Patients present with an inability to achieve or sustain erection when performing sexual acts. Decreased pleasure, premature ejaculation or nocturnal erection may also be the presenting complaints.

• Pain

  In spite of significant dose escalation, considerable pain relief had not been achieved. Ziconotide had been tried but not only did it not provide pain relief, but it also caused severe side effects in this patient. [ncbi.nlm.nih.gov]

  Call your doctor immediately if you have any of these rarer problems: Curving of the penis with pain during an erection Erection lasts for 4 to 6 hours with severe and continuing pain in the penis Swelling or pain in the testes Bleeding or spotting from [webmd.com]

  Viagra Sildenafil citrate was originally developed in 1991 as a treatment for angina, or chest pain. [medical-dictionary.thefreedictionary.com]

• Inflammation

  The most studied serum biomarkers for ED in men with DM included endothelial dysfunction markers such as serum E-selectin, endothelial progenitor cells, and endothelial microparticles and specific markers of inflammation such as interleukin-10, ratio [ncbi.nlm.nih.gov]

  […] pressure in the buttocks and genital area (the so-called saddle area), as occurs when riding a bicycle or a horse Usually competitive athletes who bicycle for long periods Symptoms occur shortly after riding Only a doctor's examination Prostatitis (inflammation [msdmanuals.com]

• Fatigue

  Supplementation and sun exposure Muskuloskeletal health Heart health Cancer Autoimmune conditions Mental health Developmental disorders Pregnancy and fertility Aging Fitness and exercise Gastrointestinal health Asthma Infections Everyday aliments: fatigue [vitamindcouncil.org]

  Fatigue, Lethargy, or Daytime Sleepiness Fatigue, lethargy, and somnolence (daytime sleepiness) are very common symptoms. [verywellhealth.com]

  Some temporary causes of erectile dysfunction can stem from excessive alcohol consumption, stress, fatigue, or even just having an argument with your partner. [rd.com]

  Depression, stress, fatigue, and sleep disorders can contribute to ED by disrupting feelings of sexual excitement in the brain, according to Mayo Clinic. While sex can be a stress reliever, ED can make sex a stressful chore. [healthline.com]

  […] cancer Parkinson's disease Multiple sclerosis Hormonal disorders such as low testosterone (hypogonadism) Peyronie's disease Surgeries or injuries that affect the pelvic area or spinal cord Some psychological causes include: Depression Anxiety Stress Fatigue [nuh.com.sg]

• Falling

  Hypercortisolism was excluded after the dexamethasone suppression test, levels of DHEAS all falling within the normal range. [ncbi.nlm.nih.gov]

  COGS Sex-bot owners swap USED parts and ’bruised battered dolls’ on creepy web forum dear deidre I'm still tormented by memory of seeing my half-naked husband with sexy sister PERIOD DRAMA How exercising while on your period can cause your tampon to FALL [thesun.co.uk]

  Methods for reversing ED fall into three categories: Short-term treatments These help with achieving or maintaining erections but do not address the underlying cause of ED. [medicalnewstoday.com]

  The combination can lead to a sudden drop in blood pressure, which may cause you to become faint or dizzy, or fall, leading to possible injuries. [niddk.nih.gov]

• Weakness

  […] such as radical prostatectomy) or radiation therapy Only a doctor's examination Spinal cord disorders (such as tumors or injuries) Numbness in the area between the penis and anus Usually other symptoms of spinal cord disorder (for example, numbness and weakness [msdmanuals.com]

  It is important to realize that any illness that is associated with weakness, discomfort, or psychological distress may contribute to erectile dysfunction. [health.am]

  This is probably the most important question as this will give you the clue as to where the main cause of the weak erection lies. [consumerhealthdigest.com]

  They include: Heart failure: One of the most common complications of heart disease, heart failure occurs when your heart becomes damaged and weak, leaving it unable to pump your blood the way it should. [verywellhealth.com]

• Snoring

  […] indexed databases were searched up to May 2017 without time or language restrictions using various key words including: obstructive sleep apnea, sleep apnea syndromes, erectile dysfunction, sleep-disordered breathing, snoring, sexual function, and impotence [ncbi.nlm.nih.gov]

