View source for Erectile dysfunction

{{Short description|Form of sexual dysfunction in males}}
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{{Infobox medical condition (new)
| name          = Erectile dysfunction
| synonyms      = Impotence
| image         = 
| caption       = 
| field         = [[urology]], [[sexual medicine]], [[andrology]]
| symptoms      = Inability to gain or maintain an [[erection]]
| complications = 
| onset         = 
| duration      = 
| causes        = Low [[testosterone]] levels,<ref name="Gokce" /><ref name="ed-biotapublishing" /> certain [[prescription drug]]s,<ref name="uptodate" /><ref name="LMCC" /> neurogenic disorders<ref name="uptodate"/><ref name="LMCC"/><ref name="booksexualdisfunction" /><ref name="ed-biotapublishing" />
| risks         = [[Cardiovascular disease]], [[diabetes]], [[smoking]], [[Stress (biology)|stress]],<ref name="health.am" /> [[mental disorder]]s,<ref name="health.am" /> [[ageing]],<ref name="Gokce" /> high [[saturated fat]] diet,<ref name="dietcauseerectiledysfunction" /><ref name="erectandheartdisease" /> kidney disease<ref name="Papa"/>
| diagnosis     = Depends if psychological or physiological; absence of involuntary erections suggests physiological<ref name="LMCC"/>
| differential  = [[Hypogonadism]],<ref name="LMCC"/> [[prolactinoma]]<ref name="LMCC"/>
| prevention    = Adequate [[exercise]]<ref name="EuroGuideline" />
| treatment     = [[Penis pump]],<ref name="lecturioerect" /> [[counseling]] (psychological treatment)<ref name=":0" />
| medication    = [[Sildenafil]]<ref name="Vardi">{{cite journal | vauthors = Vardi M, Nini A | title = Phosphodiesterase inhibitors for erectile dysfunction in patients with diabetes mellitus | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD002187 | date = January 2007 | volume = 2009 | pmid = 17253475 | pmc = 6718223 | doi = 10.1002/14651858.CD002187.pub3 }}</ref>
| prognosis     = 
| frequency     = 
| deaths        = 
| alt           = 
}}
<!-- Definition and symptoms -->
'''Erectile dysfunction''' ('''ED'''), also referred to as '''impotence''', is a form of [[sexual dysfunction]] in males characterized by the persistent or recurring inability to achieve or maintain a [[Human penis|penile]] [[erection]] with sufficient rigidity and duration for satisfactory [[sexual activity]]. It is the most common sexual problem in males and can cause [[psychological distress]] due to its impact on [[self-image]] and sexual relationships.
<!-- Cause and diagnosis -->
Majority of ED cases are attributed to physical risk factors and predictive factors. These factors can be categorized as vascular, neurological, local penile, hormonal, and drug-induced. Notable predictors of ED include aging, [[cardiovascular disease]], [[diabetes mellitus]], [[Hypertension|high blood pressure]], obesity, [[Dyslipidemia|abnormal lipid levels in the blood]], [[hypogonadism]], smoking, [[Depression (mood)|depression]], and [[Adverse drug reactions|medication use]]. Approximately 10% of cases are linked to psychosocial factors, encompassing conditions like depression, stress, and problems within relationships.<ref name=":1">{{Cite book |last1=Rosen |first1=RC |title=UpToDate |last2=Khera |first2=M |publisher=[[UpToDate]] |others=Post, TW |year=2023 |editor-last=O'Leary |editor-first=MP |location=Waltham, MA |chapter=Epidemiology and etiologies of male sexual dysfunction |editor-last2=Cummingham |editor-first2=GR}}</ref>

It is worth noting that the term ''erectile dysfunction'' does not encompass other erection-related disorders, such as [[priapism]].<!-- Treatment and epidemiology-->

Treatment of ED encompasses addressing the underlying causes, lifestyle modification, and addressing psychosocial issues.<ref name="LMCC" /> In many instances, medication-based therapies are used, specifically [[PDE5 inhibitor|PDE5 inhibitors]] like [[sildenafil]].<ref name="Vardi" /> These drugs function by dilating blood vessels, facilitating increased blood flow into the spongy tissue of the penis, analogous to opening a valve wider to enhance water flow in a fire hose. Less frequently employed treatments encompass [[prostaglandin]] pellets inserted into the [[urethra]], the injection of smooth-muscle relaxants and vasodilators directly into the penis, [[Penile implant|penile implants]], the use of [[Penis pump|penis pumps]], and [[vascular surgery]].<ref name="LMCC" /><ref name="pmid15947645">{{cite journal |vauthors=Montague DK, Jarow JP, Broderick GA, Dmochowski RR, Heaton JP, Lue TF, Milbank AJ, Nehra A, Sharlip ID |date=July 2005 |title=Chapter 1: The management of erectile dysfunction: an AUA update |editor-last=Smith |editor-first=JA Jr. |editor-link=Joseph A. Smith Jr. |journal=[[The Journal of Urology]] |publisher=[[Elsevier]] |volume=174 |issue=1 |pages=230–39 |doi=10.1097/01.ju.0000164463.19239.19 |issn=1527-3792 |pmid=15947645 |s2cid=1761196}}</ref>

ED is reported in 18% of males aged 50 to 59 years, and 37% in males aged 70 to 75.<ref name=":1" />

==Signs and symptoms==
ED is characterized by the persistent or recurring inability to achieve or maintain an [[erection]] of the [[Human penis|penis]] with sufficient rigidity and duration for satisfactory [[sexual activity]].<ref name=":1" /> It is defined as the "persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity for at least 3 months."<ref name="LMCC">Chowdhury SH, Cozma AI, Chowdhury JH. Erectile Dysfunction. Essentials for the Canadian Medical Licensing Exam: Review and Prep for MCCQE Part I. 2nd edition. Wolters Kluwer. Hong Kong. 2017.</ref>

===Psychological impact===
ED often has an impact on the emotional well-being of both males and their partners.<ref name=":1" /> Many males do not seek treatment due to feelings of embarrassment. About 75% of diagnosed cases of ED go untreated.<ref>{{cite journal |vauthors=Frederick LR, Cakir OO, Arora H, Helfand BT, McVary KT |date=October 2014 |title=Undertreatment of erectile dysfunction: claims analysis of 6.2 million patients |editor-last=Mulhall |editor-first=JP |journal=[[The Journal of Sexual Medicine]] |publisher=[[Wiley (publisher)|John Wiley & Sons]] on behalf of the [[International Society for Sexual Medicine]] |volume=11 |issue=10 |pages=2546–53 |doi=10.1111/jsm.12647 |issn=1743-6109 |pmid=25059314 |s2cid=9708426}}</ref>

