunter de Win a Belgian professor and sex researcher Put simply respondents who watch 60 minutes a week and think they re addicted were more likely to report sexual dysfunction than those who watch a care free 160 minutes weekly 40 41 In seemingly rare cases medications such as SSRIs isotretinoin Accutane and finasteride Propecia are reported to induce long lasting iatrogenic disorders characterized by sexual dysfunction symptoms including erectile dysfunction in males these disorders are known as post SSRI sexual dysfunction PSSD post retinoid sexual dysfunction post Accutane syndrome PRSD PAS and post finasteride syndrome PFS These conditions remain poorly understood and lack effective treatments although they have been suggested to share a common etiology 42 PathophysiologyPenile erection is managed by two mechanisms the reflex erection which is achieved by directly touching the penile shaft and the psychogenic erection which is achieved by erotic or emotional stimuli The former involves the peripheral nerves and the lower parts of the spinal cord whereas the latter involves the limbic system of the brain In both cases an intact neural system is required for a successful and complete erection Stimulation of the penile shaft by the nervous system leads to the secretion of nitric oxide NO which causes the relaxation of the smooth muscles of the corpora cavernosa the main erectile tissue of the 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 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 2 Spinal cord injury causes sexual dysfunction including ED Restriction of blood flow can arise from impaired endothelial function due to the usual causes associated with coronary artery disease but can also be caused by prolonged exposure to bright light citation needed DiagnosisIn many cases the diagnosis can be made based on the person s history of symptoms In other cases a physical examination and laboratory investigations are done to rule out more serious causes such as hypogonadism or prolactinoma 4 One of the first steps is to distinguish between physiological and psychological ED Determining whether involuntary erections are present is important in eliminating the possibility of psychogenic causes for ED 4 Obtaining full erections occasionally such as nocturnal penile tumescence when asleep that is when the mind and psychological issues if any are less present tends to suggest that the physical structures are functionally working 43 44 Similarly performance with manual stimulation as well as any performance anxiety or acute situational ED may indicate a psychogenic component to ED 4 Another factor leading to ED is diabetes mellitus a well known cause of neuropathy 4 ED 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 4 Screening for cardiovascular risk factors such as smoking dyslipidemia hypertension and alcoholism is helpful 4 In some cases the simple search for a previously undetected groin hernia can prove useful since it can affect sexual functions in males and is relatively easily curable 33 The current diagnostic and statistical manual of mental diseases DSM IV lists ED Ultrasonography nbsp Transverse ultrasound image ventral view of the penis Image obtained after induction of an erection 15 min after injection of prostaglandin E1 showing dilated sinusoids arrows 45 Penile ultrasonography with doppler can be used to examine the erect penis Most cases of ED of organic causes are related to changes in blood flow in the corpora cavernosa represented by occlusive artery disease in which less blood is allowed to enter the penis most often of atherosclerotic origin or due to failure of the veno occlusive mechanism in which too much blood circulates back out of the penis Before the Doppler sonogram the penis should be examined in B mode in order to identify possible tumors fibrotic plaques calcifications or hematomas and to evaluate the appearance of the cavernous arteries which can be tortuous or atheromatous 45 Erection can be induced by injecting 10 20 µg of