  Testosterone treatment may rarely have certain side effects, such as snoring, increase in symptoms of urinary tract blockage (usually caused by benign prostatic hyperplasia), mood changes, acne, blood clots, and breast enlargement. [msdmanuals.com]

  Your snoring is more persistent than a telemarketer with a quota All that snoring your bedmate complains about? It could be a symptom of sleep apnea, a disorder that causes people to stop breathing for 10 to 30-second increments. [prevention.com]

• Hypertension

  KEYWORDS: Erectile dysfunction; Hypertension [ncbi.nlm.nih.gov]

• Prolapse

  An interesting idea is to use pelvic floor muscle exercises. 19 Beneficial to woman (exercises known as Kegels ) for prolapse and improving sexual feeling, it is becoming clear that they help male sexual satisfaction as well. [consumerhealthdigest.com]

• Fear

  You may develop ED if you have one or more of the following: fear of sexual failure anxiety depression guilt about sexual performance or certain sexual activities low self-esteem stress—about sexual performance, or stress in your life in general Certain [niddk.nih.gov]

  While erectile dysfunction often devastates those affected by it, out of fear, embarrassment, or countless other reasons, few men seek treatment. However, the problem is almost always treatable. It has definite physical and/or psychological causes. [urology.jhu.edu]

  While ED that is purely psychological is not common, many men who experience difficulty with erections may develop anxiety or fear about being able to get an erection the next time they try. [urology.ucsf.edu]

  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. Talk About It! It's not easy to accept that you have ED. [diabetes.org]

  However, worrying about it can increase the likelihood of it happening again due to ‘fear of failure’. Until about 20 years ago, ED was thought to be almost entirely due to psychological causes (in the mind). [sexualadviceassociation.co.uk]

• Low Self-Esteem

  Patients may experience embarrassment, low self-esteem, and problems with their relationships because of it. [docdoc.com.sg]

  Anxiety, guilt, depression, low self-esteem and paranoia about sexual failure are estimated to cause between 10% and 20% of ED cases. How is ED diagnosed? Erectile dysfunction is diagnosed using several different methods. [diabetes.co.uk]

  While ED may contribute to psychological symptoms like depression, anxiety, low self-esteem, and low self-worth, those same symptoms may be an underlying cause of ED, which can lead to a vicious cycle and worsen the condition. [verywellhealth.com]

  You may develop ED if you have one or more of the following: fear of sexual failure anxiety depression guilt about sexual performance or certain sexual activities low self-esteem stress—about sexual performance, or stress in your life in general Certain [niddk.nih.gov]

  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. Talk About It! It's not easy to accept that you have ED. [diabetes.org]

• Anger

  Various psychological conditions, such as performance and anticipatory anxiety, negative expectation, anger, relationship problems (arguments, divorce), mental disorders (depression, schizophrenia, substance abuse, panic disorder, generalized anxiety [health.am]

  […] studies the prevalence of ED has been shown to be associated both with anger and depression. [nature.com]

  Select as many as you like ADHD Abuse Acne Adderall Adoption and Fostering Agoraphobia Alcohol Alzheimers Ambien Amputee Anemia Anger Management Anorexia Anxiety Arthritis Asperger Syndrome Asthma Ativan Autism Back Pain Bedwetting Binge Eating Bipolar [erectile-dysfunction.supportgroups.com]

• Distractibility

  Most men will experience difficulty getting an erection occasionally in their lives (if they are tired, stressed, distracted or have drunk too much alcohol). Erectile Dysfunction (ED) is only a problem when it is persistent or recurring. [lloydsonlinedoctor.ie]

  Even if you are able to get aroused, you may be too distracted to reach orgasm. Sexual performance anxiety leads to a cycle of troubles. [webmd.com]

  For example, you may not get an erection so easily if you are tired, stressed, distracted, or have drunk too much alcohol. For most men it is only temporary and an erection occurs most times when you are sexually aroused. [patient.info]

