Porn shows that making sex is so easy. In real life many of us struggle with some not-so-sexy issues.

Thanks, Hollywood, for making sex look so easy. In real bedrooms, the rest of us must wrangle with some not-so-sexy issues: unsatisfactory erections, untimely ejaculation, pain, low libido, and more. Yet tending to a problem might save not only a relationship but also your life. “Sexual health problems are very often the first sign of underlying serious medical issues,” says Michael Krychman, medical director of sexual medicine at Hoag Memorial Hospital Presbyterian in Newport Beach, Calif. In women, for example, dulled desire may signal thyroid dysfunction or other hormonal troubles; painful sex could even be an early symptom of pelvic cancer. And erectile dysfunction is now recognized as an early whiff of looming cardiovascular disease. “Your problems shouldn’t be ignored,” he says.

Of course, they are ignored, jammed deeply into back corners of brains, denied. Patients and doctors, it’s clear, have trouble talking sex. Many adults would like to discuss sexual problems, research indicates, but don’t—for fear that doctors will dismiss their concerns, or worse. Women appear especially likely to stay mum, says Anita Clayton, a professor of psychiatry at the University of Virginia and coauthor of Satisfaction: Women, Sex, and the Quest for Intimacy. “Everyone has the right to a satisfying sex life.”

Satisfying sex has been linked to increased longevity, better immunity, better stress-coping abilities, and enhanced connectivity with a partner, says Krychman. So, if you’re sinking, not sailing, between the sheets, help can come in many forms, from sex therapy to various pharmacological options. Most important, if you’re not getting the answers that you’re looking for, “keep seeking,” says Irwin Goldstein, director of sexual medicine at San Diego’s Alvarado Hospital. Your sex life—and health—will thank you. Here are a few places to start:

More Than Just an Erectile Problem

Men, you may not realize it, but you’ve got a canary in your pants. Doctors now recognize that the penis functions as an exquisitely simple gauge for detecting impending heart problems. That’s one reason flagging erections, which affect more than a third of men over the age of 40, should not be ignored. Another: Drugs like Viagra, which celebrated its 10th birthday this year, are just one set—among several—of time-tested treatments.

A decade into the medical revolution that turned erectile dysfunction into a household term, a shift in thinking is afoot. There’s ample evidence that Viagra, Levitra, and Cialis can revitalize a man’s sex life; in trials, Viagra enabled 83 percent of men struggling with ED to have intercourse at least once compared with 45 percent of those taking a placebo. Still, other drugs may be necessary to deal with vascular disease or diabetes, which often accompany ED. And long-impotent men may want to consider options like penile implants because, as vascular disease progresses, the usefulness of Viagra and its kin often wanes.

ED heralds heart trouble because arteries in the penis have about a quarter the diameter of coronary arteries. When plaque builds up, the slender vessels reach the strangling point first—but cardiac problems are often just around the corner. “In many cases, erectile dysfunction is quite literally vascular disease under the belt,” says Randy Fagin, a urologist and director of the Prostate Center of Austin. Symptoms often occur three to four years before cardiac problems, such as chest pain or heart attack, begin to crop up, says Robert Kloner, a cardiologist at the University of Southern California. New guidelines in 2006 advised physicians to consider a man with erectile dysfunction and no cardiac symptoms a cardiac patient until proved otherwise.

In addition to any treatment they may need for vascular disease or diabetes, men have options for fixing ED. Eating better and exercising regularly can not only stave off plaque buildup in arteries but reverse it, research has shown. A 2004 study of obese men with erectile dysfunction found, for example, that erectile function improved in a third of men who adopted healthful behaviors and lost about 30 pounds.

Among medical options, doctors say, one of the best is to inject a medication such as alprostadil into the base or side of the penis. A quick, relatively painless shot, which can produce an erection within 10 minutes, costs about twice as much as a dose of an oral ED drug.

Other ED fixes are made to last. Vacuum pumps put negative pressure on the penis, creating an erection that can be maintained for about 30 minutes by placing an elastic band around its base. Studies report success rates of 70 to 94 percent with the devices, but side effects can include pain, numbness, bruising, and obstructed ejaculation. Surgical implants are pricier but have upsides. Men can inflate the implants at will, using a pump placed in the scrotum. Satisfaction rates are high.

Yet despite the availability of solutions, many harried doctors are not as aggressive as they could be about sleuthing out sexual problems. That puts the burden of speaking up on men.