==Causes==
Causes of or contributors to ED include the following:
* Diets high in [[saturated fat]] are linked to [[heart diseases]], and males with heart diseases are more likely to experience ED.<ref name="dietcauseerectiledysfunction">{{cite web |author=<!--Staff writer(s); no by-line.--> |title=Can Your Diet Cause Erectile Dysfunction? |url=https://health.clevelandclinic.org/can-your-diet-cause-erectile-dysfunction/ |date=20 January 2021 |website=www.clevelandclinic.org |location=[[Cleveland, Ohio]] |publisher=[[Cleveland Clinic]] |access-date=4 January 2022}}</ref><ref name="erectandheartdisease">{{cite web |author=<!--Staff writer(s); no by-line.--> |date=17 July 2019 |title=Erectile Dysfunction & Heart Disease |url=https://my.clevelandclinic.org/health/diseases/15029-heart-disease--erectile-dysfunction |website=www.clevelandclinic.org |location=[[Cleveland, Ohio]] |publisher=[[Cleveland Clinic]] |access-date=4 January 2022 |archive-date=4 January 2022 |archive-url=https://web.archive.org/web/20220104083110/https://my.clevelandclinic.org/health/diseases/15029-heart-disease--erectile-dysfunction |url-status=dead }}</ref> By contrast, [[plant-based diet]]s show a lower risk for ED.<ref>{{cite journal |last1=Bauer |first1=SR |last2=Breyer |first2=BN |last3=Stampfer |first3=MJ |last4=Rimm |first4=EB |last5=Giovannucci |first5=EL |last6=Kenfield |first6=SA |date=November 2020 |title=Association of Diet With Erectile Dysfunction Among Men in the Health Professionals Follow-up Study |editor-last=Rivara |editor-first=FP |editor-link=Fred Rivara |journal=[[JAMA Network Open]] |publisher=[[American Medical Association]] |volume=3 |issue=11 |pages=e2021701 |doi=10.1001/jamanetworkopen.2020.21701 |issn=2574-3805 |pmc=7666422 |pmid=33185675 |s2cid=226850997}}</ref><ref>{{cite journal |last1=Lu |first1=Y |last2=Kang |first2=J |last3=Li |first3=Z |last4=Wang |first4=X |last5=Liu |first5=K |last6=Zhou |first6=K |last7=Wang |first7=W |last8=Shen |first8=C |date=May 2021 |title=The association between plant-based diet and erectile dysfunction in Chinese men |journal=Basic and Clinical Andrology |publisher=[[BioMed Central]] |volume=31 |issue=1 |pages=11 |doi=10.1186/s12610-021-00129-5 |doi-access=free |issn=2051-4190 |pmc=8117588 |pmid=33980148 |s2cid=234476038}}</ref><ref>{{cite journal |last1=Russo |first1=GI |last2=Broggi |first2=G |last3=Cocci |first3=A |last4=Capogrosso |first4=P |last5=Falcone |first5=M |last6=Sokolakis |first6=I |last7=Gül |first7=M |last8=Caltabiano |first8=R |last9=Di Mauro |first9=M |date=November 2021 |title=Relationship between Dietary Patterns with Benign Prostatic Hyperplasia and Erectile Dysfunction: A Collaborative Review |journal=[[Nutrients (journal)|Nutrients]] |publisher=[[MDPI]] on behalf of the EAU-YAU Sexual and Reproductive Health Group |volume=13 |issue=11 |pages=4148 |doi=10.3390/nu13114148 |doi-access=free |issn=2072-6643 |pmc=8618879 |pmid=34836403 |s2cid=244453931}}</ref>
*[[Prescription drugs]] (e.g., [[SSRI]]s,<ref>{{cite journal |vauthors=Delgado PL, Brannan SK, Mallinckrodt CH, Tran PV, McNamara RK, Wang F, Watkin JG, Detke MJ |date=June 2005 |title=Sexual functioning assessed in 4 double-blind placebo- and paroxetine-controlled trials of duloxetine for major depressive disorder |editor-last=Freeman |editor-first=MP |journal=[[The Journal of Clinical Psychiatry]] |publisher=Physicians Postgraduate Press |volume=66 |issue=6 |pages=686–92 |doi=10.4088/JCP.v66n0603 |issn=1555-2101 |pmid=15960560 |s2cid=39581439}}</ref> [[beta blockers]], [[antihistamines]],<ref>{{cite journal | url=https://pubmed.ncbi.nlm.nih.gov/7850330/ | pmid=7850330 | year=1995 | last1=Cará | first1=A. M. | last2=Lopes-Martins | first2=R. A. | last3=Antunes | first3=E. | last4=Nahoum | first4=C. R. | last5=De Nucci | first5=G. | title=The role of histamine in human penile erection | journal=British Journal of Urology | volume=75 | issue=2 | pages=220–224 | doi=10.1111/j.1464-410x.1995.tb07315.x }}</ref><ref>{{cite web | url=https://www.webmd.com/erectile-dysfunction/guide/drugs-linked-erectile-dysfunction | title=Drugs That Can Cause Erectile Dysfunction }}</ref><ref>{{cite web | url=https://www.yahoo.com/lifestyle/8-substances-that-may-be-killing-your-erection-127187355828.html | title=8 Substances That May be Killing Your Erection | date=26 August 2015 }}</ref> alpha-2 adrenergic receptor agonists, [[thiazides]], hormone modulators, and [[5α-reductase inhibitors]])<ref name="uptodate">Cunningham GR, Rosen RC. Overview of male sexual dysfunction. In: UpToDate, Martin KA (Ed), UpToDate, Waltham, MA, 2018.</ref><ref name="LMCC" />
* Neurogenic disorders (e.g., [[diabetic neuropathy]], [[temporal lobe epilepsy]], [[multiple sclerosis]], [[Parkinson's disease]], [[multiple system atrophy]])<ref name="uptodate"/><ref name="LMCC"/><ref name="booksexualdisfunction">{{cite book |last1=Azadzoi |first1=Kazem M. |last2=Siroky |first2=Mike B. |title=Male Sexual Function |year=2006 |chapter=Neurogenic Sexual Dysfunction in and |location=[[Cham, Switzerland]] |publisher=[[Springer Nature]] |series=Current Clinical Urology |doi=10.1007/978-1-59745-155-0_9 |isbn=978-1-59745-155-0 |pages=195–226 |s2cid=67897138}}</ref>
* Cavernosal disorders (e.g., [[Peyronie's disease]])<ref name="uptodate"/><ref name=AMN>{{cite web |author=<!--Staff writer(s); no by-line.--> |year=2006 |title=Male Sexual Dysfunction Epidemiology |url=http://www.health.am/sex/more/male_sexual_dysfunction_epid/ |work=Erectile dysfunction |publisher=Armenian Health Network, Health.am |access-date=2007-10-07}}</ref>
* [[Hyperprolactinemia]] (e.g., due to a [[prolactinoma]])<ref name="uptodate"/>
* Psychological causes: [[Stage fright|performance anxiety]], [[stress (biology)|stress]], and [[mental disorders]]<ref name=health.am>{{cite web |vauthors=Lue TF |year=2006 |title=Causes of Erectile Dysfunction |url=http://www.health.am/sex/more/causes_of_erectile_dysfunction/ |work=Erectile dysfunction |publisher=Armenian Health Network, Health.am |access-date=2007-10-07}}</ref>
* Surgery (e.g., radical [[prostatectomy]])<ref name=healthcommunities>{{cite web | title =Erectile Dysfunction Causes | publisher =Healthcommunities.com | work =Erectile Dysfunction | url =http://www.urologychannel.com/erectiledysfunction/causes.shtml | year =1998 | access-date =2007-10-07 | archive-date =2007-10-09 | archive-url =https://web.archive.org/web/20071009220836/http://www.urologychannel.com/erectiledysfunction/causes.shtml | url-status =dead }}</ref>
* [[Ageing]]: after age 40 years, ageing itself is a [[risk factor]] for ED, although numerous other pathologies that may occur  with ageing, such as [[testosterone deficiency]], [[cardiovascular diseases]], or [[diabetes]], among others, appear to have interacting effects<ref name="Gokce">{{cite journal | vauthors = Gökçe Mİ, Yaman Ö | title = Erectile dysfunction in the elderly male | journal = Turkish Journal of Urology | volume = 43 | issue = 3 | pages = 247–251 | date = September 2017 | pmid = 28861293 | pmc = 5562240 | doi = 10.5152/tud.2017.70482 }}</ref><ref name="Meldrum">{{cite journal | vauthors = Meldrum DR, Morris MA, Gambone JC, Esposito K | title = Aging and erectile function | journal = The Aging Male | volume = 23 | issue = 5 | pages = 1115–1124 | date = December 2020 | pmid = 31724458 | doi = 10.1080/13685538.2019.1686756 | s2cid = 208018226 }}</ref>
* [[Kidney disease]]: ED and chronic kidney disease have pathological mechanisms in common, including vascular and hormonal dysfunction, and may share other comorbidities, such as hypertension and diabetes mellitus that can contribute to ED<ref name="Papa">{{cite journal | vauthors = Papadopoulou E, Varouktsi A, Lazaridis A, Boutari C, Doumas M | title = Erectile dysfunction in chronic kidney disease: From pathophysiology to management | journal = World Journal of Nephrology | volume = 4 | issue = 3 | pages = 379–387 | date = July 2015 | pmid = 26167462 | pmc = 4491929 | doi = 10.5527/wjn.v4.i3.379 | doi-access = free }}</ref>
* Lifestyle habits, particularly [[smoking]], which is a key risk factor for ED as it promotes [[Atherosclerosis|arterial narrowing]].<ref>{{cite journal | vauthors = Peate I | title = The effects of smoking on the reproductive health of men | journal = Br J Nurs | volume = 14 | issue = 7 | pages = 362–66 | year = 2005 | pmid = 15924009 | doi=10.12968/bjon.2005.14.7.17939}}</ref><ref>{{cite journal | vauthors = Korenman SG | title = Epidemiology of erectile dysfunction | journal = Endocrine | volume = 23 | issue = 2–3 | pages = 87–91 | year = 2004 | pmid = 15146084 | doi = 10.1385/ENDO:23:2-3:087 | s2cid = 29133230 }}</ref><ref>{{cite journal |vauthors=Kendirci M, Nowfar S, Hellstrom WJ | title = The impact of vascular risk factors on erectile function | journal = Drugs of Today | volume = 41 | issue = 1 | pages = 65–74 | year = 2005 | pmid = 15753970 | doi = 10.1358/dot.2005.41.1.875779 }}</ref> Due to its propensity for causing [[detumescence]] and erectile dysfunction, some studies have described [[tobacco]] as an anaphrodisiacal substance.<ref>{{cite journal |pmid=28723353 |year=2015 |last1=Verze |first1=P. |title=The Link Between Cigarette Smoking and Erectile Dysfunction: A Systematic Review |journal=European Urology Focus |volume=1 |issue=1 |pages=39–46 |last2=Margreiter |first2=M. |last3=Esposito |first3=K. |last4=Montorsi |first4=P. |last5=Mulhall |first5=J. |doi=10.1016/j.euf.2015.01.003}}</ref>
*[[COVID-19]]: preliminary research indicates that COVID-19 viral infection may affect sexual and reproductive health.<ref name="Sansone">{{cite journal | vauthors = Sansone A, Mollaioli D, Ciocca G, Limoncin E, Colonnello E, Vena W, Jannini EA |author7-link=Emmanuele A. Jannini| title = Addressing male sexual and reproductive health in the wake of COVID-19 outbreak | journal = Journal of Endocrinological Investigation | volume = 44 | issue = 2 | pages = 223–231 | date = February 2021 | pmid = 32661947 | pmc = 7355084 | doi = 10.1007/s40618-020-01350-1 }}</ref><ref name="Tian">{{cite journal | vauthors = Tian Y, Zhou LQ | title = Evaluating the impact of COVID-19 on male reproduction | journal = Reproduction | volume = 161 | issue = 2 | pages = R37–R44 | date = February 2021 | pmid = 33434886 | doi = 10.1530/rep-20-0523 | s2cid = 229455124 | doi-access = free }}</ref>
Surgical intervention for a number of conditions may remove anatomical structures necessary to erection, damage nerves, or impair blood supply.<ref name=healthcommunities/> ED is a common complication of treatments for prostate cancer, including [[prostatectomy]] and destruction of the [[prostate]] by [[external beam radiation]], although the prostate gland itself is not necessary to achieve an erection. As far as inguinal hernia surgery is concerned, in most cases, and in the absence of postoperative complications, the operative repair can lead to a recovery of the sexual life of people with preoperative sexual dysfunction, while, in most cases, it does not affect people with a preoperative normal sexual life.<ref name=groin-cause>{{cite journal |vauthors=Zieren J, Menenakos C, Paul M, Müller JM | title = Sexual function before and after mesh repair of inguinal hernia | journal = Journal of Pharmaceutical and Biomedical Analysis | volume = 12 | issue = 1 | pages = 35–38 | year = 2005 | pmid = 15661052 | doi = 10.1111/j.1442-2042.2004.00983.x | s2cid = 30209465 }}</ref>