prostaglandin E1 with evaluations of the arterial flow every five minutes for 25 30 min see image The use of prostaglandin E1 is contraindicated in patients with predisposition to priapism e g those with sickle cell anemia anatomical deformity of the penis or penile implants Phentolamine 2 mg is often added Visual and tactile stimulation produces better results Some authors recommend the use of sildenafil by mouth to replace the injectable drugs in cases of contraindications although the efficacy of such medication is controversial 45 Before the injection of the chosen drug the flow pattern is monophasic with low systolic velocities and an absence of diastolic flow After injection systolic and diastolic peak velocities should increase decreasing progressively with vein occlusion and becoming negative when the penis becomes rigid see image below The reference values vary across studies ranging from gt 25 cm s to gt 35 cm s Values above 35 cm s indicate the absence of arterial disease values below 25 cm s indicate arterial insufficiency and values of 25 35 cm s are indeterminate because they are less specific see image below The data obtained should be correlated with the degree of erection observed If the peak systolic velocities are normal the final diastolic velocities should be evaluated those above 5 cm s being associated with venogenic ED 45 nbsp Graphs representing the color Doppler spectrum of the flow pattern of the cavernous arteries during the erection phases A Single phase flow with minimal or absent diastole when the penis is flaccid B Increased systolic flow and reverse diastole 25 min after injection of prostaglandin 45 nbsp Longitudinal ventral ultrasound of the penis with pulsed mode and color Doppler Flow of the cavernous arteries at 5 15 and 25 min after prostaglandin injection A B and C respectively The cavernous artery flow remains below the expected levels at least 25 35 cm s which indicates ED due to arterial insufficiency 45 Other workup methods Penile nerves function Tests such as the bulbocavernosus reflex test are used to ascertain whether there is enough 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 in the anus 46 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 A significant proportion quantify of males who have no sexual dysfunction nonetheless do not have regular nocturnal erections citation needed Penile biothesiometry This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glans and shaft of the penis 47 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 citation needed 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 visualized by infusing a mixture of saline and x ray contrast medium and performing a cavernosogram 48 In Digital Subtraction Angiography DSA the images are acquired digitally citation needed 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 The doctor may inject into the patient s bloodstream a contrast agent which causes vascular tissues to stand out against other tissues so that information about blood supply and vascular anomalies is easier to gather citation needed Treatment nbsp One ad from 1897 claims to restore perfect manhood Failure is impossible with our method 49 Another will quickly cure you of all nervous or diseases of the generative organs such as Lost Manhood Insomnia Pains in the Back Seminal Emissions Nervous Debility Pimples Unfitness to Marry Exhausting Drains Varicocele and Constipation 49 The U S Federal Trade Commission warns that phony cures exist even today 50 Treatment depends on the underlying cause In general exercise particularly of the aerobic type is effective for preventing ED during midlife 10 Counseling can be used if the underlying cause is psychological including how to lower stress or anxiety related to sex 12 Medications by mouth and vacuum erection devices are first line treatments 10 20 24 followed by injections of drugs into the penis as well as penile implants 10 25 26 Vascular reconstructive surgeries are beneficial in certain groups 51 Treatments other than surgery do