Pacing Performance

Is premature ejaculation the most common form of male sexual dysfunction? The answer is debated, but one thing is clear: For men who have the problem, it can be a showstopper. “I see young guys who simply cannot establish a relationship with a woman because of this,” says Ira Sharlip, a spokesperson for the American Urological Association.

The past few years have brought a surge of interest from pharmaceutical researchers aiming to relieve the problem with a pill. So far, no medication has been approved for the purpose; the Food and Drug Administration turned down a drug called dapoxetine in 2005. Yet doctors can and often do prescribe drugs that are approved for other conditions, such as the antidepressants paroxetine (Paxil) and fluoxetine (Prozac), which have been shown to lengthen intercourse by a few minutes. Potential downsides, experts say, include diminished intensity of a man’s orgasm and libido and a hampered ability to maintain an erection.

Creams and gels that numb the sensitivity of the penis are another option. They usually contain lidocaine or prilocaine. Studies have shown them to be effective, but some couples find them difficult to use. They generally involve a messy application within a condom and can numb a partner.

A man’s mind-set can play a role. “It’s pretty unusual to see premature ejaculation without some degree of psychological component,” says Fagin, the Prostate Center of Austin urologist. Therapists can work with men to address anxiety, stress, guilt, and depression—and can impart techniques like the “stop and go” method or the “squeeze” method to help men slow down. Honest partner-to-partner communication is also critical, says Barry McCarthy, coauthor of Coping With Premature Ejaculation. For example, he says, some women simply can’t achieve orgasm through vaginal penetration, yet a partner might blame himself unless the couple discusses how the woman can reach a climax.

More often than not, the only real problem may be outsize hopes. In various surveys, between 20 and 40 percent of men complain about the short duration of intercourse. But fewer than 5 percent have a sustained disorder in which they consistently ejaculate in a minute or less, estimates Marcel Waldinger, associate professor in sexual psychopharmacology at the Hague Leyenburg Hospital in the Netherlands.

“Nobody really knows how long is normal. It’s very subjective,” says Martin Miner, a clinical assistant professor of family medicine at Brown University Medical School. In a March survey, sex therapists typically said satisfactory intercourse should last three to 13 minutes. That’s a far cry from the 30-plus minutes that many men say they want.

Overcoming an Anticlimax

It begins as a swelling of excitement and tension. Then, it’s like falling off a cliff. That’s how Linda Banner, 59, describes an orgasm, the deli-cious sensation that she couldn’t experience for the first decade of her sex life.
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There’s new advice for older men who want to preserve their sexual function: have sex, and have it often, researchers say.

In a study that followed nearly 1,000 older Finnish men for five years, researchers found that those who were regularly having sex at the start of the study were at lower risk of developing erectile dysfunction (ED) by the study’s end.

In fact, the more often the men had sex, the lower their ED risk.

The implication, say the researchers, is that men should be encouraged to stay sexually active into their golden years.

Dr. Juha Koskimaki and colleagues at the University of Tampere in Finland report the findings in the American Journal of Medicine. The study included 989 men who were between the ages of 55 and 75 at the outset.

Overall, those who said they had sex less than once per week were twice as likely to develop ED over the next five years as men who had sex at least once a week. Furthermore, compared with men who had sex three or more times per week, their ED risk was increased nearly four-fold.

A number of factors contribute to ED development, many of which could also affect a man’s sexually activity — such as age, diabetes and heart disease. However, after taking account of those factors, sexual activity itself remained linked to ED risk, Koskimaki’s team found.

It may be a matter of “use it or lose it,” according to the researchers. Just as exercise boosts physical fitness, they note, regular sexual activity may help a man preserve his erectile function.

ED occurs when there are problems with blood flow to the penis. Regular sexual activity, Koskimaki’s team writes, may help maintain healthy blood vessel function in the erectile tissue.

Sex Tips for older men

Getting older changes sexual function and desire. Senior sex isn’t the same as it was in your 20s — but it can still be satisfying. Contrary to common myths about sexuality and older adults, sex is not just for the young. Many seniors continue to enjoy their sexuality into their 80s and beyond.

A healthy sex life is not only fulfilling, but it’s also good for other aspects of your life, including your physical health and self-esteem. Adapting to your changing body can help you maintain a healthy and satisfying sex life. But you may have to make a few changes, such as allowing yourself more time to become aroused and talking more openly with your partner.

What changes as men get older?

As men age, testosterone levels decline and changes in desire and sexual function are common. These changes can include:
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Having sex at early age has long been linked to a laundry list of health problems from an increased risk of sexual disease to an increased risk of cancer.