  "Erections require the nervous system to trigger them, and if the system is depressed or distracted, then it won't happen," he says. [prevention.com]

• Anxiety Disorder

  Various psychological conditions, such as performance and anticipatory anxiety, negative expectation, anger, relationship problems (arguments, divorce), mental disorders (depression, schizophrenia, substance abuse, panic disorder, generalized anxiety [health.am]

• Sexual Dysfunction

  ^ "Neurogenic Sexual Dysfunction in Men and Women" (PDF). Neurologic Bladder, Bowel and Sexual Dysfunction. Retrieved 2015-08-10. ^ "Male Sexual Dysfunction Epidemiology". Erectile dysfunction. Armenian Health Network, Health.am. 2006. [en.wikipedia.org]

  This case report describes four cases of substance abusers with sexual dysfunction, three of them with erectile dysfunction, and the fourth with erectile dysfunction and ejaculatia praecox. [ncbi.nlm.nih.gov]

  Sexual Dysfunction Indian physician Dr. Sudhakar Krishnamurti provides information on a variety of sexual dysfunctions; site offers free consultation by email. [curlie.org]

• Premature Ejaculation

  Video: Premature ejaculation Premature ejaculation affects a surprisingly large number of men. Dr Joe Kosterich defines premature ejaculation and when it may be considered a problem. [myvmc.com]

  Premature ejaculation is divided into lifelong and acquired categories: Lifelong premature ejaculation. With lifelong premature ejaculation, the patient has experienced premature ejaculation since first beginning coitus. [hopkinsmedicine.org]

  Premature ejaculation is often confused with erectile dysfunction. [emedicinehealth.com]

  After he was switched to sertraline 50 mg/day, his erectile dysfunction, premature and spontaneous ejaculation symptoms subsided in 2 weeks. [ncbi.nlm.nih.gov]

  Premature Ejaculation Premature ejaculation is another common problem. Premature ejaculation is when you orgasm/come too quickly for your liking. It can be lifelong issue or of recent onset. Don’t be tempted to respond to commercial calls to action! [clinic66.com.au]

• Prostatic Disease

  Prostate disease and ED Prostate cancer does not cause ED. However, prostate surgery to remove the cancer and radiation therapy to treat prostate cancer can cause ED. Treatment of non-cancerous, benign prostate disease can also cause the condition. [medicalnewstoday.com]

  Erectile impotence occasionally occurs with age and, although attributed by the individual to the aging process itself, it is usually secondary to disorders of aging, such as faulty blood circulation or prostate disease. [britannica.com]

  Parkinson’s disease and Alzheimer’s disease reduced blood flow to the penis, caused by atherosclerosis (clogging of the arteries) conditions like prostate disease, high blood pressure, underactive thyroid gland (hypothyroidism), cardiovascular disease [healthdirect.gov.au]

  […] with maintaining an erection may cause the man to feel anxious about sexual performance, which makes the problem worse medications – prescribed medicines used to treat high blood pressure, high cholesterol, depression and psychiatric disorders, and prostate [betterhealth.vic.gov.au]

• Headache

  Side effects of Stendra include a headache, flushing, runny nose, sore throat, and back pain. Consult your doctor before taking Stendra. Click here to Buy Stendra [accessrx.com]

  […] and sun exposure Muskuloskeletal health Heart health Cancer Autoimmune conditions Mental health Developmental disorders Pregnancy and fertility Aging Fitness and exercise Gastrointestinal health Asthma Infections Everyday aliments: fatigue, pain and headaches [vitamindcouncil.org]

  Just a mild headache and no other changes here Quick easy and quality. I will use again. Excellent. Fast processing, relevant follow up questions. [onlinedoctor.superdrug.com]

  Ph usually presents with symptoms including paroxysmal headache, sweating, palpitations, and hypertension. During a computed tomography (CT) scan in a normotensive 49-year-old man, an incidentaloma of 4.5 cm was detected. [ncbi.nlm.nih.gov]

• Excitement

  Psychosexual dysfunction w inhibited sexual excitement Psychosexual dysfunction, inhibited sexual excitement Sexual disorder, female Clinical Information (im-po-tent) unable to have an erection adequate for sexual intercourse Inability to perform sexual [icd9data.com]