ED can also be associated with bicycling due to both neurological and vascular problems due to compression.<ref>{{cite journal |vauthors=Sommer F, Goldstein I, Korda JB | s2cid = 34409059 | title = Bicycle riding and erectile dysfunction: a review. | journal = The Journal of Sexual Medicine | volume = 7 | issue = 7 | pages = 2346–58 | date = July 2010 | pmid = 20102446 | doi = 10.1111/j.1743-6109.2009.01664.x }}</ref> The increased risk appears to be about 1.7-fold.<ref>{{cite journal |vauthors=Huang V, Munarriz R, Goldstein I | title = Bicycle riding and erectile dysfunction: an increase in interest (and concern). | journal = The Journal of Sexual Medicine | volume = 2 | issue = 5 | pages = 596–604 | date = September 2005 | pmid = 16422816 | doi = 10.1111/j.1743-6109.2005.00099.x }}</ref>

Concerns that use of pornography can cause ED<ref>{{cite journal | vauthors = Robinson M, Wilson G | title=Porn-Induced Sexual Dysfunction: A Growing Problem | journal=Psychology Today | date = July 11, 2011}}</ref> have little support<ref>{{cite journal |last1=Whelan |first1=Georgina |last2=Brown |first2=Jac |title=Pornography Addiction: An Exploration of the Association Between Use, Perceived Addiction, Erectile Dysfunction, Premature (Early) Ejaculation, and Sexual Satisfaction in Males Aged 18-44 Years |journal=The Journal of Sexual Medicine |date=September 2021 |volume=18 |issue=9 |pages=1582–1591 |doi=10.1016/j.jsxm.2021.06.014 |pmid=34400111 |issn=1743-6109 |quote=There was no evidence for an association between internet pornography use with erectile dysfunction, premature ejaculation, or sexual satisfaction. However, there were small to moderate positive correlations between self-perceived internet pornography addiction and erectile dysfunction, premature ejaculation or sexual dissatisfaction.|doi-access=free }}</ref><ref>{{cite journal |last1=Grubbs |first1=Joshua B. |last2=Gola |first2=Mateusz |title=Is Pornography Use Related to Erectile Functioning? Results From Cross-Sectional and Latent Growth Curve Analyses |journal=The Journal of Sexual Medicine |date=January 2019 |volume=16 |issue=1 |pages=111–125 |doi=10.1016/j.jsxm.2018.11.004 |pmid=30621919 |s2cid=58592884 |issn=1743-6109 |quote=there was evidence of a positive, cross-sectional association between self-reported problematic use and ED, but no consistent association between mere use itself and ED.|doi-access=free }}</ref> in epidemiological studies, according to a 2015 literature review.<ref>{{cite journal | vauthors = Landripet I, Štulhofer A | title = Is Pornography Use Associated with Sexual Difficulties and Dysfunctions among Younger Heterosexual Men? | journal = The Journal of Sexual Medicine | volume = 12 | issue = 5 | pages = 1136–1139 | date = May 2015 | pmid = 25816904 | doi = 10.1111/jsm.12853 | doi-access = free }}</ref> According to [[Gunter de Win]], a Belgian professor and sex researcher, "Put simply, respondents who watch 60 minutes a week and think they're addicted were more likely to report sexual dysfunction than those who watch a care-free 160 minutes weekly."<ref name="Boom 2020">{{cite web | vauthors = Van Boom D | title=Porn addiction is ruining lives, but scientists aren't convinced it's real | website=CNET | date=1 December 2020 | url=https://www.cnet.com/features/porn-addiction-is-ruining-lives-but-scientists-arent-convinced-its-real/ | access-date=2 October 2021}}</ref><ref name="Jacobs Geysemans Van Hal Glazemakers p. ">{{cite journal | vauthors = Jacobs T, Geysemans B, Van Hal G, Glazemakers I, Fog-Poulsen K, Vermandel A, De Wachter S, De Win G | display-authors = 6 | title = Is online pornography consumption linked to offline sexual dysfunction in young men? A multivariate analysis based on an international web-based survey | journal = JMIR Public Health and Surveillance | date = September 2021 | volume = 7 | issue = 10 | pages = e32542 | pmid = 34534092 | doi = 10.2196/32542 | publisher = JMIR Publications Inc. | pmc = 8569536 | quote = '''Conclusions:''' This prevalence of ED in young men is alarmingly high and the results of presented study suggest a significant association with PPC. | doi-access = free }}</ref>

In seemingly rare cases, medications such as SSRIs, [[isotretinoin]] (Accutane) and [[finasteride]] (Propecia) are reported to induce long-lasting [[Iatrogenesis|iatrogenic]] disorders characterized by sexual dysfunction symptoms, including erectile dysfunction in males; these disorders are known as [[Selective serotonin reuptake inhibitor#Sexual dysfunction|post-SSRI sexual dysfunction]] (PSSD), post-retinoid sexual dysfunction/post-Accutane syndrome (PRSD/PAS), and [[Finasteride|post-finasteride syndrome (PFS)]]. These conditions remain poorly understood and lack effective treatments, although they have been suggested to share a common etiology.<ref>{{Cite journal |last1=Giatti |first1=Silvia |last2=Diviccaro |first2=Silvia |last3=Panzica |first3=Giancarlo |last4=Melcangi |first4=Roberto Cosimo |date=August 2018 |title=Post-finasteride syndrome and post-SSRI sexual dysfunction: two sides of the same coin? |url=https://pubmed.ncbi.nlm.nih.gov/29675596/ |journal=Endocrine |volume=61 |issue=2 |pages=180–193 |doi=10.1007/s12020-018-1593-5 |issn=1559-0100 |pmid=29675596|s2cid=4974636 }}</ref>