not fix the underlying physiological problem but are used as needed before sex 52 Medications The PDE5 inhibitors sildenafil Viagra vardenafil Levitra and tadalafil Cialis are prescription drugs which are taken by mouth 10 20 21 As of 2018 sildenafil is available in the UK without a prescription 53 Additionally a cream combining alprostadil with the permeation enhancer DDAIP has been approved in Canada as a first line treatment for ED 54 Penile injections on the other hand can involve one of the following medications papaverine phentolamine and prostaglandin E1 also known as alprostadil 10 In addition to injections there is an alprostadil suppository that can be inserted into the urethra Once inserted an erection can begin within 10 minutes and last up to an hour 12 Medications to treat ED may cause a side effect called priapism 12 Prevalence of medical diagnosis In a study published in 2016 based on US health insurance claims data out of 19 833 939 US males aged 18 years only 1 108 842 5 6 were medically diagnosed with erectile dysfunction or on a PDE5I prescription m age 55 2 years s 11 2 years Prevalence of diagnosis or prescription was the highest for age group 60 69 at 11 5 lowest for age group 18 29 at 0 4 and 2 1 for 30 39 5 7 for 40 49 10 for 50 59 11 for 70 79 4 6 for 80 89 0 9 for 90 respectively 55 Focused shockwave therapy Focused shockwave therapy involves passing short high frequency acoustic pulses through the skin and into the penis These waves break down any plaques within the blood vessels encourage the formation of new vessels and stimulate repair and tissue regeneration 56 57 Focused shockwave therapy appears to work best for males with vasculogenic ED which is a blood vessel disorder that affects blood flow to tissue in the penis The treatment is painless and has no known side effects Treatment with shockwave therapy can lead to a significant improvement of the IIEF International Index of Erectile Function 58 59 60 Testosterone nbsp Testosterone Supplementation Content 88 g GelMen with low levels of testosterone can experience ED Taking testosterone may help maintain an erection 61 males with type 2 diabetes are twice as likely to have lower levels of testosterone and are three times more likely to experience ED than non diabetic men 61 Pumps Main article penis pump A vacuum erection device helps draw blood into the penis by applying negative pressure This type of device is sometimes referred to as penis pump and may be used just prior to sexual intercourse Several types of FDA approved vacuum therapy devices are available under prescription When pharmacological methods fail a purpose designed external vacuum pump can be used to attain erection with a separate compression ring fitted to the base of the penis to maintain it These pumps should be distinguished from other penis pumps supplied without compression rings which rather than being used for temporary treatment of impotence are claimed to increase penis length if used frequently or vibrate as an aid to masturbation More drastically inflatable or rigid penile implants may be fitted surgically 11 Vibrators Main article Vibrator sex toy The vibrator was invented in the late 19th century as a medical instrument for pain relief and the treatment of various ailments Sometimes described as a massager the vibrator is used on the body to produce sexual stimulation Several clinical studies have found vibrators to be an effective solution for Erectile Dysfunction 62 63 Examples of FDA registered vibrators for erectile dysfunction include MysteryVibe s Tenuto 64 and Reflexonic s Viberect 65 Surgery Main article Penile implant Often as a last resort if other treatments have failed the most common procedure is prosthetic implants which involves the insertion of artificial rods into the penis 10 26 Some sources show that vascular reconstructive surgeries are viable options for some people 51 Alternative medicine The Food and Drug Administration FDA does not recommend alternative therapies to treat sexual dysfunction 