  If you have an emotional disorder, it’ll affect your ability to become sexually excited. Depression and anxiety are associated with increased risk for impotence. Depression is a feeling of sadness, loss of hope, or helplessness. [healthline.com]

  Lead author Arnold Melman, MD, professor and chair of the Department of Urology at Albert Einstein College of Medicine and Montefiore Medical Center, says, "This is an exciting field of research because current treatments for men with erectile dysfunction [web.archive.org]

  When your mind is too stressed out to focus on sex, your body can't get excited either. [webmd.com]

• Confusion

  Thus, because of its pejorative connotation in lay usage and because of confusion about its definition, the word impotence has been eliminated from the technical vocabulary in favour of the term “erectile dysfunction.” [britannica.com]

  Those emotions can range from confusion, anxiety, fear, and even sadness. 10 If you have a partner who is struggling with ED treatment, you can talk to someone who knows exactly what you’re going through — and can help. [coloplastmenshealth.com]

  If your partner suffers from erectile dysfunction, it can be confusing, but communication is key. [netdoctor.co.uk]

  Premature ejaculation is often confused with erectile dysfunction. [emedicinehealth.com]

  Low libido, which is a low interest in having sex, should not be confused with ED, Samadi added. People often have drops in testosterone levels as they age, often called male menopause or "manopause," Samadi said. [livescience.com]

• Apathy

  Depression Apathy, frustration, low levels of self-esteem—these can all inhibit sexual expression. But keep in mind that the usual antidote, antidepressants, can make ED worse. [rd.com]

  If conflicting results are found on the neuropsychiatric effect of apomorphine, growing evidence tends to suggest that it is safe, and could even be beneficial for mood and apathy [ 59, 159 ], as well as induce a decrease in visual hallucinations [ 182 [dx.doi.org]

• Convulsions

  Subcutaneous injections of apomorphine were used in the past to prevent or curtail epileptic seizures [ 47, 86, 90, 139, 140 ], alcohol-induced convulsions, eclampsia, and puerperal convulsions [ 90 ]. [dx.doi.org]

  Majun Sara Indications: Epilepsy and infantile convulsion Administration & Dosage: 5gms with Kh. G.J.U.S. 112. [jinsi-taleem.blogspot.com]

The patient should be inquired about any history of diabetes mellitus, hypertension, cardiovascular diseases, prostate surgery or recent trauma. History of drugs, alcohol and caffeine intake should also be carefully taken. Psychological history regarding any worries, depression or recent significant event e.g. divorce should also be taken.

The physical examination should include the measurement of blood pressure, peripheral pulses and sensations. Examination of the genitalia should be performed to look for any lesions such as penile plaques, small testis, prostate carcinoma or infection. The size and texture of testes should also be inspected. It is also necessary to look for penile abnormalities such as priapism, Peyronie disease and epispadias.

Additional workup includes evaluation of the following:

• Hormonal levels:

1. Free testosterone levels should be checked at 8 am (peak level) if there is depression and decreased libido and secondary sex characteristics.
2. Luteinizing hormone should also be evaluated. If the levels of luteinizing hormone are high with low testosterone levels, Leydig cell failure might be present. On the other hand, if the levels of luteinizing hormone are low, there may be an underlying central nervous system defect.
3. Prolactin levels should be measured to detect hyperfunctioning of the pituitary gland.
4. The levels of thyroid stimulating hormone should be evaluated.

• HBA1c level: This test is helpful in detecting diabetes.
• PSA (Prostate specific antigen): Very high PSA levels indicate for prostatic carcinoma.
• Urinalysis: The presence of red or white blood cells, proteins or glucose indicate an underlying genitourinary or organic disorder.
• Injection of PGE1 into corpus cavernosa: If erection did not occur within 5 minutes of injection of PGE1 into the corpus cavernosa, an underlying abnormality is indicated.
• Biothesiometry: In this procedure, electromagnetic probe is attached on the left and right side of the glans and on the penis. The vibrational sense is then tested and compared with normal.
• Ultrasonography: It is used to measure the blood flow in corpus cavernosa after PGE1 is injected.
• Nocturnal penile tumescence test: In this test, bands are applied on penis for 2 or 3 nights and erection during sleep is evaluated with the help of a graph. It helps in differentiating between psychogenic and organic causes of erectile dysfunction. If erection is normal, the cause is most probably psychogenic.

