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Sexual difficulties can begin early in a person's sex life or they may develop after an individual has previously experienced enjoyable and satisfying sex. A problem may develop gradually over time, or may occur suddenly as a total or partial inability to participate in one or more stages of the sexual act. The causes of sexual difficulties can be physical, psychological, or both. Physical factors include drugs (alcohol, nicotine, narcotics, stimulants, antihypertensives, antihistamines, and some psychotherapeutic drugs); injuries to the back, problems with an enlarged prostate gland, problems with blood supply, nerve damage (as in spinal cord injuries); or disease (diabetic neuropathy, multiple sclerosis, tumors, and, rarely, tertiary syphilis); failure of various organ systems (such as the heart and lungs); endocrine disorders (thyroid, pituitary, or adrenal gland problems); hormonal deficiencies (low testosterone, estrogen, or androgens); and some birth defects. Sexual dysfunction disorders are generally classified into four categories: sexual desire disorders, sexual arousal disorders, orgasm disorders, and sexual pain disorders. There may be medical causes to these disorders, such as decreased blood flow or lack of vaginal lubrication. Chronic disease can also contribute, as well as the nature of the relationship between the partners. As the success of sildenafil (Viagra) attests, most erectile disorders in men are primarily physical, not psychological conditions. Orgasm disorders are a persistent delay or absence of orgasm following a normal sexual excitement phase. The disorder can occur in both women and men. Again, the SSRI antidepressants are frequent culprits -- these can delay the achievement of orgasm or eliminate it entirely. Sexual dysfunctions are more common in the early adult years, with the majority of people seeking care for such conditions during their late twenties through thirties. The incidence increases again in the geriatric population, typically with gradual onset of symptoms that are associated most commonly with medical causes of sexual dysfunction. A recent study estimates that 30 million men suffer from various degrees of erectile dysfunction. This can range from mild to severe. It is clearly an age-related phenomenon with the prevalence of erectile dysfunction increasing significantly with age. Surprisingly, by the time men reach 40, 5% of them are completely impotent never achieving an erection rigid enough for penetration. Approximately 15% have significant problems achieving or maintaining an erection. The creation of an erection is an extremely complicated cascade of events that requires many different things to happen. There are numerous chemical transmitters involved in this including epinephrine, norepinephrine, acetylcholine, prostaglandins and nitric oxide. The exact mechanism by which erection occurs is still unclear but we do know that the neural input from the brain is extremely important. Reflex erections, as seen in people with cord damage such as paraplegics, are often poor erections and not sustainable for prolonged periods of intercourse. An erection occurs when the nervous system activates a rapid increase in blood flow. The vascular muscle in the spongy area becomes engorged with blood and the outflow of blood is cut off. An erection can occur as a reflex as we see in spinal cord patients, or can be caused by psychogenic (originating in the mind) stimulation. Numerous sexual stimuli are processed by the brain and transmitted to the penis via the nervous system. Erections can change over time, sometimes stronger or weaker than other times. When men are in their teens they often have little control over their erections and obtain erections when not in a sexual situation. For most men this stops in their late teens to early twenties. As men get older, erections may not always be obtained when they want one. Almost every man has the occasional time when their erection is less strong than they would like but sometimes it becomes a problem. Erectile dysfunction, also called impotence, means that a man's penis doesn't get hard enough to have intercourse. The man cannot get or maintain an erection. This condition affects approximately 30 million men in the United States. Erectile dysfunction is not the same as premature ejaculation, the inability to ejaculate (retarded ejaculation) or infertility.) Because erections are caused by the buildup of blood in the shaft of the penis, poor blood flow in the penis can result in problems with erections. Damage to blood vessels can be caused by hardening of the arteries (atherosclerosis) or from trauma. Vascular disease is believed to be the most common medical cause of erectile dysfunction. A man with erectile dysfunction has either a problem getting an erection or difficulty maintaining one. This usually interferes with sexual activity by preventing penetration during intercourse. How long your erectile dysfunction lasts depends upon what causes it and how quickly your treatment starts to work. The important thing to remember is that erectile dysfunction is treatable in all age groups. Sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) drugs can cause minor side effects such as flushing and headache, but they have been shown to be safe in most men, including those with heart disease. However, these drugs can interact with other medications and cause dangerously low blood pressure. In particular, they should never be taken with nitroglycerin or other nitrate medications commonly used to treat heart disease. Men with enlarged prostates who take alpha-blocker drugs such tamsulosin (Flomax) or doxazosin (Cardura) should probably avoid PDE5 drugs. If Sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) drugs don't work or cannot be used because of potential side effects, your doctor can recommend other therapies. The drug alprostadil (Caverject, Edex, Muse) causes blood vessels to widen. This can allow blood to flow more freely in the penis, leading to an erection. The drug can be injected with a tiny needle, or a small pellet (suppository) can be inserted into the opening of the penis. Suppositories like this are effective in approximately two-thirds of men. Injections are effective about 80 percent of the time. Men who do not benefit from medical or psychological treatment often have success with mechanical or prosthetic devices. External products, known as vacuum erection devices, are safe and highly effective, but many men and their partners find them unappealing. Another option is a surgically placed penile implant. However, because implants require surgery (with the risk of surgical complications), only 10 percent of men with erectile dysfunction choose this option. Vascular (blood vessel) surgery sometimes is recommended for young, healthy men who develop impotence after trauma to the groin.
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