==Pathophysiology==
Penile erection is managed by two mechanisms: the reflex erection, which is achieved by directly touching the penile shaft, and the psychogenic erection, which is achieved by erotic or emotional stimuli. The former involves the peripheral nerves and the lower parts of the spinal cord, whereas the latter involves the [[limbic system]] of the [[Human brain|brain]]. In both cases, an intact neural system is required for a successful and complete erection. Stimulation of the penile shaft by the [[nervous system]] leads to the secretion of [[nitric oxide]] (NO), which causes the relaxation of the smooth muscles of the [[Corpus cavernosum penis|corpora cavernosa]] (the main erectile tissue of the penis), and subsequently penile erection.  Additionally, adequate levels of [[testosterone]] (produced by the [[testes]]) and an intact [[pituitary gland]] are required for the development of a healthy erectile system. As can be understood from the mechanisms of a normal erection, impotence may develop due to hormonal deficiency, disorders of the neural system, lack of adequate penile blood supply or psychological problems.<ref name="ed-biotapublishing">{{cite book | vauthors = Shamloul R, Bella AJ | title = Erectile Dysfunction | url = https://books.google.com/books?id=elg-AwAAQBAJ&pg=PR6 | date = 2014-03-01 | publisher = Biota Publishing | isbn = 978-1-61504-653-9 | pages = 6– }}</ref> [[Spinal cord injury]] causes [[Sexuality after spinal cord injury|sexual dysfunction]], including ED. Restriction of blood flow can arise from impaired [[endothelium|endothelial]] function due to the usual causes associated with [[coronary artery disease]], but can also be caused by [[over-illumination|prolonged exposure to bright light]].{{Citation needed|date=January 2020}}

==Diagnosis==
In many cases, the diagnosis can be made based on the person's history of symptoms. In other cases, a physical examination and [[blood test|laboratory investigations]] are done to rule out more serious causes such as [[hypogonadism]] or [[prolactinoma]].<ref name="LMCC"/>

One of the first steps is to distinguish between physiological and psychological ED. Determining whether involuntary erections are present is important in eliminating the possibility of psychogenic causes for ED.<ref name="LMCC"/> Obtaining full erections occasionally, such as [[nocturnal penile tumescence]] when asleep (that is, when the mind and psychological issues, if any, are less present), tends to suggest that the physical structures are functionally working.<ref name="pmid7483128">{{cite journal |vauthors=Levine LA, Lenting EL | title = Use of nocturnal penile tumescence and rigidity in the evaluation of male erectile dysfunction | journal = Urol. Clin. North Am. | volume = 22 | issue = 4 | pages = 775–88 | year = 1995 | pmid = 7483128 }}</ref><ref name="WebMD">{{cite web|title = Tests for Erection Problems|publisher = [[WebMD]], Inc|url = http://www.webmd.com/erectile-dysfunction/tests-for-erection-problems|access-date = 2007-03-03}}</ref> Similarly, performance with [[masturbation|manual stimulation]], as well as any performance anxiety or acute situational ED, may indicate a psychogenic component to ED.<ref name="LMCC"/>

Another factor leading to ED is [[diabetes mellitus]], a well known cause of [[neuropathy]].<ref name="LMCC"/> ED is also related to generally poor physical health, poor dietary habits, [[obesity]], and most specifically [[cardiovascular disease]], such as [[coronary artery disease]] and [[peripheral vascular disease]].<ref name="LMCC"/>  Screening for cardiovascular risk factors, such as [[smoking]], [[dyslipidemia]], [[hypertension]], and [[alcoholism]], is helpful.<ref name="LMCC"/>

In some cases, the simple search for a previously undetected [[groin hernia (disambiguation)|groin hernia]]<!--intentional link to DAB page--> can prove useful since it can affect sexual functions in males and is relatively easily curable.<ref name="groin-cause"/>

The current diagnostic and statistical manual of mental diseases ([[DSM-IV]]) lists ED.

===Ultrasonography===
[[File:Ultrasonography of dilated penile sinusoids during erection.jpg|thumb|Transverse ultrasound image, ventral view of the penis. Image obtained after induction of an erection, 15 min after injection of prostaglandin E1, showing dilated sinusoids (arrows).<ref name="FernandesSouza2018"/>]]
[[Penile ultrasonography]] with [[doppler ultrasound|doppler]] can be used to examine the erect penis. Most cases of ED of organic causes are related to changes in blood flow in the corpora cavernosa, represented by occlusive artery disease (in which less blood is allowed to enter the penis), most often of atherosclerotic origin, or due to failure of the veno-occlusive mechanism (in which too much blood circulates back out of the penis). Before the Doppler sonogram, the penis should be examined in B mode, in order to identify possible tumors, fibrotic plaques, calcifications, or hematomas, and to evaluate the appearance of the cavernous arteries, which can be tortuous or atheromatous.<ref name="FernandesSouza2018">Originally copied from:<br>{{cite journal | vauthors = Fernandes MA, de Souza LR, Cartafina LP | title = Ultrasound evaluation of the penis | journal = Radiologia Brasileira | volume = 51 | issue = 4 | pages = 257–261 | year = 2018 | pmid = 30202130 | pmc = 6124582 | doi = 10.1590/0100-3984.2016.0152 }}<br>[[Creative Commons|CC-BY]] license</ref>

Erection can be induced by injecting 10–20&nbsp;µg of prostaglandin E1, with evaluations of the arterial flow every five minutes for 25–30&nbsp;min (see image). The use of prostaglandin E1 is contraindicated in patients with predisposition to priapism (e.g., those with sickle cell anemia), anatomical deformity of the penis, or penile implants. Phentolamine (2&nbsp;mg) is often added. Visual and tactile stimulation produces better results. Some authors recommend the use of sildenafil by mouth to replace the injectable drugs in cases of contraindications, although the efficacy of such medication is controversial.<ref name="FernandesSouza2018"/>

Before the injection of the chosen drug, the flow pattern is monophasic, with low systolic velocities and an absence of diastolic flow. After injection, systolic and diastolic peak velocities should increase, decreasing progressively with vein occlusion and becoming negative when the penis becomes rigid (see image below). The reference values vary across studies, ranging from > 25&nbsp;cm/s to > 35&nbsp;cm/s. Values above 35&nbsp;cm/s indicate the absence of arterial disease, values below 25&nbsp;cm/s indicate arterial insufficiency, and values of 25–35&nbsp;cm/s are indeterminate because they are less specific (see image below). The data obtained should be correlated with the degree of erection observed. If the peak systolic velocities are normal, the final diastolic velocities should be evaluated, those above 5&nbsp;cm/s being associated with venogenic ED.<ref name="FernandesSouza2018"/>

<gallery mode="packed" heights="200">
File:Doppler ultrasonography of cavernous artery flow in flaccid and erected state.jpg|Graphs representing the color Doppler spectrum of the flow pattern of the cavernous arteries during the erection phases. A: Single-phase flow with minimal or absent diastole when the penis is flaccid. B: Increased systolic flow and reverse diastole 25 min after injection of prostaglandin.<ref name="FernandesSouza2018"/>
File:Doppler ultrasonography of cavernous arterial insufficiency.jpg|Longitudinal, ventral ultrasound of the penis, with pulsed mode and color Doppler. Flow of the cavernous arteries at 5, 15, and 25 min after prostaglandin injection (A, B, and C, respectively). The cavernous artery flow remains below the expected levels (at least 25–35&nbsp;cm/s), which indicates ED due to arterial insufficiency.<ref name="FernandesSouza2018"/>
</gallery>

===Other workup methods===
;Penile nerves function:Tests such as the [[bulbocavernosus reflex]] test are used to ascertain whether there is enough nerve sensation in the penis. The physician squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal. A physician measures the latency between squeeze and contraction by observing the anal sphincter or by feeling it with a gloved finger in the anus.<ref>{{cite journal | vauthors = Vodušek DB, Deletis V | title = Intraoperative Neurophysiological Monitoring of the Sacral Nervous System | journal = Neurophysiology in Neurosurgery, A Modern Intraoperative Approach | pages = 153–165 | date = January 2002 | doi = 10.1016/B978-012209036-3/50011-1 | isbn = 9780122090363 | s2cid = 78605592 }}</ref>