The best solution for every patient should be identified and the partner should preferably be included in the discussion.

Pharmacological treatment:

These include:

• Phosphodiestrase-5 inhibitors such as sildenafil (Viagra) are very effective in inducing and maintaining erection. In the patients who are refractory to oral phosphodiesterase-5 inhibitors, they can be combined with prostaglandin E1 (PGE1) injections for better efficacy.
• Androgens are available in oral, injectable or gel form. They may have other side effects and should be used with caution.
• Intracavernosal injections of alprostradil are used in 40 ug dose to maintain adequate rigidity for 90 minutes
• Intraurethral PGE1 pallet is used in the patients suffering from diabetes, hypertension or myocardial infarction.
• Vascular Endothelial Growth Factor can also be used.

Devices:

Two types of devices are used for treating erectile dysfunction.

• Constriction devices: These are applied it at the base of the penis in case of venous leak.
• Vacuum devices: These devices create vacuum which draws the blood inside penis and sustains an erection of around 30 minutes. Side effects include hematoma, ecchymosis and perineal pain.

Surgery:

Surgical options include:

• Revascularization: This is performed in young patients with traumatic history by rotating the epigastric artery.
• Penile implant placement: Penile implants are used for organic erectile dysfunction when other treatments have failed. They are of two types; semi-rigid and inflatable. The inflatable type is better tolerated and can be used for 7 to 10 years.

Counselling:

Sexual counselling is an essential part of the treatment. The emotional aspect should be addressed with active involvement of the partner in order to reduce stress and improve the patient’s quality of life.

The all-cause mortality in patients suffering from erectile increases up to 25% with up to 44% higher risk of cerebrovascular events and 62% higher risk of myocardial infarction [10]. 
Associated morbidities include premature ejaculation, hypoactive sex desire, lack of pleasure, and depression.

Erectile dysfunction results from psychogenic causes or due to any organic disease.

Psychogenic causes

The psychogenic causes of erectile dysfunction include depression, performance anxiety and post-traumatic stress disorder

Organic causes

There are many organic abnormalities that may lead to erectile dysfunction.

• Vascular: Vascular disorders such as arterial insufficiency (as in atherosclerosis) and veno-occlusive dysfunction are the most frequent organic causes of erectile dysfunction. Erectile dysfunction may be one of the earliest manifestations of atherosclerosis in some patients [1]. Hypertension is also associated with erectile dysfunction [2].
• Neurologic: Erectile dysfunction may be seen in the patients suffering from epilepsy, multiple sclerosis and Guillain-Barré Syndrome.
• Endocrine: Erectile dysfunction is associated with diabetes mellitus with poor glycaemic control [3] [4]. Hypogonadism and hypothyroidism may also cause erectile dysfunction.
• Medication: Drugs such as antihypertensives, antidepressants, antipsychotics and cholesterol-lowering agents may also cause erectile dysfunction.
• Surgery: Erectile dysfunction may follow radical prostectomy that is performed to treat benign prostatic hyperplasia [5].
• Penile abnormalities: Erectile dysfunction may accompany penile abnormalities such as Peyronie disease, epispadias and priapism.

Erectile dysfunction is more common in the elderly with up to 25% prevalence in men in their 60’s and 89% in those in their 80’s, seriously affecting their quality of life [6] [7]. It is also more common in the lower socioeconomic classes.

Erection of the penis is controlled by a balance between contraction and relaxation of blood vessels, and the action of the ischiocavernous muscle. Contraction is mediated by noradrenaline and endothilin 1 whereas relaxation is mediated by nitric oxide, acetyl choline and adenosine triphosphate.