But now, Columbia University and New York state researchers say waiting too long to have sex may carry its own risks.

Losing Virginity Later Linked to Sexual Problems

Those who have sex later, particularly men, seem to experience more sexual dysfunction

While past research has linked early sexual activity to health problems, a new study suggests that waiting too long to start having sex carries risks of its own.

Those who lose their virginity at a later age — around 21 to 23 years of age — tend to be more likely to experience sexual dysfunction problems later, say researchers at Columbia University and the New York State Psychiatric Institute’s HIV Center for Clinical and Behavioral Studies.

The study will appear in the January 2008 issue of the American Journal of Public Health.

Men who lose their virginity in their 20s, in particular, seemed to be more likely to experience sexual problems that include difficulty becoming sexually aroused and reaching orgasm.

The increase in sexual problems was also seen in those who had a comparably earlier sexual debut. And the researchers were quick to point out that there isn’t enough evidence to say for sure whether waiting to have sex necessarily leads to sexual dysfunction down the road.

“Our results do not allow for causal interpretations,” the study authors write.

Rather, they note in the study, there may be factors common to both the delay of sexual activity and the onset of sexual dysfunction — for example, they write, “[M]en with sexual problems may avoid sexual interactions and consequently start later.”

The researchers, who looked at data from the 1996 National Sexual Health Survey, conducted by the Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco, also found that men and women who begin having sex in their early teens had their share of problems. They were more likely to have risky sexual partners, to contract a sexually transmitted infection (STI) and to have sex while under the influence of drugs or alcohol.

While sexuality experts not affiliated with the study agree that it is too early to draw a direct causal link about those who have sex later in life, they say the research offers some interesting new avenues for learning more about certain sexual problems that may be devastating to long-term relationships.

“Clinically, we see many individuals who marry late and who have had little or no sexual experience have great difficulty with developing a rich and satisfying sexual experience within their relationship,” said Eli Coleman, academic chair in sexual health at the University of Minnesota Medical School Program in Human Sexuality.

“Sexual dysfunction is common. Difficulty in consummating the marriage is also a frequent problem,” he added.

Sexual Hang-Ups May Have Physiological Effects

Even though the research stops short of indicating a causal relationship between the age at which one loses his or her virginity and sexual problems they may experience later, Coleman said a number of possible factors could contribute to both of these things.

“From a clinical standpoint, there are often dynamics other than the desire to be abstinent until marriage, such as fear of intimacy, body image problems, alcohol and drug abuse, and sexual dysfunction,” he said. He adds that these factors “might influence the delay of sexual debut as a means of avoiding sexual issues.”

Conditioning that results in shame over sexual expression may also be a factor, said Gina Ogden, a Boston-based sexuality expert and author of “The Heart and Soul of Sex.”

“In my sex therapy office I see countless women and men who have received messages about sex that shame them about their sexual feelings and also terrify them about their sexual behavior.”

These messages, she said, can differ between men and women.

For women, she said, the message that “good girls” should not engage in or enjoy sex may cause women to shut down sexually, leading to dysfunction.

“One of the many dysfunctions that arises is that women never develop the ability to ask for what they want, which leaves them open for life-long disappointment, desire disorders, orgasmic dysfunction, and worse — they’re ripe for abuse and violence,” she said.

For men, the opposite message — that “real men score” — may lead to negative mindsets both among those who lose their virginity early and those who become sexually active only later — mindsets that impact their ability to perform sexually.

Because of the intimate link between the psyche and sexual performance, some sexuality experts say the results of these conditions most likely bring about sexual dysfunction through their psychological impacts.

“There are mostly, if not exclusively, psychological factors at play here, based on poor sexual skills that lead to a poor sexual debut, with lasting negative effects,” said Patti Britton, president of the American Association of Sexuality Educators, Counselors and Therapists and Los Angeles-based author of books including “The Art of Sex Coaching.”

Coleman, however, said that biological factors may also be involved.

“There are probably both biological and psychological factors at play — which cannot be elucidated from this study — but suggests that further research needs to be conducted to explore those factors,” he said.

The Role of Abstinence-Only Education

The researchers say this preliminary evidence may point up detrimental effects of abstinence-only education.

The authors write that the study “lends credence to research showing that abstinence-only education may actually increase health risks,” adding that other approaches may better equip young people to avoid both short- and long-term sexual health consequences.

Many sexuality experts agree.

“In my view as a sexuality therapist since the 1970s, the abstinence-only approach is a public health hazard,” Ogden said. “Sexual relationship is complex, and the moment of marriage is not a magic marker.