66 Many products are advertised as herbal viagra or natural sexual enhancement products but no clinical trials or scientific studies support the effectiveness of these products for the treatment of ED and synthetic chemical compounds similar to sildenafil have been found as adulterants in many of these products 67 68 69 70 71 The FDA has warned consumers that any sexual enhancement product that claims to work as well as prescription products is likely to contain such a contaminant 72 A 2021 review indicated that ginseng had only trivial effects on erectile function or satisfaction with intercourse compared to placebo 73 History nbsp An unhappy wife is complaining to the qadi about her husband s impotence Ottoman miniature Attempts to treat ED date back well over 1 000 years In the 8th century males of Ancient Rome and Greece wore talismans of rooster and goat genitalia believing these talismans would serve as an aphrodisiac and promote sexual function 74 In the 13th century Albertus Magnus recommended ingesting roasted wolf penis as a remedy for impotence 74 During the late 16th and 17th centuries in France male impotence was considered a crime as well as legal grounds for a divorce The practice which involved inspection of the complainants by court experts was declared obscene in 1677 75 76 The first successful vacuum erection device or penis pump was developed by Vincent Marie Mondat in the early 1800s 74 A more advanced device based on a bicycle pump was developed by Geddings Osbon a Pentecostal preacher in the 1970s In 1982 he received FDA approval to market the product as the ErecAid 77 John R Brinkley initiated a boom in male impotence cures in the U S in the 1920s and 1930s His radio programs recommended expensive goat gland implants and mercurochrome injections as the path to restored male virility including operations by surgeon Serge Voronoff Modern drug therapy for ED made a significant advance in 1983 when British physiologist Giles Brindley dropped his trousers and demonstrated to a shocked Urodynamics Society audience his papaverine induced erection 78 The drug Brindley injected into his penis was a non specific vasodilator an alpha blocking agent and the mechanism of action was clearly corporal smooth muscle relaxation The effect that Brindley discovered established the fundamentals for the later development of specific safe and orally effective drug therapies 79 better source needed 80 better source needed The current first line treatment for ED the oral PDE5 inhibitor was introduced by Pfizer in 1999 81 AnthropologyAnthropological research presents ED not as a disorder but as a normal and sometimes even welcome sign of healthy aging Wentzell s study of 250 Mexican males in their 50s and 60s found that most simply did not see decreasing erectile function as a biological pathology 82 The males interviewed described the decrease in erectile function as an aid for aging in socially appropriate ways 82 A common theme amongst the interviewees showed that respectable older males shifted their focus toward the domestic sphere into a second stage of life 82 The Mexican males of this generation often pursued sex outside of marriage decreasing erectile function acted as an aid to overcoming infidelity thus helping to attain the ideal second stage of life 82 A 56 year old about to retire from the public health service said he would now dedicate myself to my wife the house gardening caring for the grandchildren the Mexican classic 82 Wentzell found that treating ED as a pathology was antithetical to the social view these males held of themselves and their purpose at this stage of their lives In the 20th and 21st centuries anthropologists investigated how common treatments for ED are built upon assumptions of institutionalized social norms In offering a range of clinical treatments to correct a person s ability to produce an erection biomedical institutions encourage the public to strive for prolonged sexual function Anthropologists argue that a biomedical focus places