;Nocturnal penile tumescence (NPT):It is normal for a man to have five to six erections during sleep, especially during [[Rapid eye movement sleep|rapid eye movement (REM)]]. Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge. A significant proportion{{how many|date=December 2022}} of males who have no sexual dysfunction nonetheless do not have regular nocturnal erections.{{citation needed|date=March 2021}}

;Penile biothesiometry:This test uses electromagnetic vibration to [[Biothesiometry|evaluate sensitivity]] and nerve function in the glans and shaft of the penis.<ref>{{Citation |last1=Mulhall |first1=John P. |title=Biothesiometry |date=2017 |url=http://link.springer.com/10.1007/978-3-319-42178-0_2 |work=Atlas of Office Based Andrology Procedures |pages=9–14 |editor-last=Mulhall |editor-first=John P. |place=Cham |publisher=Springer International Publishing |language=en |doi=10.1007/978-3-319-42178-0_2 |isbn=978-3-319-42176-6 |access-date=2022-02-27 |last2=Jenkins |first2=Lawrence C. |editor2-last=Jenkins |editor2-first=Lawrence C.}}</ref>

;Dynamic infusion cavernosometry (DICC):Technique in which fluid is pumped into the penis at a known rate and pressure. It gives a measurement of the vascular pressure in the corpus cavernosum during an erection.{{citation needed|date=December 2020}}

;Corpus cavernosometry:[[#Corpus Cavernosometry|Cavernosography]] measurement of the vascular pressure in the corpus cavernosum.  Saline is infused under pressure into the corpus cavernosum with a butterfly needle, and the flow rate needed to maintain an erection indicates the degree of venous leakage. The leaking veins responsible may be visualized by infusing a mixture of saline and x-ray contrast medium and performing a cavernosogram.<ref>{{cite journal |vauthors=Dawson C, Whitfield H | title = ABC of urology. Subfertility and male sexual dysfunction | journal = BMJ | volume = 312 | issue = 7035 | pages = 902–05 | date = April 1996 | pmid = 8611887 | pmc = 2350600 | doi = 10.1136/bmj.312.7035.902 }}</ref> In Digital Subtraction Angiography (DSA), the images are acquired digitally.{{citation needed|date=December 2020}}

;Magnetic resonance angiography (MRA): This is similar to [[magnetic resonance imaging]]. Magnetic resonance angiography uses magnetic fields and radio waves to provide detailed images of the blood vessels. The doctor may inject into the patient's bloodstream a contrast agent, which causes vascular tissues to stand out against other tissues, so that information about blood supply and vascular anomalies is easier to gather.{{citation needed|date=December 2020}}

==Treatment==
[[File:18971230 Male sexual dysfunction ads - The Helena Weekly Independent.jpg|thumb|upright=1.5| One ad from 1897 claims to restore "perfect manhood. Failure is impossible with our method".<ref name=1897ads/> Another "will quickly cure you of all nervous or diseases of the generative organs, such as Lost Manhood, Insomnia, Pains in the Back, Seminal Emissions, Nervous Debility, Pimples, Unfitness to Marry, Exhausting Drains, Varicocele and Constipation".<ref name=1897ads>{{cite news |title=Wonderful Medicine Free / Manhood Restored / The Great Hudyan |url=https://newspaperarchive.com/helena-weekly-independent-dec-30-1897-p-7/ |work=The Helena Weekly Independent |date=December 30, 1897 |location=Helena, Montana, U.S. |pages=7–8}} (and [https://newspaperarchive.com/helena-weekly-independent-dec-30-1897-p-8/ page 8])</ref> The U.S. Federal Trade Commission warns that "phony cures" exist even today.<ref name=FTC_PhonyCures>{{cite web |title=Phony Cures for Erectile Dysfunction |url=https://www.consumer.ftc.gov/articles/0202-phony-cures-erectile-dysfunction |website=ftc.gov |publisher=U.S. Federal Trade Commission |archive-url=https://web.archive.org/web/20200430095049/https://www.consumer.ftc.gov/articles/0202-phony-cures-erectile-dysfunction |archive-date=April 30, 2020 |url-status=live}}</ref> ]]
Treatment depends on the underlying cause. In general, [[exercise]], particularly of the [[aerobic exercise|aerobic]] type, is effective for preventing ED during midlife.<ref name="EuroGuideline">Wespes E (chair), et al.
Guidelines on Male Sexual Dysfunction: Erectile dysfunction and  premature ejaculation. European Association of Urology 2013{{rp|6, 18–19}}<!--Not sure how to fix the rp template or how it is supposed to be placed--></ref> Counseling can be used if the underlying cause is psychological, including how to lower stress or anxiety related to sex.<ref name=":0" /> Medications by mouth and vacuum erection devices are first-line treatments,<ref name=EuroGuideline/>{{rp|20, 24}} followed by injections of drugs into the penis, as well as penile implants.<ref name=EuroGuideline/>{{rp|25–26}} Vascular reconstructive surgeries are beneficial in certain groups.<ref name="elsevier.com">{{Cite web|url=https://www.elsevier.com/books/encyclopedia-of-reproduction/skinner/978-0-12-811899-3|title=Encyclopedia of Reproduction - 2nd Edition|website=www.elsevier.com|access-date=2019-01-17}}</ref> Treatments, other than surgery, do not fix the underlying physiological problem, but are used as needed before sex.<ref>{{Cite web|url=https://www.urologyhealth.org/urologic-conditions/erectile-dysfunction|title=What is Erectile Dysfunction? - Urology Care Foundation|website=www.urologyhealth.org|access-date=2019-08-05}}</ref>

===Medications===
The [[PDE5 inhibitor]]s [[sildenafil]] (Viagra), [[vardenafil]] (Levitra) and [[tadalafil]] (Cialis) are prescription drugs which are taken by mouth.<ref name=EuroGuideline/>{{rp|20–21}} As of 2018, sildenafil is available in the UK without a prescription.<ref>{{cite news |url=https://www.bbc.com/news/health-42155489 |title=Viagra can be sold over the counter |date=28 November 2017 |work=BBC News |access-date=5 April 2018}}</ref> Additionally, a cream combining [[alprostadil]] with the permeation enhancer [[DDAIP]] has been approved in Canada as a [[First-line treatment|first line treatment]] for ED.<ref>{{cite web| vauthors = Bujdos B |title=New Topical Erectile Dysfunction Drug Vitaros Approved in Canada; Approved Topical Drug Testim Proves Helpful for Erectile Dysfunction|url=http://www.accessrx.com/blog/current-health-news/vitaros-testim-topical-drugs-treat-erectile-dysfunction-a1115|access-date=15 April 2011}}</ref> Penile injections, on the other hand, can involve one of the following medications: [[papaverine]], [[phentolamine]], and [[prostaglandin E1]], also known as [[alprostadil]].<ref name=EuroGuideline/> In addition to injections, there is an alprostadil [[suppository]] that can be inserted into the urethra. Once inserted, an erection can begin within 10 minutes and last up to an hour.<ref name=":0">{{Cite web|url=https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction/treatment|title=Treatment for erectile dysfunction {{!}}|website=US National Institute of Diabetes and Digestive and Kidney Diseases|language=en-US|access-date=2019-08-04}}</ref> Medications to treat ED may cause a side effect called [[priapism]].<ref name=":0" />

====Prevalence of medical diagnosis====
In a study published in 2016, based on US health insurance claims data, out of 19,833,939 US males aged ≥18 years, only 1,108,842 (5.6%), were medically diagnosed with erectile dysfunction or on a PDE5I prescription (''μ'' age 55.2 years, ''σ'' 11.2 years). Prevalence of diagnosis or prescription was the highest for age group 60–69 at 11.5%, lowest for age group 18–29 at 0.4%, and 2.1% for 30–39, 5.7% for 40–49, 10% for 50–59, 11% for 70–79, 4.6% for 80–89, 0.9% for ≥90, respectively.<ref name="US study">{{cite journal | vauthors = Mulhall JP, Luo X, Zou KH, Stecher V, Galaznik A | title = Relationship between age and erectile dysfunction diagnosis or treatment using real-world observational data in the USA | journal = International Journal of Clinical Practice | volume = 70 | issue = 12 | pages = 1012–1018 | date = December 2016 | pmid = 28032424 | pmc = 5540144 | doi = 10.1111/ijcp.12908 }}</ref>