“Instead of making young people pledge ‘no’ until marriage, we need to be encouraging them to understand their own sexual responses and orientations, learn how to engage in sexual practices that are safe, and acquire intimacy skills that will lead them into caring relationships.”

Said Coleman, “While abstinence only programs seem to be helpful in delaying onset of sexual activity, there have been suggestions that this approach could cause more problems when sexual debut takes place due to insufficient preparation and knowledge of responsible sexual behavior.

“This study is interesting because it suggests that sexual experimentation is a normal developmental process, and when this process is inhibited or not guided, there can be poor sexual health outcomes.”

And we do have some other reasons to have sex!

Early Teen Sex May Not Be a Path to Delinquency

A new study by University of Virginia clinical psychologists has found that teens who have sex at an early age may be less inclined to exhibit delinquent behavior in early adulthood than their peers who waited until they were older to have sex. The study also suggests that early sex may play a role in helping these teens develop better social relationships in early adulthood.

The finding is published in the current online edition of the Journal of Youth and Adolescence, and runs counter to most assumptions that relate early teen sex to later drug use, criminality, antisocial behavior and emotional problems. The finding also contradicts parts of a study published earlier this year in the same journal that found a connection between early teen sex and later behavioral problems.

The researchers analyzed data on 534 same-sex twin pairs in the United States gathered at three time points over a seven-year period. By examining surveys of twins, the investigators were able to eliminate the genetic and socio-economic variables that otherwise might influence the behaviors of adolescents.

“We got a very surprising finding, particularly that early sex seems to forecast less antisocial behavior a few years later, rather than more,” said Kathryn Paige Harden, the study’s lead author and a Ph.D. candidate in clinical psychology at the University of Virginia.

“There is a cultural assumption in the United States that if teens have sex early it is somehow bad for their psychological health,” Harden said. “But we actually found that teens who had sex earlier seem to have better relationships later. Now we want to find out why.”

Harden says she plans further investigations that will look closely at the contexts of early teen sexual activity, such as the types of relationships, whether they were casual or intimate, how old the partners were, where the sex occurred and why, and how long the relationships lasted. She and her colleagues will then try to relate that to later behaviors and attitudes.

“Our hypothesis as a result of this finding is that teens who become involved in intimate romantic relationships early are having sex early and more often, but that those intimate relationships might later protect them from becoming involved in delinquent acts later,” Harden said. “People assume there is an association between early sex and later delinquency. It could be because teen sex transgresses parental expectations and is seen as impulsive or influenced by peer pressure. But people’s concerns about early sex leading to delinquency may not be warranted.”

Harden does acknowledge that early adolescent sexuality is linked to early pregnancy and disease, but these risks are not inevitable. She notes that in other Western countries, such as Australia, there are similar rates and patterns of teen sexual activity as in the United States, but drastically lower rates of teen pregnancy. She attributes this to a poor level of sexual health knowledge in the United States, ineffective contraceptive use and lower abortion rates.

“I doubt that early sexuality per se reduces delinquency,” said Harden’s advisor and co-author, Robert Emery, a U.Va. professor of psychology. “Early sex probably is a proxy for a strong romantic relationship, and strong relationships — think marriage — encourage pro-social instead of antisocial behavior. So, while our findings do run counter to received wisdom, the implication in my mind is to encourage strong romantic relationships not casual, early sex.”

Harden and her colleagues mined their data from the National Longitudinal Study of Adolescent Health, a nationally representative study designed to assess adolescent health and risk behavior. The data is gleaned from extensive surveys of teens that were collected in three waves between 1994 and 2002.

Erectile dysfunction may boost Parkinson’s risk

Results of a study suggest an association between erectile dysfunction and an increased risk of developing Parkinson’s disease.

The autonomic nervous system, which regulates involuntary bodily functions like heart rate and digestion, is often affected in Parkinson’s disease, and erectile function, which is controlled by the autonomic system, is commonly compromised, the study team notes in a report.

“An important question,” according to Dr. Xiang Gao, of Harvard School of Public Health, Boston, Massachusetts, and colleagues, “is whether erectile dysfunction precedes the onset of motor symptoms of Parkinson’s disease.”

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They examined the question using data from the Health Professionals Follow-up Study. A total of 32,616 men free of Parkinson’s disease in 1986 were included in the present study. In 2000, the men completed a questionnaire with questions on erectile dysfunction in different time periods. The relation between erectile dysfunction before 1986 and Parkinson’s disease risk from 1986 to 2002 was analyzed.