emphasis on the biological processes of fixing the body thereby disregarding holistic ideals of health and aging 83 By relying on a wholly medical approach Western biomedicine can become blindsided by bodily dysfunctions which can be understood as appropriate functions of age and not as a medical problem 84 Anthropologists understand that a biosocial approach to ED considers a person s decision to undergo clinical treatment more likely a result of society political economy history and culture than a matter of personal choice 83 In rejecting biomedical treatment for ED males can challenge common forms of medicalized social control by deviating from what is considered the normal approach to dysfunction LexicologyThe Latin term impotentia coeundi describes simple inability to insert the penis into the vagina it is now mostly replaced by more precise terms such as erectile dysfunction ED The study of ED within medicine is covered by andrology a sub field within urology Research indicates that ED is common and it is suggested that approximately 40 of males experience symptoms compatible with ED at least occasionally 85 The condition is also on occasion called phallic impotence 86 Its antonym or opposite condition is priapism 87 88 References a b c Gokce MI Yaman O September 2017 Erectile dysfunction in the elderly male Turkish Journal of Urology 43 3 247 251 doi 10 5152 tud 2017 70482 PMC 5562240 PMID 28861293 a b c Shamloul R Bella AJ 2014 03 01 Erectile Dysfunction Biota Publishing pp 6 ISBN 978 1 61504 653 9 a b c d e f Cunningham GR Rosen RC Overview of male sexual dysfunction In UpToDate Martin KA Ed UpToDate Waltham MA 2018 a b c d e f g h i j k l m n o p Chowdhury SH Cozma AI Chowdhury JH Erectile Dysfunction Essentials for the Canadian Medical Licensing Exam Review and Prep for MCCQE Part I 2nd edition Wolters Kluwer Hong Kong 2017 a b Azadzoi Kazem M Siroky Mike B 2006 Neurogenic Sexual Dysfunction in and Male Sexual Function Current Clinical Urology Cham Switzerland Springer Nature pp 195 226 doi 10 1007 978 1 59745 155 0 9 ISBN 978 1 59745 155 0 S2CID 67897138 a b c Lue TF 2006 Causes of Erectile Dysfunction Erectile dysfunction Armenian Health Network Health am Retrieved 2007 10 07 a b Can Your Diet Cause Erectile Dysfunction www clevelandclinic org Cleveland Ohio Cleveland Clinic 20 January 2021 Retrieved 4 January 2022 a b Erectile Dysfunction amp Heart Disease www clevelandclinic org Cleveland Ohio Cleveland Clinic 17 July 2019 Archived from the original on 4 January 2022 Retrieved 4 January 2022 a b Papadopoulou E Varouktsi A Lazaridis A Boutari C Doumas M July 2015 Erectile dysfunction in chronic kidney disease From pathophysiology to management World Journal of Nephrology 4 3 379 387 doi 10 5527 wjn v4 i3 379 PMC 4491929 PMID 26167462 a b c d e f g Wespes E chair et al Guidelines on Male Sexual Dysfunction Erectile dysfunction and premature ejaculation European Association of Urology 2013 6 18 19 a b Erectile Dysfunction The Lecturio Medical Concept Library Retrieved 21 July 2021 a b c d Treatment for erectile dysfunction US National Institute of Diabetes and Digestive and Kidney Diseases Retrieved 2019 08 04 a b Vardi M Nini A January 2007 Phosphodiesterase inhibitors for erectile dysfunction in patients with diabetes mellitus The Cochrane Database of Systematic Reviews 2009 1 CD002187 doi 10 1002 14651858 CD002187 pub3 PMC 6718223 PMID 17253475 a b c d Rosen RC Khera M 2023 Epidemiology and etiologies of male sexual dysfunction In O Leary MP Cummingham GR eds UpToDate Post TW Waltham MA UpToDate Montague DK Jarow JP Broderick GA Dmochowski RR Heaton JP Lue TF Milbank AJ Nehra A Sharlip ID July 2005 Smith J Jr ed Chapter 1 The management of erectile dysfunction an AUA update The Journal of Urology Elsevier 174 1 230 39 doi 10 1097 01 ju 0000164463 19239 19 ISSN 1527 3792 PMID 15947645 S2CID 1761196 Frederick LR Cakir OO Arora H Helfand BT McVary KT October 2014 Mulhall JP ed Undertreatment of erectile dysfunction claims analysis of 6 2 million patients The Journal