===Focused shockwave therapy===
[[Extracorporeal shockwave therapy|Focused shockwave therapy]] involves passing short, high frequency acoustic pulses through the skin and into the penis. These waves break down any plaques within the blood vessels, encourage the formation of new vessels, and stimulate repair and tissue regeneration.<ref>{{cite journal | vauthors = Vardi Y, Appel B, Jacob G, Massarwi O, Gruenwald I | title = Can low-intensity extracorporeal shockwave therapy improve erectile function? A 6-month follow-up pilot study in patients with organic erectile dysfunction | journal = European Urology | volume = 58 | issue = 2 | pages = 243–8 | date = August 2010 | pmid = 20451317 | doi = 10.1016/j.eururo.2010.04.004 }}</ref><ref>{{Cite web|url=https://edclinics.co.uk/shockwave-therapy/|title=Shockwave Therapy for Erectile Dysfunction &#124; ED Clinics|date=27 July 2020}}</ref>

Focused shockwave therapy appears to work best for males with vasculogenic ED, which is a blood vessel disorder that affects blood flow to tissue in the penis. The treatment is painless and has no known side effects. Treatment with shockwave therapy can lead to a significant improvement of the IIEF (International Index of Erectile Function).<ref>{{cite web | title = International Index of Erectile Function (IIEF): Guidelines on Clinical Application of IIEF patient Questionnaire | work = Department of Urology | publisher = Addenbrooke's Hospital | location = Hills Road, Cambridge, CB2 0QQ | url = https://www.camurology.org.uk/wp-content/uploads/interpretation-of-the-iief.pdf | access-date = 2021-09-22 | archive-date = 2021-10-26 | archive-url = https://web.archive.org/web/20211026022523/https://www.camurology.org.uk/wp-content/uploads/interpretation-of-the-iief.pdf | url-status = dead }}</ref><ref>{{cite journal | vauthors = Man L, Li G | title = Low-intensity Extracorporeal Shock Wave Therapy for Erectile Dysfunction: A Systematic Review and Meta-analysis | journal = Urology | volume = 119 | pages = 97–103 | date = September 2018 | pmid = 28962876 | doi = 10.1016/j.urology.2017.09.011 | s2cid = 7048621 }}</ref><ref>{{cite journal | vauthors = Clavijo RI, Kohn TP, Kohn JR, Ramasamy R | title = Effects of Low-Intensity Extracorporeal Shockwave Therapy on Erectile Dysfunction: A Systematic Review and Meta-Analysis | journal = The Journal of Sexual Medicine | volume = 14 | issue = 1 | pages = 27–35 | date = January 2017 | pmid = 27986492 | doi = 10.1016/j.jsxm.2016.11.001 }}</ref>

=== Testosterone ===
[[File:Testosteron - Suplimation - Gel - Inhalt 88 g.jpg|thumb|Testosterone Supplementation - Content 88&nbsp;g Gel]]
Men with low levels of testosterone can experience ED. Taking testosterone may help maintain an erection.<ref name="cdc">{{Cite web|url=https://www.cdc.gov/diabetes/library/features/diabetes-and-men.html|title=Men and diabetes|date=2019-04-01|publisher=US Centers for Disease Control and Prevention|language=en-us|access-date=2019-08-04}}</ref> Males with [[type 2 diabetes]] are twice as likely to have lower levels of testosterone, and are three times more likely to experience ED than non-diabetic men.<ref name=cdc/>

===Pumps===
{{Main|penis pump}}

A vacuum erection device helps draw blood into the penis by applying negative pressure. This type of device is sometimes referred to as [[penis pump]] and may be used just prior to [[sexual intercourse]]. Several types of FDA approved vacuum therapy devices are available under prescription. When pharmacological methods fail, a purpose-designed external vacuum pump can be used to attain erection, with a separate compression ring fitted to the base of the penis to maintain it. These pumps should be distinguished from other [[penis pump]]s (supplied without compression rings) which, rather than being used for temporary treatment of impotence, are claimed to increase penis length if used frequently, or vibrate as an aid to [[masturbation]]. More drastically, inflatable or rigid penile implants may be fitted surgically.<ref name="lecturioerect">{{cite web |url=https://www.lecturio.com/concepts/erectile-dysfunction/| title=Erectile Dysfunction
|website=The Lecturio Medical Concept Library |access-date= 21 July 2021}}</ref>

=== Vibrators ===
{{Main|Vibrator (sex toy)}}

The vibrator was invented in the late 19th century as a medical instrument for pain relief and the treatment of various ailments. Sometimes described as a massager, the vibrator is used on the body to produce [[sexual stimulation]]. Several clinical studies have found vibrators to be an effective solution for Erectile Dysfunction.<ref>{{Cite journal |last1=Ismail |first1=Ezzat A. |last2=El-Sakka |first2=Ahmed I. |date=2016-06-01 |title=Innovative trends and perspectives for erectile dysfunction treatment: A systematic review |journal=Arab Journal of Urology |language=en |volume=14 |issue=2 |pages=84–93 |doi=10.1016/j.aju.2016.04.002 |pmid=27493808 |issn=2090-598X|pmc=4963167 }}</ref><ref>{{Cite journal |last1=Miranda |first1=Eduardo P. |last2=Taniguchi |first2=Hisanori |last3=Cao |first3=David L. |last4=Hald |first4=Gert M. |last5=Jannini |first5=Emmanuele A. |last6=Mulhall |first6=John P. |date=2019-06-01 |title=Application of Sex Aids in Men With Sexual Dysfunction: A Review |journal=The Journal of Sexual Medicine |language=en |volume=16 |issue=6 |pages=767–780 |doi=10.1016/j.jsxm.2019.03.265 |pmid=31029536 |issn=1743-6095|pmc=8519170 }}</ref> Examples of FDA registered vibrators for erectile dysfunction include [[MysteryVibe]]'s Tenuto<ref>{{Cite journal |last1=Rodríguez Martínez |first1=Jesús E. |last2=Alcaina |first2=Leandro R. |last3=Agullo |first3=Guillermo H. |date=2022-11-01 |title=Improved erectile function after focal muscle vibrations therapy in a patient with neurogenic erectile dysfunction: a case report |url=https://www.sciencedirect.com/science/article/pii/S1743609522015867 |journal=The Journal of Sexual Medicine |language=en |volume=19 |issue=11, Supplement 4 |pages=S69 |doi=10.1016/j.jsxm.2022.08.012 |s2cid=253821604 |issn=1743-6095}}</ref> and Reflexonic's Viberect.<ref>{{Cite journal |last1=Clavell Hernandez |first1=J. |last2=Wu |first2=Q. |last3=Zhou |first3=X. |last4=Nguyen |first4=J. N. |last5=Davis |first5=J. W. |last6=Wang |first6=R. |date=2018-07-01 |title=319 Penile vibratory stimulation in penile rehabilitation after radical prostatectomy: a randomized, controlled trial |url=https://www.sciencedirect.com/science/article/pii/S1743609518305551 |journal=The Journal of Sexual Medicine |series=Proceedings of the 21st World Meeting on Sexual Medicine |language=en |volume=15 |issue=7, Supplement 3 |pages=S253–S254 |doi=10.1016/j.jsxm.2018.04.282 |s2cid=58240260 |issn=1743-6095}}</ref>

=== Surgery ===
{{Main|Penile implant}}
Often, as a last resort, if other treatments have failed, the most common procedure is [[Penile implant|prosthetic implants]] which involves the insertion of artificial rods into the penis.<ref name=EuroGuideline/>{{rp|26}} Some sources show that vascular reconstructive surgeries are viable options for some people.<ref name="elsevier.com"/>

