Erectile Dysfunction 

Erectile dysfunction, or impotence, is the inability to gain or maintain an erection for the purpose of sex. ED affects 15 to 30 million American men, and many medical problems can affect a man's ability to sustain an erection. Common ones include cardiovascular disease, peripheral vascular disease, and diabetes. Even some highly common types of medications have an effect on erectile function, especially some antidepressants and medications that lower blood pressure. Other causes include psychological factors and issues concerning performance anxiety and depression.

Important questions to ask yourself regarding ED include:

* Do you wake up with morning erections?

* Are you able to sustain an erection for penetration?

* Do you have decreased sexual thoughts?

* Are you able to ejaculate despite an inability to sustain a full erection?

An erection has two phases: One is the direct stimulation of the penis, and the other is psychogenic, based on erotic stimuli. Physiologically, erectile stimulation leads to the release of nitric oxide, which causes the muscles of the main erectile tissue of the penis to relax. The penis then engorges with blood and an erection is produced. An adequate amount of testosterone must be present for an erection to take place. Impotence occurs when there is hormonal deficiency, disruption of the neural pathway, or an inadequate blood supply to the penis. Other causes can include post- surgical procedures, especially operations involving the prostate, or excessive alcohol or drug use. ED has also been linked to prolonged bicycle and horse back riding.

Treatment of ED depends on the cause. Testosterone replacement therapy is recommended for symptomatic men with low testosterone due to hypogonadism or androgen deficiency. ED that results from inadequate blood fl ow to the penis caused by damaged blood vessels is strongly associated with diabetes and peripheral vascular disease. Tight control of blood sugar is essential to maintain competency of blood vessels. Uncontrolled diabetics run the risk of damaging their vascular network, which can result in problems with the kidneys, eyes, and circulation to the extremities.

Medications indicated for the treatment of ED include Viagra (sildenafil), Cialis (tadalafil), and Levitra (vardenafil). Taken orally, these medications work by producing smooth muscle relaxation of the corpus cavernosum. The response is mediated by the release of nitric oxide, which results in increased blood flow and an erection. With the exception of testosterone replacement, these medications work on a temporary basis. They enable an erection to be attained and maintained long enough for intercourse but do not improve any underlying medical conditions. These medications treat ED; they do not cure it.

For most men, the average time to an erection is thirty to sixty minutes after ingesting the pill. All three medications require stimulation like kissing or touching. Among the most common side effects are headache, nasal congestions, flushing, and in some instances visual disturbances. More serious side effects include low blood pressure, irregular heart rate, and priapism. Men should not take these medications if they use nitrates, which can be found in certain chest pain medications (sublingual nitro) or amyl nitrite (poppers) for recreational use. The combined effect can severely lower blood pressure.

Used appropriately, these drugs have been widely successful, especially in older men with medical problems such as diabetes and hypertension. It is important to discuss your general health with your physician before using any of these medications in order to establish if you are healthy enough to engage in sexual activity. Remember to provide your doctor with a complete list of all your medications, especially blood pressure medications. Consult your doctor immediately if you develop chest pain or discomfort during sex and avoid further use. In cases of priapism or prolonged erections for longer then four hours, seek medical attention immediately.

Some clinicians have made the argument that these medications promote unsafe sex, especially among gay men, leading to increased cases of HIV. This concern has never been substantiated, but some MSMs do use recreational drugs that require ED medication to facilitate their sexual activity. The apprehension is that recreational drugs impair judgment and some gay men take part in long marathons of sex due in part to the aid of these ED medications. In light of these facts, it is important to note that Cialis has a half- life of 36 hours. Again, remember to always use condoms during sex and note that ED medications do not protect against STDs or HIV. Even more important, know that the use of amyl nitrite, or "poppers," with ED drugs is contraindicated. Taken together, they can have detrimental effects on blood pressure, leading to loss of consciousness and even death.

Previous medications used to treat ED came in the form of a urethral suppository under the brand name Muse (medicated urethral system for erection), which employs a prostaglandin pellet that is inserted into the urethra with an applicator. Said to be effective in 30 to 60 percent of the men who use it, the onset of action is about ten minutes after insertion and lasts anywhere from thirty minutes to an hour. Reported side effects include pain and urethral injury.

Other forms of prostaglandins were initially injectable under the brand names Caverject or Edex. This medication is injected into the side of the penis (the corpus cavernosum), producing erections in 80 percent of the men. The injections are relatively painless; the erection begins five to fifteen minutes after the injection. It is recommended that self- injection be performed no more than once every four to seven days. Side effects include infection, bleeding, and bruising at the injection site, dizziness, heart palpitations, and flushing. There is a risk for priapism, a medical emergency. Repeated injection may cause scarring of erectile tissue, which can further impair erection.