of Sexual Medicine John Wiley amp Sons on behalf of the International Society for Sexual Medicine 11 10 2546 53 doi 10 1111 jsm 12647 ISSN 1743 6109 PMID 25059314 S2CID 9708426 Bauer SR Breyer BN Stampfer MJ Rimm EB Giovannucci EL Kenfield SA November 2020 Rivara FP ed Association of Diet With Erectile Dysfunction Among Men in the Health Professionals Follow up Study JAMA Network Open American Medical Association 3 11 e2021701 doi 10 1001 jamanetworkopen 2020 21701 ISSN 2574 3805 PMC 7666422 PMID 33185675 S2CID 226850997 Lu Y Kang J Li Z Wang X Liu K Zhou K Wang W Shen C May 2021 The association between plant based diet and erectile dysfunction in Chinese men Basic and Clinical Andrology BioMed Central 31 1 11 doi 10 1186 s12610 021 00129 5 ISSN 2051 4190 PMC 8117588 PMID 33980148 S2CID 234476038 Russo GI Broggi G Cocci A Capogrosso P Falcone M Sokolakis I Gul M Caltabiano R Di Mauro M November 2021 Relationship between Dietary Patterns with Benign Prostatic Hyperplasia and Erectile Dysfunction A Collaborative Review Nutrients MDPI on behalf of the EAU YAU Sexual and Reproductive 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Archived from the original on 2007 10 09 Retrieved 2007 10 07 Meldrum DR Morris MA Gambone JC Esposito K December 2020 Aging and erectile function The Aging Male 23 5 1115 1124 doi 10 1080 13685538 2019 1686756 PMID 31724458 S2CID 208018226 Peate I 2005 The effects of smoking on the reproductive health of men Br J Nurs 14 7 362 66 doi 10 12968 bjon 2005 14 7 17939 PMID 15924009 Korenman SG 2004 Epidemiology of erectile dysfunction Endocrine 23 2 3 87 91 doi 10 1385 ENDO 23 2 3 087 PMID 15146084 S2CID 29133230 Kendirci M Nowfar S Hellstrom WJ 2005 The impact of vascular risk factors on erectile function Drugs of Today 41 1 65 74 doi 10 1358 dot 2005 41 1 875779 PMID 15753970 Verze P Margreiter M Esposito K Montorsi P Mulhall J 2015 The Link Between Cigarette Smoking and Erectile Dysfunction A Systematic Review European Urology Focus 1 1 39 46 doi 10 1016 j euf 2015 01 003 PMID 28723353 Sansone A Mollaioli D Ciocca G Limoncin E Colonnello E Vena W Jannini EA February 2021 Addressing male 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Robinson M Wilson G July 11 2011 Porn Induced Sexual Dysfunction A Growing Problem Psychology Today Whelan Georgina Brown Jac September 2021 Pornography Addiction An Exploration of the Association Between Use Perceived Addiction Erectile Dysfunction Premature Early Ejaculation and Sexual Satisfaction in Males Aged 18 44 Years The Journal of Sexual Medicine 18 9 1582 1591 doi 10 1016 j jsxm 2021 06 014 ISSN 1743 6109 PMID 34400111 There was no evidence for an association between internet pornography use with erectile dysfunction premature ejaculation or sexual satisfaction However there were small to moderate positive correlations between self perceived internet pornography addiction and erectile dysfunction premature ejaculation or sexual dissatisfaction Grubbs Joshua B Gola Mateusz January 2019 Is Pornography Use Related to Erectile Functioning Results From Cross Sectional and Latent Growth Curve Analyses The Journal of Sexual Medicine 16 1 111 125 doi 10 1016 j jsxm 2018 11 004 ISSN 1743 6109 PMID 30621919 S2CID 58592884 there was evidence of a positive cross sectional association between self reported problematic use and ED but no consistent association between mere use itself and ED Landripet I Stulhofer A May 2015 Is Pornography Use Associated with Sexual Difficulties and Dysfunctions among Younger Heterosexual Men The Journal of Sexual Medicine 12 5 1136 1139 doi 10 1111 jsm 12853 PMID 25816904 Van Boom D 1 December 2020 Porn addiction is ruining lives but scientists aren t convinced it s real CNET Retrieved 2 October 2021 Jacobs T Geysemans B Van Hal G Glazemakers I Fog Poulsen K Vermandel A et al September 2021 Is online pornography consumption linked to offline sexual dysfunction in young men A multivariate analysis based on an international web based survey JMIR Public Health and Surveillance JMIR