Sildenafil for Erectile Dysfunction: A Complete Guide for Indian Men

Penile erection depends on an intact nervous system, so any neurological injury or disease can cause ED. Parkinson's disease, Alzheimer's disease, stroke or head injury can lead to ED by affecting the libido or by interfering with the nerve impulses responsible for erections. Spinal cord injuries cause a decrease in erections related to the extent of the injury. Pelvic surgery – such as radical prostatectomy, cystectomy or colectomy – may injure the nerves that control erection. Long-standing diabetes may affect some nerves and lead to ED. Anything that decreases circulating testosterone in the body, including undergoing chemical or surgical castration or hormone therapy for prostate cancer, decreases libido and may make natural erections more difficult. A variety of conditions and habits can damage penile blood vessels over time and contribute to ED. High LDL ("bad") cholesterol or low HDL ("good") cholesterol Pelvic radiation therapy to treat prostate, bladder or rectal cancer Peyronie's disease (scarring with curvature of the penis) Damage to the penile spongy tissue that results in leaky veins (sometimes associated with aging) ED is common in patients with diabetes, cirrhosis (liver scarring), chronic kidney failure and many other chronic medical issues. Many types of drugs are associated with developing ED. Here are some to be aware of: Certain antidepressants (including Prozac, Zoloft and Paxil) and antipsychotics, especially those that regulate serotonin, noradrenaline or dopamine. Beta-blockers and thiazide agents used to treat high blood pressure. Cimetidine, a drug for acid reflux disease. Estrogens and drugs with antiandrogenic action, such as ketoconazole and spironolactone, can lead to ED, decreased libido and breast enlargement. Many drugs of abuse, including tobacco, marijuana and narcotics. The cavernous nerves travel from the underside of the penis to the prostate. They regulate blood flow within the penis. In the flaccid state, relatively little blood flows in through the arteries and there is free outflow via the small veins exiting the spongy tissue just under the thick tunica (membrane surrounding the spongy tissue).

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The cavernous nerve bundles – the nerves that drive erection – are located next to the prostate gland. During a radical prostatectomy, these nerves may be injured. In many cases, this results in ED that is permanent, although the degree of dysfunction may be lessened through treatment. Because the prostate makes most of the fluid in semen, patients who have undergone prostatectomy don't experience ejaculation. Radiation to the prostate, bladder or rectum also can damage the cavernous nerves and lead to problems with erections and ejaculation. During erection, the smooth muscle in the penis relaxes while the arteries widen to bring in more blood.

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LiSWT may eventually have a role as part of a multimodal protocol, but at this time it should be considered experimental. ED is most commonly related to aging, but it also has a wide range of psychological, neurological, vascular, hormonal and pharmaceutical causes, and may result from radiation and surgical treatments for prostate and bladder cancer. This table lays out the basics, and more detailed explanations for each cause follow. Aging causes a progressive decline in sexual function even in healthy patients. Studies show that as men age, erections become less turgid (stiff) and the force and volume of ejaculation decrease. This expands the three cylinders of erectile tissue in the penis, thus lengthening and enlarging the penis. The expansion of these cylinders compresses the small veins, reducing the outflow of blood. The processes of penile erection are driven by the actions of nerves and blood vessels. Hormones, such as testosterone, also play important roles. Finally, a patient's psychological state and the health of his sexual relationship with a partner are critical determinants of sexual response.