Erection of the penis requires a coordinated interaction of the peripheral nerves (S2 to S4), vascular events and events in corpora of the penis. Nitric oxide locally relaxes the vasculature of corposal smooth muscle with a half-life of about 5 seconds. Due to this relaxation, blood fills the corposa. Furthermore, there is occlusion of venules beneath tunica albuginea. This raises the intercarvosal pressure as high as 100mmHg. The ischiocavernous muscle then contracts and causes the pressure to rise up to 200 mmHg.

A normal level of testosterone is essential for the proper physiology of erection. Low levels of testosterone are associated with low libido, poor erection and ejaculatory dysfunction [8]. Erectile dysfunction occurs when this complex cycle of events is disrupted due to vascular, endocrine, psychogenic or other causes [9].

The following measures can be helpful in prevention of erectile dysfunction.

• Adequate daily exercise reduces the occurrence of erectile dysfunction and associated organic diseases.
• Weight loss: This reduces inflammation, increases testosterone level and improve the patient’s self-esteem.
• Cessation of smoking is essential.
• Precise glycaemic control in diabetics and pharmacologic treatment of hypertension is necessary to prevent erectile dysfunction.

Erectile dysfunction refers to an inability to achieve or maintain erection for intercourse. An underdiagnosed disorder, it occur either due to sensory abnormalities or decreased blood flow to the penis. The causes of erectile dysfunction may be vascular, neurogenic, psychogenic, endocrine or drug-related.

Phosphodiestrase 5 inhibitors such as sildenafil (Viagra) offer good short term treatment. Penile implants may be considered as long term treatment. If untreated, erectile dysfunction may increase the mortality by increasing vascular accidents such as myocardial infarction and cerebrovascular accidents.

Erectile dysfunction is associated with sexual deprivation which causes anxiety and depression. Exercise, weight reduction and cessation of smoking play huge role in prevention of this disease.

Erectile dysfunction means an inability to achieve or sustain normal erection of the penis. In the younger age, the cause is usually psychogenic. In older individuals, an underlying disease may be present. Diabetes and high blood pressure often cause erectile dysfunction. Erectile dysfunction can be treated by the use of drugs or implants.

1. Nehra A, Jackson G, Miner M, et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clinic proceedings. Aug 2012;87(8):766-778.
2. Burchardt M, Burchardt T, Baer L, et al. Hypertension is associated with severe erectile dysfunction. The Journal of urology. Oct 2000;164(4):1188-1191.
3. Romeo JH, Seftel AD, Madhun ZT, Aron DC. Sexual function in men with diabetes type 2: association with glycemic control. The Journal of urology. Mar 2000;163(3):788-791.
4. De Berardis G, Pellegrini F, Franciosi M, et al. Identifying patients with type 2 diabetes with a higher likelihood of erectile dysfunction: the role of the interaction between clinical and psychological factors. The Journal of urology. Apr 2003;169(4):1422-1428.
5. Larson TR. Current treatment options for benign prostatic hyperplasia and their impact on sexual function. Urology. Apr 2003;61(4):692-698.
6. Lopushnyan NA, Chitaley K. Genetics of erectile dysfunction. The Journal of urology. Nov 2012;188(5):1676-1683.
7. Latini DM, Penson DF, Lubeck DP, Wallace KL, Henning JM, Lue TF. Longitudinal differences in disease specific quality of life in men with erectile dysfunction: results from the Exploratory Comprehensive Evaluation of Erectile Dysfunction study. The Journal of urology. Apr 2003;169(4):1437-1442.
8. Guay AT. Testosterone and erectile physiology. The aging male : the official journal of the International Society for the Study of the Aging Male. Dec 2006;9(4):201-206.
9. Andersson KE. Erectile physiological and pathophysiological pathways involved in erectile dysfunction. The Journal of urology. Aug 2003;170(2 Pt 2):S6-13; discussion S13-14.
10. Miner M, Seftel AD, Nehra A, et al. Prognostic utility of erectile dysfunction for cardiovascular disease in younger men and those with diabetes. American heart journal. Jul 2012;164(1):21-28.