During the 16 years’ follow-up, 200 men were diagnosed with Parkinson’s disease.

Compared to men who reported very good erectile function before 1986, those who reported erectile dysfunction had a significant 3.8-fold increased risk of developing Parkinson’s disease, the investigators report.

“We further explored possible interactions of erectile function with age, body mass index, cigarette smoking, caffeine intake, and the presence of diabetes during follow-up,” Gao’s team explains. “None of these interactions was significant.”

These findings, they conclude, support the hypothesis that the autonomic nervous system “may have been impaired years before Parkinson’s disease is clinically recognizable.”

Parkinson’s Disease: An Introductory Note

Men generally fall prey to erectile dysfunction on account of a host of physiological, psychological and lifestyle factors and among all the possible causes that can accelerate erectile dysfunction in men, Parkinson’s disease is a one such physical factor. All the physical factors of erectile dysfunction, including Parkinson’s disease affect a specific portion of the body and lead to the disorder.

A person might be victim of Parkinson’s disease when he exhibits an array of symptoms such as feeling of stiffness in the limbs, trembling in the face, arms, jaws, legs et al and also individuals showing loss of balance and coordination might be identified as Parkinson’s disease victims by the doctor. Parkinson’s disease, the neurological disease, occurs in the central nervous system and accelerates these symptoms.

Parkinson’s Disease & Erectile Dysfunction: A Glance
Physicians across the world are consistently trying to evaluate the association between Parkinson’s disease and erectile dysfunction. Research results make it evident that in men suffering from Parkinson’s disease, nerve signals are not adequately conveyed from brain to the blood vessels in the penis and this improper transmission of nerve signals may occasionally lead to erectile dysfunction.

It has also been found that depression triggered off on account of Parkinson’s disease and the usage of anti-depressants to treat Parkinson’s disease induced depression are probable factors that can result in erectile dysfunction in men. Depression is one of the significant psychological factors responsible for erectile dysfunction in men and when a person suffers from bouts of depression due to Parkinson’s disease or any other factor, his sexual excitement disappears and he starts to lose interest in sexual activity. Mostly in this or similar situations, men are likely to suffer from erectile dysfunction.

ED Solution for People Suffering from Parkinson’s Disease

After suffering from erectile dysfunction due to Parkinson’s disease, men become incapable of facilitating erections requisite for sexual intercourse and as a consequence their sex lives turn upside down. Nevertheless, the doctor should be immediately consulted once a man suffers from erectile dysfunction and with the help of a physician, erectile dysfunction treatments should be opted for.

Alongside Parkinson’s disease, on suffering from specific disorders such as spinal cord injury and multiple sclerosis, the nerve signals from the brain fail to reach the penis and ultimately lead to erectile dysfunction. Whatever the cause only a doctor can give you the best possible ED solution for your specific ED cause.

A Harbinger of Heart Trouble

Few men may realize it, but if they’re having problems achieving or sustaining erections, it may signal underlying heart trouble.

Erectile dysfunction, or impotence, affects more than 18 million American men, according to a recent study by researchers at the Johns Hopkins Bloomberg School of Public Health.

And now a growing body of research ties erectile dysfunction to vascular diseases, such as coronary artery disease.

“Erectile dysfunction is often caused by vascular disease,” explained Dr. Ian Thompson, professor and chairman of the department of urology at the University of Texas Health Science Center at San Antonio. “A man could perceive decreased blood flow to the penis as being a less strong, a weaker erection, and that may actually be one of the first indicators of blood vessel disease.”

One recent report found men with erectile dysfunction had poorer scores on exercise tests and other measures of coronary heart disease. They also had evidence of significant coronary artery blockages.

“Our study found that among men who were sent for a stress test by their doctor, the presence of erectile dysfunction was a potent predictor — a strong risk factor — for significant underlying heart disease,” said lead researcher Dr. R. Parker Ward, an assistant professor of medicine and director of the cardiology clinic at the University of Chicago Hospitals.

“It was a stronger risk factor than some of the traditional risk factors we commonly ask questions about, things like high blood pressure and high cholesterol,” he added.

Ward’s study, published last year in the Archives of Internal Medicine, involved men who had been referred to cardiologists for nuclear stress testing, a noninvasive way to determine the severity of coronary heart disease. But even among men without heart symptoms, erectile dysfunction is a strong risk factor for future risk of heart attack, he noted.