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The drop in testosterone reduces libido and can lead to erection difficulties. Whether these effects are reversible is related to the patient's age, degree of sexual function he had before treatment, and length of time on hormone therapy. Depression and performance anxiety both can lead to ED. Depression is associated with decreases in energy, interest in usual activities and libido. Performance anxiety, work stress and strained personal relationships also can affect erectile function in both conscious and subconscious ways. Stress, anxiety and depression activate the sympathetic nervous system; this is a natural response to any form of stress. However, that response tends to restrict blood flow into the penis and can make erections difficult or impossible. Careful attention to both mental and physical health is important in preserving erectile function. A normal erection requires the penis to have intact nerves and blood vessel systems. Nerves that travel to the penis include fibers from the autonomic nervous system – the part of the nervous system that functions independently of conscious thought – as well as the somatic nervous system – the part responsible for sensation and contraction of muscles attached to the penis. The autonomic nervous system controls the smooth muscle in the penis, prostate and urinary sphincter – muscle that is important for initiating erections and facilitating ejaculation. The autonomic nervous system has two parts. The sympathetic division tends to restrict penile blood flow and is important for closing the bladder neck to prevent urine leakage during sex. The parasympathetic division increases penile blood flow and stimulates erection. Coordination of these two components of the autonomic nervous system is critical to sexual response. Sensory nerves travel to the head and shaft of the penis; these nerves are responsible for conveying sensations (such as touch, temperature and pain) to the brain and may be important for stimulating sexual response. Motor nerves control contraction of the ischiocavernosus and bulbocavernosus muscles, which are necessary to producing a fully rigid erection and to ejecting semen during ejaculation. With sexual stimulation, parasympathetic cavernous nerves release chemicals (primarily nitric oxide) that significantly increase blood flow to the penis. The erectile tissue of the penis rapidly fills with blood and expands, becoming firm and erect. With increasing sexual arousal, the somatic nervous system causes the bulbocavernosus and ischiocavernosus muscles of the penis to contract, forcing additional blood into the penis and making it very rigid. At peak sexual arousal, the sympathetic nervous system causes contraction of the prostate and seminal vesicles, leading to emission, which is the deposition of seminal fluid into the urethra. The sympathetic nervous system also makes the bladder sphincter close, preventing the semen from leaking into the bladder. As the amount of fluid builds in the urethra, pressure increases and the sensation of the inevitability of ejaculation is experienced. The bulbocavernosus muscle, which is under control of the somatic nervous system, then contracts and expels the semen forcibly from the urethra. Detumescence, or loss of erection, occurs shortly thereafter, as the nerves that trigger penile erection stop sending those signals. Saving Your Sex Life: A Guide for Men with Prostate Cancer, by John Mulhall, Hilton Publishing, 2010. Going the Distance: Finding and Keeping Lifelong Love, by Lonnie Barbach and David L. Geisinger, Plume, 1993. Hold Me Tight: Seven Conversations for a Lifetime of Love, by Sue Johnson, Little Brown, Spark, 2008. Stellar book on communication and intimacy for couples. Intimacy With Impotence: The Couple's Guide to Better Sex After Prostate Disease, by Ralph Alterowitz and Barbara Alterowitz, De Capo Lifelong Books, 2004. Written in an honest, compassionate style by a patient with prostate cancer and his wife. Discusses ED in nonmedical terms, with information on treatments. Gives practical advice about sex, covering everything from getting into the mood to common-sense suggestions for achieving sexual satisfaction and intimacy when erections are not possible.

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Also, with age, more time is needed to achieve another erection after orgasm (the so-called refractory period). Sensitivity to touch decreases over time, as do testosterone levels, and both changes can diminish sexual desire. While it's not possible to reverse the effects of aging, there's no age at which a person is too old for sex. Men can avoid or at least delay the most severe manifestations of age-associated sexual dysfunction by remaining physically active, sticking to a healthy diet, avoiding weight gain, not using tobacco, and generally doing things that promote heart health. ED is the most common side effect of both surgical and radiation treatments for prostate cancer. The Lovin' Ain't Over: The Couple's Guide to Better Sex after Prostate Disease, by Ralph and Barbara Alterowitz, Health Education Literary Publisher, 1999.

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These effects usually manifest a few years after treatment. Although ED and absence of ejaculation are common after prostate surgery or radiation, sexual desire and the ability to achieve orgasm are still possible. Doctors may be able to use nerve-sparing approaches in surgery or radiation therapy that can preserve one or both nerve bundles. While the nerve-sparing technique preserves the possibility of penile erections, most patients nevertheless experience a decline in erectile function that may never be completely recovered. Hormone therapy for prostate cancer (androgen deprivation therapy) can also cause ED. Men, Women and Prostate Cancer: A Medical and Psychological Guide for Women and the Men They Love, by Barbara Rubin Wainrib, Jack Maguire and Sandra Haber, New Harbinger Publications, 2000. Prostate Cancer Foundation: funds high-impact research aimed at finding better treatments and a cure. Zero Cancer: a large nonprofit prostate cancer education and support network.