An erection problem is the inability to get or maintain an erection that is firm enough for a man to have intercourse. You may be unable to get an erection at all, or you may lose the erection during intercourse before you are ready. If the condition persists, the medical term is erectile dysfunction.

Erection problems are common in adult men. In fact, almost all men experience occasional difficulty getting or maintaining an erection. In many cases, it is a temporary condition that will go away with little or no treatment. In other cases, it can be an ongoing problem that can damage a man's self esteem and harm his relationship with his partner, and thus requires treatment.

If you have difficulty having or keeping an erection more than 25% of the time, it is considered a problem.

In the past, erection problems were thought to be "all in the man's mind." Men often were given unhelpful advice such as "don't worry" or "just relax and it will take care of itself." Today, doctors believe that when the problem is not temporary or does not go away on its own, physical factors are often the cause.

One way to know if the cause is physical or psychologic is to determine if you are having nighttime erections. Normally, men have 3 to 5 erections per night, each lasting up to 30 minutes. Your doctor can explain a test to find out if you are having the normal number of nighttime erections.

In most men, erection difficulties do not affect their sex drive.

Premature ejaculation (when orgasm comes on too quickly) is not the same as impotence. Together with your partner, you should seek counseling for this problem, which is usually due to psychological factors.

Male infertility is also quite different from impotence. A man who is unable to maintain an erection may be very capable of producing sperm that could fertilize an egg. An infertile man is usually able to maintain an erection, but he may be unable to father a child due to problems with sperm count or other factors.

An erection requires the interaction of your brain, nerves, hormones, and blood vessels. Anything that interferes with the normal process can become a problem. Common causes include:

• Diseases and conditions such as diabetes, high blood pressure, heart or thyroid conditions, poor circulation, low testosterone, depression, spinal cord injury, nerve damage (for example, from prostate surgery), or neurologic disorders (such as multiple sclerosis or Parkinson's disease)
• Medications such as blood pressure medications (especially beta-blockers), heart medications (such as digoxin), some peptic ulcer medications, sleeping pills, and antidepressants
• Nicotine, alcohol, or cocaine
• Poor communication with your partner
• Stress, fear, anxiety, or anger
• Unrealistic sexual expectations, which make sex a task rather than a pleasure
• "Vicious cycle" of doubt, failure, or negative communication that reinforces the erection problems

Erection problems tend to become more common as you age, but it can affect men at any age and at any time in their lives. Physical causes are more common in older men, while psychological causes are more common in younger men.

For many men, lifestyle changes can help:

• Cut down on smoking, alcohol, and illegal drugs.
• Get plenty of rest and take time to relax.
• Exercise and eat a healthy diet to maintain good circulation.
• Use safe sex practices, which reduces fear of HIV and STDs.
• Talk openly to your partner about sex and your relationship. If you are unable to do this, counseling can help.

Couples who cannot talk to each other are not likely to be able to make love to each other. Men who have trouble communicating their feelings may find it difficult to share with their partner any anxieties about their sexual performance. If you keep worries to yourself, you are more likely to lose erections. Men who cannot express and resolve feelings of anger or frustration towards their partner may hold back their erection as a weapon in the conflict. In these circumstances, counseling can be very helpful for both you and your partner.

If erection problems seem to be caused by a medication you are taking for an unrelated condition, consult your doctor. You may benefit from reducing the dose of the drug or changing to another drug that has the same result but not the same side effects. DO NOT adjust or discontinue medications without consulting your doctor first.

Talk to your health care provider if your erection problems are related to fear of recurring heart problems -- sexual intercourse is usually safe in these circumstances.

Call your doctor if:

• Self-care measures do not resolve the problem and you continue having difficulty with erections -- effective treatments are available
• You suspect that a medication is causing the problem
• The problems begin after an injury or prostate surgery
• You have other symptoms like low back pain, abdominal pain, or change in urination

Call your doctor immediately or go to an emergency room if medication for erection problems give you an unwanted erection that lasts more than 4 hours. Permanent impotence or other lasting damage to your penis may result from this condition.

Your doctor will perform a physical examination, which will likely include checking your circulation, a rectal exam, a neurological exam, and an exam of your penis.

To help diagnose the cause of the problem, your doctor will ask medical history questions, such as:

• Have you been able to achieve and maintain erections in the past?
• Is the difficulty in achieving erections or maintaining the erection?
• Do you have erections during sleep?
• How long have you had difficulty with erections?
• What medications are you taking (including prescription medications, over-the-counter medications, recreational drugs)?
• Do you smoke? How much each day?
• Do you use alcohol? How much?
• Have you recently had surgery?
• Have you ever had vascular surgery or other treatments for your blood vessels?
• Are you depressed?
• Are you afraid or worried about something?
• Are you experiencing a lot of stress?
• Has your energy level decreased?
• Are you sleeping well each night?
• Are you afraid of sexual activity because of physical problems?
• Have there been any recent changes in your life?
• What other symptoms do you have?
• Have you noticed changes in sensations in your penis?
• Do you have any problems with urination?

Tests that may be performed include:

• Urine analysis
• Blood tests, including CBC, metabolic panel, hormone profile, PSA
• Penile ultrasound (to evaluate for blood vessel or blood flow problems)
• Nocturnal penile tumescence (NPT) to test if you are having nighttime erections and rigidity monitoring (Rigiscan)
• Neurological testing
• Psychometric testing

The treatment depends on the cause. For example, if the problem is caused by a hormonal imbalance, medication to treat the underlying endocrine disorder will be prescribed. Consult your health care provider for appropriate evaluation and management.

There are many treatment options today. These include medicines taken by mouth, injections into the penis, vacuum devices, and surgery. In order to treat erectile dysfunction effectively, you must be aware of and comfortable with the possible side-effects and complications that may occur with each therapy.

Sildenafil (Viagra), vardenafil (Levitra), and tadalafil are medicines prescribed for mild-to-moderate erection difficulties caused by either physical or psychological problems. Although these medicines have become extremely popular, they are not "cure-alls," and they do not enhance erections if you are not impotent. And, they DO have side effects. These pills should not be used with certain other medications.

Men who take nitroglycerin for a heart condition (as either tablets, spray, or patches) should NOT take these medications. When taken with nitroglycerin, these drugs can significantly lower blood pressure. Some men have died from combining these drugs and nitroglycerin.

If pills do not work, other options are available. Testosterone may be prescribed by either skin patch or injection, especially if the problem is related to age. Alprostadil, injected at the penis or inserted as pellets, improves blood flow to the penis. This technique is usually more effective than medications taken by mouth.

For some patients, a vacuum pump or penile prosthesis (implant) may also be recommended or required.

Consult your health care provider to see if one of these treatments is right for you.

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Kaiser DR, Billups K, Mason C, et. al. Impaired Brachial Artery Endothelium-Dependent and Independent Vasodilation in Men With Erectile Dysfunction and No Other Clinical Cardiovascular Disease. JACC. 2004:179–84

Glina S. Testosterone and erectile dysfunction. J Men’s Health Gend. 2004; 1(4): 407-412.

Use of Sildenafil (Viagra) in Patients with Cardiovascular Disease: Expert Consensus Document. J Am Coll Cardiol. 1999; 33: 273-82.