===Alternative medicine===
The [[United States Food and Drug Administration|Food and Drug Administration]] (FDA) does not recommend alternative therapies to treat sexual dysfunction.<ref>{{Cite web|url=http://www.medscape.com/viewarticle/562177|title=Dangers of Sexual Enhancement Supplements|website=Medscape}}</ref> Many products are advertised as "[[herbal viagra]]" or "natural" sexual enhancement products, but no clinical trials or scientific studies support the effectiveness of these products for the treatment of ED, and synthetic chemical compounds similar to sildenafil have been found as [[adulterant]]s in many of these products.<ref>{{cite journal |vauthors=Gryniewicz CM, Reepmeyer JC, Kauffman JF, Buhse LF | title = Detection of undeclared erectile dysfunction drugs and analogues in dietary supplements by ion mobility spectrometry | journal = Journal of Pharmaceutical and Biomedical Analysis | volume = 49 | issue = 3 | pages = 601–06 | year = 2009 | pmid = 19150190 | doi = 10.1016/j.jpba.2008.12.002 }}</ref><ref>{{cite journal |vauthors=Choi DM, Park S, Yoon TH, Jeong HK, Pyo JS, Park J, Kim D, Kwon SW | title = Determination of analogs of sildenafil and vardenafil in foods by column liquid chromatography with a photodiode array detector, mass spectrometry, and nuclear magnetic resonance spectrometry | journal = Journal of AOAC International | volume = 91 | issue = 3 | pages = 580–88 | year = 2008 | pmid = 18567304 | doi = 10.1093/jaoac/91.3.580 | doi-access = free }}</ref><ref>{{cite journal |vauthors=Reepmeyer JC, Woodruff JT | title = Use of liquid chromatography-mass spectrometry and a chemical cleavage reaction for the structure elucidation of a new sildenafil analogue detected as an adulterant in an herbal dietary supplement | journal = Journal of Pharmaceutical and Biomedical Analysis | volume = 44 | issue = 4 | pages = 887–93 | year = 2007 | pmid = 17532168 | doi = 10.1016/j.jpba.2007.04.011 | url = https://zenodo.org/record/1259165 }}</ref><ref>{{cite journal |vauthors=Reepmeyer JC, Woodruff JT, d'Avignon DA | title = Structure elucidation of a novel analogue of sildenafil detected as an adulterant in an herbal dietary supplement | journal = Journal of Pharmaceutical and Biomedical Analysis | volume = 43 | issue = 5 | pages = 1615–21 | year = 2007 | pmid = 17207601 | doi = 10.1016/j.jpba.2006.11.037 | url = https://zenodo.org/record/1259163 }}</ref><ref>[https://www.fda.gov/Safety/Recalls/EnforcementReports/ucm217780.htm Enforcement Report for June 30, 2010], [[United States Food and Drug Administration]]</ref> The FDA has warned consumers that any sexual enhancement product that claims to work as well as prescription products is likely to contain such a contaminant.<ref>[https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm048386.htm Hidden Risks of Erectile Dysfunction "Treatments" Sold Online], [[United States Food and Drug Administration]], February 21, 2009</ref> A 2021 review indicated that ginseng had "only trivial effects on erectile function or satisfaction with intercourse compared to placebo".<ref>{{cite journal | vauthors = Lee HW, Lee MS, Kim TH, Alraek T, Zaslawski C, Kim JW, Moon DG | title = Ginseng for erectile dysfunction | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | pages = CD012654 | date = April 2021 | issue = 4 | pmid = 33871063 | pmc = 8094213 | doi = 10.1002/14651858.cd012654.pub2 }}</ref>

==History==
[[File:Zibik.jpg|thumb|An unhappy wife is complaining to the [[qadi]] about her husband's impotence. [[Ottoman miniature]].]]{{Further|Medicalisation of sexuality}}
Attempts to treat the symptoms described by ED date back well over 1,000 years. In the 8th century, males of Ancient Rome and Greece wore talismans of rooster and goat genitalia, believing these talismans would serve as an aphrodisiac and promote sexual function.<ref name="MCLAREN">{{cite book | vauthors = McLaren A  |title=Impotence: A Cultural History |date=2007 |publisher=University of Chicago Press |isbn=978-0226500768}}</ref> In the 13th century, [[Albertus Magnus]] recommended ingesting roasted wolf penis as a remedy for impotence.<ref name="MCLAREN" /> During the late 16th and 17th centuries in France, male impotence was considered a crime, as well as legal grounds for a divorce. The practice, which involved inspection of the complainants by court experts, was declared obscene in 1677.<ref>{{cite book| vauthors = Roach M |title=Bonk: The Curious Coupling of Science and Sex|year=2009|publisher=W.W. Norton & Co|location=New York|isbn=9780393334791|pages=149–52|title-link=Bonk: The Curious Coupling of Science and Sex}}</ref><ref>{{cite book | vauthors = Darmon P |title=Trial by Impotence: Virility and Marriage in Pre-Revolutionary France |date=1985 |publisher=Vintage/Ebury |isbn=978-0701129156}}</ref>

The first major publication describing a broad medicalization of sexual disorders was the first edition of the [[Diagnostic and Statistical Manual of Mental Disorders|''Diagnostic and Statistical Manual of Mental Disorders'']] in 1952.<ref name=":15">{{Cite journal |last1=Hart |first1=Graham |last2=Wellings |first2=Kaye |date=2002-04-13 |title=Sexual behaviour and its medicalisation: in sickness and in health |url=https://www.bmj.com/content/324/7342/896 |journal=BMJ |language=en |volume=324 |issue=7342 |pages=896–900 |doi=10.1136/bmj.324.7342.896 |issn=0959-8138 |pmc=1122837 |pmid=11950742}}</ref> In the early 20th century, medical folklore held that 90-95% of cases of ED were psychological in origin, but around the 1980s research took the opposite direction of searching for physical causes of sexual dysfunction, which also happened in the 1920s and 30s.<ref name=":9">{{Cite journal |last=Tiefer |first=Leonore |date=1996 |title=The medicalization of sexuality: Conceptual, normative, and professional issues |journal=[[Annual Review of Sex Research]] |volume=7 |issue=1 |via=EBSCO}}</ref> Physical causes as explanations continue to dominate literature when compared with psychological explanations {{As of|2022|lc=y}}.<ref name=":14">{{Cite journal |last=Grunt-Mejer |first=Katarzyna |date=2022-07-03 |title=The history of the medicalisation of rapid ejaculation—A reflection of the rising importance of female pleasure in a phallocentric world |url=https://www.tandfonline.com/doi/full/10.1080/19419899.2021.1888312 |journal=Psychology & Sexuality |language=en |volume=13 |issue=3 |pages=565–582 |doi=10.1080/19419899.2021.1888312 |issn=1941-9899 |s2cid=233924065}}</ref> 

Treatments in the 80s for ED included [[penile implant]]<nowiki/>s and [[Intracavernous injection|intracavernosal injection]]<nowiki/>s.<ref name=":9" /> The first successful vacuum erection device, or [[penis pump]], was developed by Vincent Marie Mondat in the early 1800s.<ref name="MCLAREN" /> A more advanced device based on a bicycle pump was developed by Geddings Osbon, a Pentecostal preacher, in the 1970s. In 1982, he received FDA approval to market the product.<ref>{{cite journal |vauthors=Hoyland K, Vasdev N, Adshead J |date=2013 |title=The use of vacuum erection devices in erectile dysfunction after radical prostatectomy |journal=Reviews in Urology |volume=15 |issue=2 |pages=67–71 |pmc=3784970 |pmid=24082845}}</ref> [[John R. Brinkley]] initiated a boom in male impotence treatments in the U.S. in the 1920s and 1930s, with radio programs that recommended expensive goat gland implants and "mercurochrome" injections as the path to restored male virility, including operations by surgeon [[Serge Voronoff]].