Publications Inc 7 10 e32542 doi 10 2196 32542 PMC 8569536 PMID 34534092 Conclusions This prevalence of ED in young men is alarmingly high and the results of 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9780122090363 S2CID 78605592 Mulhall John P Jenkins Lawrence C 2017 Mulhall John P Jenkins Lawrence C eds Biothesiometry Atlas of Office Based Andrology Procedures Cham Springer International Publishing pp 9 14 doi 10 1007 978 3 319 42178 0 2 ISBN 978 3 319 42176 6 retrieved 2022 02 27 Dawson C Whitfield H April 1996 ABC of urology Subfertility and male sexual dysfunction BMJ 312 7035 902 05 doi 10 1136 bmj 312 7035 902 PMC 2350600 PMID 8611887 a b Wonderful Medicine Free Manhood Restored The Great Hudyan The Helena Weekly Independent Helena Montana U S December 30 1897 pp 7 8 and page 8 Phony Cures for Erectile Dysfunction ftc gov U S Federal Trade Commission Archived from the original on April 30 2020 a b Encyclopedia of Reproduction 2nd Edition www elsevier com Retrieved 2019 01 17 What is Erectile Dysfunction Urology Care Foundation www urologyhealth org Retrieved 2019 08 05 Viagra can be sold over the counter BBC News 28 November 2017 Retrieved 5 April 2018 Bujdos B New Topical Erectile Dysfunction Drug Vitaros Approved in Canada Approved Topical Drug Testim Proves Helpful for Erectile Dysfunction Retrieved 15 April 2011 Mulhall JP Luo X Zou KH Stecher V Galaznik A December 2016 Relationship between age and erectile dysfunction diagnosis or treatment using real world observational data in the USA International Journal of Clinical Practice 70 12 1012 1018 doi 10 1111 ijcp 12908 PMC 5540144 PMID 28032424 Vardi Y Appel B Jacob G Massarwi O Gruenwald I August 2010 Can low intensity extracorporeal shockwave therapy improve erectile function A 6 month follow up pilot study in patients with organic erectile dysfunction European Urology 58 2 243 8 doi 10 1016 j eururo 2010 04 004 PMID 20451317 Shockwave Therapy for Erectile Dysfunction ED Clinics 27 July 2020 International Index of Erectile Function IIEF Guidelines on Clinical Application of IIEF patient Questionnaire PDF Department of Urology Hills Road Cambridge CB2 0QQ Addenbrooke s Hospital Archived from the original PDF on 2021 10 26 Retrieved 2021 09 22 a href Template Cite web html title Template Cite web cite web a CS1 maint location link Man L Li G September 2018 Low intensity Extracorporeal Shock Wave Therapy for Erectile Dysfunction A Systematic Review and Meta analysis Urology 119 97 103 doi 10 1016 j urology 2017 09 011 PMID 28962876 S2CID 7048621 Clavijo RI Kohn TP Kohn JR Ramasamy R January 2017 Effects of Low Intensity Extracorporeal Shockwave Therapy on Erectile Dysfunction A Systematic Review and Meta Analysis The Journal of Sexual Medicine 14 1 27 35 doi 10 1016 j jsxm 2016 11 001 PMID 27986492 a b Men and diabetes US Centers for Disease Control and Prevention 2019 04 01 Retrieved 2019 08 04 Ismail Ezzat A El Sakka Ahmed I 2016 06 01 Innovative trends and perspectives for erectile dysfunction treatment A systematic review Arab Journal of Urology 14 2 84 93 doi 10 1016 j aju 2016 04 002 ISSN 2090 598X PMC 4963167 PMID 27493808 Miranda Eduardo P Taniguchi Hisanori Cao David L 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Kauffman JF Buhse LF 2009 Detection of undeclared erectile dysfunction drugs and analogues in dietary supplements by ion mobility spectrometry Journal of Pharmaceutical and Biomedical Analysis 49 3 601 06 doi 10 1016 j jpba 2008 12 002 PMID 19150190 Choi DM Park S Yoon TH Jeong HK Pyo JS Park J Kim D Kwon SW 2008 Determination of analogs of sildenafil and vardenafil in foods by column liquid chromatography with a photodiode array detector mass spectrometry and nuclear magnetic resonance spectrometry Journal of AOAC International 91 3 580 88 doi 10 1093 jaoac 91 3 580 PMID 18567304 Reepmeyer JC Woodruff JT 2007 Use of liquid chromatography mass spectrometry and a chemical cleavage reaction for the structure elucidation of a new sildenafil analogue detected as an adulterant in an herbal