In the same issue of the journal, Dr. Steven A. Grover and colleagues studied a group of 3,912 Canadian men, nearly half of whom reported having erectile dysfunction in the four weeks prior to visiting their family physicians. The men’s cholesterol, glucose and blood pressure measurements were taken.

“When you calculated a global cardiovascular risk, [it] was strongly associated with the probability that you had erectile dysfunction,” said Grover, a professor of medicine and epidemiology at McGill University Health Centre in Montreal. “And subsequently there have been other studies that have shown that people who have erectile dysfunction are, in fact, more likely to develop cardiovascular disease in the future.”

Thompson and his colleagues provided the first substantial evidence linking erectile dysfunction and subsequent risk for heart disease in a December 2005 report in the Journal of the American Medical Association. Yet the connection is not as well recognized among doctors and patients as cardiologists and urologists think it should be.

“A lot of men don’t have physicians,” Thompson explained. “They may not know what their blood pressure is or their lipid profiles, or they may be smokers, and they may never have been counseled to stop smoking or to reduce their weight.

“We think that if men with erectile dysfunction went to see their physicians, it may enable the interaction with the physician to discuss other coronary risk factors,” he said.

Erectile problems aren’t always vascular in nature. Sometimes the trouble is psychological or neurological and wouldn’t necessarily be associated with a higher risk of heart disease, Ward cautioned. Still, research linking erectile dysfunction (ED) and heart disease suggests that a proactive approach is the best medicine.

“We as physicians should be asking about, and men should be reporting to their physicians, symptoms of ED, so it can be considered as we work to modify their risk — treat blood pressure, cholesterol more aggressively, advise healthy lifestyle changes like exercise and healthy diet,” he said.

Erectile dysfunction, sometimes called “impotence“, is the repeated inability to get or keep an erection firm enough for sexual intercourse. The word “impotence” may also be used to describe other problems that interfere with sexual intercourse and reproduction, such as lack of sexual desire and problems with ejaculation or orgasm. Using the term erectile dysfunction makes it clear that those other problems are not involved.

Erectile dysfunction, or ED, can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections. These variations make defining ED and estimating its incidence difficult. Estimates range from 15 million to 30 million, depending on the definition used. According to the National Ambulatory Medical Care Survey (NAMCS), for every 1,000 men in the United States, 7.7 physician office visits were made for ED in 1985. By 1999, that rate had nearly tripled to 22.3. The increase happened gradually, presumably as treatments such as vacuum devices and injectable drugs became more widely available and discussing erectile function became accepted. Perhaps the most publicized advance was the introduction of the oral drug sildenafil citrate (Viagra) in March 1998. NAMCS data on new drugs show an estimated 2.6 million mentions of Viagra at physician office visits in 1999, and one-third of those mentions occurred during visits for a diagnosis other than ED.

In older men, ED usually has a physical cause, such as disease, injury, or side effects of drugs. Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED. Incidence increases with age: About 5 percent of 40-year-old men and between 15 and 25 percent of 65-year-old men experience ED. But it is not an inevitable part of aging.

ED is treatable at any age, and awareness of this fact has been growing. More men have been seeking help and returning to normal sexual activity because of improved, successful treatments for ED. Urologists, who specialize in problems of the urinary tract, have traditionally treated ED; however, urologists accounted for only 25 percent of Viagra mentions in 1999.

How does an erection occur?

The penis contains two chambers called the corpora cavernosa, which run the length of the organ (see figure 1). A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum.

Erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed.

Figure 1. Arteries (top) and veins (bottom) penetrate the long, filled cavities running the length of the penis—the corpora cavernosa and the corpus spongiosum. Erection occurs when relaxed muscles allow the corpora cavernosa to fill with excess blood fed by the arteries, while drainage of blood through the veins is blocked.

What causes erectile dysfunction (ED)?

Since an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa.

Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED. Diseases—such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic disease—account for about 70 percent of ED cases. Between 35 and 50 percent of men with diabetes experience ED.

Lifestyle choices that contribute to heart disease and vascular problems also raise the risk of erectile dysfunction. Smoking, being overweight, and avoiding exercise are possible causes of ED.

Also, surgery (especially radical prostate and bladder surgery for cancer) can injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.

In addition, many common medicines—blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug)—can produce ED as a side effect.

Experts believe that psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure cause 10 to 20 percent of ED cases. Men with a physical cause for ED frequently experience the same sort of psychological reactions (stress, anxiety, guilt, depression). Other possible causes are smoking, which affects blood flow in veins and arteries, and hormonal abnormalities, such as not enough testosterone.

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