The Rise and Fall of You

If the prospect of Valentine’s Day romance has you wishing Cupid could spare an extra arrow from his quiver, maybe it’s time to see a doctor.

Erectile dysfunction, mainly the persistent inability to achieve or maintain an erection, is no longer the taboo subject it once was, thanks to widespread consumer marketing of prescription drugs like Viagra. And that’s good, because it makes talking about the problem and solving it easier, and because erectile dysfunction can be a sign of underlying conditions, such as heart disease.

“When you don’t get an erection, you can see the problem right there,” says Dr. Jon Pryor, professor in the Department of Urologic Surgery at the University of Minnesota.

Just knowing a pill is available can help some men perform without taking it. "It's like 'In case of erectile emergency, break glass.'"

In fact, the blood-flow problems that show up in erectile dysfunction (ED) can tell your doctor quite a bit. “The pattern of ED tells me most about what kind it is,” says Dr. Jamie Feldman, assistant professor in the university’s program in human sexuality. If a man has poor arterial blood flow, “he’ll have trouble attaining erections or getting one of adequate strength,” Feldman explains. “That’s usually indicative of a hardening of the arteries in the penis and pelvis. If it’s a venous leak, he can get an erection just fine, it’s keeping it around that’s the problem.” Purely venous problems are rare, she adds. Arterial blockage or some combination of arterial and venous problems are more likely.

Men who see their doctors about erectile dysfunction will get lots of questions about their overall health and medical history. Doctors will look for other signs of cardiovascular disease, high blood pressure or cholesterol, or diabetes. Smokers are more likely to have erectile dysfunction than nonsmokers.

“‘Have you seen a doctor in the last 10 years?’ can be the most important question,” Feldman says. “They often don’t know they’re running around with these problems.”

Chill Pills

Erectile dysfunction isn’t always a symptom of underlying chronic disease, however. Low testosterone can cause it. That isn’t common, Feldman says, but if that is the cause, a man will usually have other symptoms, such as weight gain, mood changes, and a marked loss of energy. Doctors are cautious about treating men with testosterone because if, by coincidence, a patient develops prostate cancer, testosterone will accelerate its growth.

A back injury or other condition that affects the nerves can also cause ED. So can psychological factors, or medications you’re taking for something else. “Multiple causes are typical,” Pryor says.

He cites data showing that 50 percent of men between the ages of 40 and 70—or roughly 30 million men in the United States—have erectile dysfunction. Clinical guidelines suggest seeing a doctor if the pattern persists for more than two months, but with the advent of prescription drugs, men aren’t shy about seeking help sooner. Before Viagra’s debut in 1998, treatment choices were more invasive or intrusive: topical or injected medications or surgical implants.

Viagra, Cialis, and Levitra—a class of drugs called PDE-5 inhibitors—revolutionized treatment. These drugs block an enzyme that otherwise interferes with smooth-muscle relaxation in the penis; the muscles have to relax to allow the increased blood flow that brings about an erection. PDE-5 inhibitors work 70 to 80 percent of the time, enabling men to have erections of sufficient strength and length for intercourse, say Pryor and Feldman. (With so many happy patients, it may be more than mere coincidence that they are two of the most cheerful doctors I’ve ever spoken with.)

But it’s not just a high success rate that has made these drugs the first-line treatment in most cases of ED. It’s also their ease of use, and the fact that they require sexual arousal in order to cause an erection. If something unexpected happens—your neighbor stops by, you burn dinner and need to clear the smoke out of the house—“you’re not stuck with an erection for the next four hours,” Feldman says, as you might be with other treatments.