dietary supplement Journal of Pharmaceutical and Biomedical Analysis 44 4 887 93 doi 10 1016 j jpba 2007 04 011 PMID 17532168 Reepmeyer JC Woodruff JT d Avignon DA 2007 Structure elucidation of a novel analogue of sildenafil detected as an adulterant in an herbal dietary supplement Journal of Pharmaceutical and Biomedical Analysis 43 5 1615 21 doi 10 1016 j jpba 2006 11 037 PMID 17207601 Enforcement Report for June 30 2010 United States Food and Drug Administration Hidden Risks of Erectile Dysfunction Treatments Sold Online United States Food and Drug Administration February 21 2009 Lee HW Lee MS Kim TH Alraek T Zaslawski C Kim JW Moon DG April 2021 Ginseng for erectile dysfunction The Cochrane Database of Systematic Reviews 2021 4 CD012654 doi 10 1002 14651858 cd012654 pub2 PMC 8094213 PMID 33871063 a b c McLaren A 2007 Impotence A Cultural History University of Chicago Press ISBN 978 0226500768 Roach M 2009 Bonk The Curious Coupling of Science and Sex New York W W Norton amp Co pp 149 52 ISBN 9780393334791 Darmon P 1985 Trial by Impotence Virility and Marriage in Pre Revolutionary France Vintage Ebury ISBN 978 0701129156 Hoyland K Vasdev N Adshead J 2013 The use of vacuum erection devices in erectile dysfunction after radical prostatectomy Reviews in Urology 15 2 67 71 PMC 3784970 PMID 24082845 Klotz L November 2005 How not to communicate new scientific information a memoir of the famous Brindley lecture BJU International 96 7 956 7 doi 10 1111 j 1464 410X 2005 05797 x PMID 16225508 S2CID 38931340 Brindley GS October 1983 Cavernosal alpha blockade a new technique for investigating and treating erectile impotence The British Journal of Psychiatry 143 4 332 7 doi 10 1192 bjp 143 4 332 PMID 6626852 S2CID 7576876 Helgason AR Adolfsson J Dickman P Arver S Fredrikson M Gothberg M Steineck G July 1996 Sexual desire erection orgasm and ejaculatory functions and their importance to elderly Swedish men a population based study PDF Age and Ageing 25 4 285 91 doi 10 1093 ageing 25 4 285 PMID 8831873 Valiquette L February 2003 A historical review of erectile dysfunction The Canadian Journal of Urology 10 Suppl 1 7 11 PMID 12625844 a b c d e Wentzell E Labuski C 2020 Role of Medical Anthropology in Understanding Cultural Differences in Sexuality Cultural Differences and the Practice of Sexual Medicine Trends in Andrology and Sexual Medicine Cham Springer International Publishing pp 23 35 doi 10 1007 978 3 030 36222 5 2 ISBN 978 3 030 36221 8 S2CID 214042890 Retrieved 28 August 2021 a b Farmer P Kleinman A Kim J Basilico M 2013 Reimagining Global Health An Introduction Berkeley University of California Press pp 17 20 ISBN 978 0 520 27197 5 Retrieved 28 August 2021 permanent dead link Wentzell E Salmeron J 2009 Prevalence of erectile dysfunction and its treatment in a Mexican population distinguishing between erectile function change and dysfunction Journal of Men s Health 6 1 56 62 doi 10 1016 j jomh 2008 09 009 Schouten BW Bohnen AM Groeneveld FP Dohle GR Thomas S Bosch JL July 2010 Erectile dysfunction in the community trends over time in incidence prevalence GP consultation and medication use the Krimpen study trends in ED J Sex Med 7 7 2547 53 doi 10 1111 j 1743 6109 2010 01849 x PMID 20497307 Kahane C 20 September 2011 Bad Timing The Problematics of Intimacy in On Chesil Beach PsyArt Allgeier A 1995 Sexual interactions D C Heath p 243 Grimes J 2013 Sexually Transmitted Disease An Encyclopedia of Diseases Prevention Treatment and Issues p 496 Further readingCarson Culley Faria Geraldo Hellstrom Wayne J G Krishnamurti Sudhakar Minhas Suks Moncada Ignacio Montague Drogo K 1 January 2010 Implants Mechanical Devices and Vascular Surgery for Erectile Dysfunction Journal of Sexual Medicine Wiley 7 1 501 523 doi 10 1111 j 1743 6109 2009 01626 x PMID 20092450 External linksErectile dysfunction at Curlie Retrieved from https en wikipedia org w index php title Erectile dysfunction amp oldid 1183224539, wikipedia, wiki, book, books, library,

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