Priapism is a condition that involves a sustained erection beyond four hours and is a reported side effect of medical treatments for ED. In Greek mythology, the god Priapus was punished for attempting to rape a goddess by being given a large set of useless wooden genitals. The medical condition named after him is highly serious and requires immediate medical care.

One case of priapism involved a gay male who had a three-way with a couple that convinced him to inject prostaglandin into his penis. The ensuing erection continued for well past four hours before he went to his local emergency room. After a sustained erection, the blood within the penis becomes entrapped. Imagine having a tourniquet tied around the base of your penis. If the blood is not permitted to drain, it can clot, causing further swelling and permanent damage. Treatment involves aspirating the blood using a needle that is inserted into the penis. Phenylephrine can be injected as well to dilate the blood vessels. If medical treatment fails, surgical shunts are inserted.

Other methods used to achieve erections involve vacuum pumps. The penis is inserted into a device and a hand- held pump is used to create a vacuum that draws blood into the penis. Adequate erections have been reported after one to three minutes. The penis is then removed from the pump and a rubber ring is placed around the base to maintain the erection during intercourse. The ring can be left on for up to thirty minutes.

When all other measures have been exhausted there are always surgical alternatives. The three main surgical avenues include penile implants, vascular reconstructive surgery, and venous ligation.

Penile implants involve surgically inserting malleable rods or inflatable tubes into the penis. The malleable prosthesis provides rigidity sufficient for intercourse and can be curved downward so that it is concealed. The inflatable prosthesis consists of two tubes that are inserted into the penis and attached to a small pump implanted in the scrotum. In order to produce an erection, the patient must manually pump fluid stored in a reservoir located in the abdomen. This acts to expand the penis so that it is erect. Afterward, a valve allows the fluid to return to the reservoir so that the penis can deflate. The surgical procedure to implant the inflatable prosthesis is slightly more complicated than the semi-rigid implant. Also, the inflatable prosthesis has a higher risk of mechanical failure.

Some vascular problems that cause ED can be treated surgically. A small percentage of men undergo vascular reconstructive surgery to improve blood flow to the penis. Bypassing blocked veins or arteries involves transferring a vein from the leg and attaching it so that it creates a path to the penis around the area of blockage. Young men with only local arterial blockage are the best candidates for this procedure. The procedure is almost never successful in older men with widespread blockage.

Venous ligation involves performing surgery on veins to allow blood to leave the penis. Blocking off veins, or ligating them, allows an adequate amount of blood to remain in the penis. Long- term effectiveness has been brought into question and as a result this procedure is rarely performed.

In addition to erectile dysfunction, some men suffer from ejaculatory problems like premature ejaculation. This is defined as ejaculation prior to one's wishes. This broad definition avoids a specific duration of time. Most men reach climax in five minutes, which is considered satisfactory. Other males have learned to delay their climax for up to twenty minutes and longer. If premature ejaculation occurs on occasion, it is not considered a cause for concern. However, if premature ejaculation continues for more than 50 percent of attempted sexual relations, a dysfunctional pattern probably exists.

Premature ejaculation is the most common male sexual dysfunction. In the United States, it affects approximately one out of five men aged eighteen to sixty. In gay men, premature ejaculation is thought to be related to psychological causes. Some clinicians agree that early sexual experiences, especially those in which men had to rush in order to climax in order to avoid being discovered, can set a lifelong pattern. Households that regard gay sex as sinful or dirty exacerbate this condition because the male tends to rush through sex in order to avoid feeling guilt.

If you suffer from premature ejaculation, consult your doctor. There are also biological factors that can contribute. Treatments include the use of antidepressants as well as sexual therapy and individual psychotherapy.

Delayed ejaculation refers to an inability to climax. The male is unable to ejaculate, either during intercourse or with manual stimulation in the presence of a partner. Sometimes he is able to ejaculate but only with great effort. Common causes are mainly psychological in nature and are the result, once again, of either a strict religious

upbringing or traumatic childhood events. Closeted gay men develop ejaculatory problems especially during intercourse with female partners. Lack of attraction to one's partner is another common cause as well as an underlying anger as it relates to internalized homophobia. There are a variety of medications that can cause delayed ejaculation, including some common antidepressants. Neurological disease such as strokes or nerve damage to the spinal cord or back may also cause a delay in or an inability to ejaculate.

Erectile and ejaculatory dysfunction is also age-related, and other medical problems can exacerbate these conditions. Maintaining adequate sugar control in diabetics and normalizing blood pressure in hypertensive males is the best way to decrease your chance of erectile or ejaculatory problems. Also, excessive alcohol and recreational drugs have been implicated as causes for these two conditions as well.