Modern drug therapy for ED made a significant advance in 1983, when British physiologist [[Giles Brindley]] dropped his trousers and demonstrated to a shocked Urodynamics Society audience showing his [[papaverine]]-induced erection.<ref>{{cite journal | vauthors = Klotz L | title = How (not) to communicate new scientific information: a memoir of the famous Brindley lecture | journal = BJU International | volume = 96 | issue = 7 | pages = 956–7 | date = November 2005 | pmid = 16225508 | doi = 10.1111/j.1464-410X.2005.05797.x | s2cid = 38931340 | doi-access = free }}</ref> The current most common treatment for ED, the oral [[PDE5 inhibitor]] known as [[sildenafil]] (Viagra) was approved for use for [[Pfizer Inc.|Pfizer]] by the FDA in 1998, which at the time of release was the fastest selling drug in history.<ref name=":15" /><ref>{{cite journal | vauthors = Valiquette L | title = A historical review of erectile dysfunction | journal = The Canadian Journal of Urology | volume = 10 | issue = Suppl 1 | pages = 7–11 | date = February 2003 | pmid = 12625844 | url = https://www.researchgate.net/publication/10865798 }}</ref><ref name=":02">{{Cite journal |last=Pacey |first=Susan |date=2008-08-01 |title=The medicalisation of sex: a barrier to intercourse? |url=https://doi.org/10.1080/14681990802221092 |journal=Sexual and Relationship Therapy |volume=23 |issue=3 |pages=183–187 |doi=10.1080/14681990802221092 |issn=1468-1994 |s2cid=144685850}}</ref> Sildenafil largely replaced [[Selective serotonin reuptake inhibitor|SSRI]] treatments for ED at the time<ref name=":42">{{Cite book |last=Štulhofer |first=Aleksandar |title=The International Encyclopedia of Human Sexuality |date=2015-04-20 |isbn=9781405190060 |pages=721–817 |chapter=Medicalization of sexuality |doi=10.1002/9781118896877.wbiehs297 |chapter-url=http://dx.doi.org/10.1002/9781118896877.wbiehs297}}</ref> and proliferated new types of specialised pharmaceutical marketing which emphasised social connotations of ED and Viagra rather than its physical effects.<ref name=":122">{{Cite journal |last1=Gurevich |first1=Maria |last2=Cormier |first2=Nicole |last3=Leedham |first3=Usra |last4=Brown-Bowers |first4=Amy |date=August 2018 |title=Sexual dysfunction or sexual discipline? Sexuopharmaceutical use by men as prevention and proficiency |url=http://journals.sagepub.com/doi/10.1177/0959353517750682 |journal=Feminism & Psychology |language=en |volume=28 |issue=3 |pages=309–330 |doi=10.1177/0959353517750682 |issn=0959-3535 |s2cid=149254089}}</ref><ref name=":17">{{Cite journal |last=Tiefer |first=Leonore |date=2001-05-01 |title=A new view of women's sexual problems: Why new? Why now? |url=https://www.tandfonline.com/doi/full/10.1080/00224490109552075 |journal=The Journal of Sex Research |language=en |volume=38 |issue=2 |pages=89–96 |doi=10.1080/00224490109552075 |issn=0022-4499 |s2cid=144377564}}</ref>

==Anthropology==
Anthropological research presents ED not as a disorder but, as a normal, and sometimes even welcome sign of healthy aging. Wentzell's study of 250 Mexican males in their 50s and 60s found that "most simply did not see decreasing erectile function as a biological pathology".<ref name="Wentzell">{{cite book | vauthors = Wentzell E, Labuski C |title=Cultural Differences and the Practice of Sexual Medicine |chapter=Role of Medical Anthropology in Understanding Cultural Differences in Sexuality |series=Trends in Andrology and Sexual Medicine |date=2020 |publisher=Springer International Publishing |location=Cham |isbn=978-3-030-36221-8 |pages=23–35 |doi=10.1007/978-3-030-36222-5_2 |s2cid=214042890 |chapter-url=http://link.springer.com/10.1007/978-3-030-36222-5_2 |access-date=28 August 2021}}</ref> The males interviewed described the decrease in erectile function "as an aid for aging in socially appropriate ways".<ref name="Wentzell" /> A common theme amongst the interviewees showed that respectable older males shifted their focus toward the domestic sphere into a "second stage of life".<ref name="Wentzell" />  The Mexican males of this generation often pursued sex outside of marriage; decreasing erectile function acted as an aid to overcoming infidelity thus helping to attain the ideal "second stage" of life.<ref name="Wentzell" /> A 56-year-old about to retire from the public health service said he would now "dedicate myself to my wife, the house, gardening, caring for the grandchildren—the Mexican classic".<ref name="Wentzell" /> Wentzell found that treating ED as a pathology was antithetical to the social view these males held of themselves, and their purpose at this stage of their lives.

In the 20th and 21st centuries, anthropologists investigated how common treatments for ED are built upon assumptions of institutionalized social norms. In offering a range of clinical treatments to 'correct' a person's ability to produce an erection, biomedical institutions encourage the public to strive for prolonged sexual function. Anthropologists argue that a biomedical focus places emphasis on the biological processes of fixing the body thereby disregarding holistic ideals of health and aging.<ref name="Farmer">{{cite book |vauthors=Farmer P, Kleinman A, Kim J, Basilico M |title=Reimagining Global Health: An Introduction |date=2013 |publisher=University of California Press |location=Berkeley |isbn=978-0-520-27197-5 |pages=17–20 |access-date=28 August 2021 |url=https://www.ebookcentral-proquest-com.ezproxy }}{{Dead link|date=March 2022 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> By relying on a wholly medical approach, Western biomedicine can become blindsided by bodily dysfunctions which can be understood as appropriate functions of age, and not as a medical problem.<ref>{{cite journal | vauthors = Wentzell E, Salmerón J |title=Prevalence of erectile dysfunction and its treatment in a Mexican population: distinguishing between erectile function change and dysfunction |journal=Journal of Men's Health |date=2009 |volume=6 |issue=1 |pages=56–62 |doi=10.1016/j.jomh.2008.09.009 }}</ref> Anthropologists understand that a biosocial approach to ED considers a person's decision to undergo clinical treatment more likely a result of "society, political economy, history, and culture" than a matter of personal choice.<ref name="Farmer"/> In rejecting biomedical treatment for ED, males can challenge common forms of medicalized social control by deviating from what is considered the normal approach to dysfunction.

==Lexicology==
The Latin term ''impotentia coeundi'' describes simple inability to insert the penis into the [[vagina]]; it is now mostly replaced by more precise terms, such as ''erectile dysfunction'' (ED). The study of ED within medicine is covered by [[andrology]], a sub-field within [[urology]]. Research indicates that ED is common, and it is suggested that approximately 40% of males experience symptoms compatible with ED, at least occasionally.<ref name="erectile dysfunction">{{cite journal |vauthors=Schouten BW, Bohnen AM, Groeneveld FP, Dohle GR, Thomas S, Bosch JL | title = Erectile dysfunction in the community: trends over time in incidence, prevalence, GP consultation and medication use – the Krimpen study: trends in ED | journal = J Sex Med | volume = 7 | issue = 7 | pages = 2547–53 | date = July 2010 | pmid = 20497307 | doi = 10.1111/j.1743-6109.2010.01849.x }}</ref> The condition is also on occasion called ''phallic impotence''.<ref>{{cite web | vauthors = Kahane C | title = Bad Timing: The Problematics of Intimacy in On Chesil Beach. | url = https://psyartjournal.com/article/show/kahane-bad_timing_the_problematics_of_intimacy_ | work = PsyArt | date = 20 September 2011 }}</ref> Its antonym, or opposite condition, is [[priapism]].<ref>{{cite book | vauthors = Allgeier A |title=Sexual interactions|date=1995|publisher=D.C. Heath|page=243}}</ref><ref>{{cite book| vauthors = Grimes J |title=Sexually Transmitted Disease: An Encyclopedia of Diseases, Prevention, Treatment and Issues|date=2013|page=496}}</ref>

{{clear}}

==References==
{{reflist}}

==Further reading==
* {{cite journal|last1=Carson|first1=Culley|last2=Faria|first2=Geraldo|last3=Hellstrom|first3=Wayne J. G.|last4=Krishnamurti|first4=Sudhakar|last5=Minhas|first5=Suks|last6=Moncada|first6=Ignacio|last7=Montague|first7=Drogo K.|date=1 January 2010|title=Implants, Mechanical Devices, and Vascular Surgery for Erectile Dysfunction|journal=Journal of Sexual Medicine|publisher=Wiley|volume=7|issue=1|pages=501–523|doi=10.1111/j.1743-6109.2009.01626.x|doi-access=free|pmid=20092450}}

== External links ==
{{Medical resources
| DiseasesDB      = 21555
| ICD11           = {{ICD11|HA01.1}}
| ICD10           = {{ICD10|F52.2}}, {{ICD10|N48.4}}
| ICD9            = {{ICD9|302.72}}, {{ICD9|607.84}}
| ICDO            =
| OMIM            =
| MedlinePlus     =
| eMedicineSubj   = med
| eMedicineTopic  = 3023
| MeshID          = D007172
| SNOMED CT       = 397803000
}}
<!-- BEFORE inserting new links here you should first post it to the talk page, otherwise, your edit is likely to be reverted-->
* {{Curlie|Health/Men%27s_Health/Conditions_and_Diseases/Impotence/Resources/}}

{{Mental and behavioural disorders|selected = physical}}
{{Male diseases of the pelvis and genitals}}
{{Sex}}
{{Authority control}}

[[Category:Non-sexuality]]
[[Category:Penis disorders]]
[[Category:Sexual dysfunctions]]
[[Category:Penile erection]]
[[Category:Men's health]]