Erectile dysfunction means a man is unable to maintain an erect penis sufficient for satisfactory sexual intercourse. It may have a psychological or a physical cause, either way it is distressing and may cause loss of confidence and self-esteem or depression, as well as relationship problems. There are several solutions, but recognising the problem and talking about it with your doctor are the first essential steps.
Many men have (often temporary) erection problems at times, and the likelihood increases with age. Estimates seem to be increasing as more careful studies are done and as men become more prepared to seek help. Some estimates indicate that about 40% of men over 40 will have erection problems. For some men erection problems occur suddenly but for most there is progressive difficulty. It may mean you are completely unable to get an erection, can get only a partial erection or can keep it for a short time.
The veins that allow blood to leave the penis are only so wide. During an erection, the blood vessels that let blood into the penis relax and widen (dilate). This lets more blood in – more than can escape – which causes the sponge-like tissues of the penis to swell and harden. Complex biological mechanisms are involved in allowing these blood vessels to relax and redirect blood to the penis. Your thoughts and senses (touch, hearing, smell and sight) influence a part of the brain that can trigger an erection. In addition, hormones and other substances determine how your nerves transmit ‘sexual signals’ and how blood vessels respond to the received signals. Arousing thoughts or nervous mechanisms (eg, touch reflexes) are two ways an erection is initiated.
Erectile dysfunction occurs when sexual stimulation or arousal (you may still ‘have the urge’) does not result in sufficient blood flow to the penis. For most men there is a physical or medical reason for this, for others the problem is psychological. Even when there is an initial physical reason, a man may still feel anxious about having sex, and this can compound the problem.
Recent illness, such as a heart attack, or injury to the brain or spinal cord can be a cause. Many other medical conditions can also lead to nerve damage or reduced blood supply to the penis – the most common of these is diabetes (men with diabetes are much more likely to have problems with erections). Other factors that can reduce blood flow to the penis include:
excess alcohol
smoking
narrowing of blood vessels caused by a high blood cholesterol level.
A wide range of drugs used to treat some health conditions (eg, heart failure, high blood pressure and depression) can also affect your ability to get an erection. If you are taking medication and have erectile dysfunction you should talk to your doctor about your drugs – there may be others without this side effect.
existing values or attitudes towards sex
stress, guilt, depression or fatigue
anxiety about your performance during sex
relationship problems (possible anger, power or control issues with your partner)
problems with intimacy and communication.
If you still have erections at times (eg, when you wake) this usually means psychological reasons are involved.
Most aging men manage to get erections, but only with more stimulation. It is up to each man to decide whether his erection is adequate. You can consider (with your partner) how important sexual intercourse is to your relationship – there are other aspects to intimacy, and not all couples require an active sex life to have a fulfilling relationship.
You can help yourself by cutting down on alcohol, stop smoking and reducing the stress in your life.
Tests by your doctor might include:
a physical examination, which may include the genitals and prostate gland
checking your medications for side effects
blood and urine tests for hormones, blood lipids, liver and kidney function and diabetes.
Many men are unhappy with their ability to get or maintain an erection, but only 5% of these men seek help. This is because men, in general, are unwilling to discuss their sex life, even when it is going well.
Understanding that erectile dysfunction could have a medical cause, just as asthma or arthritis do, can allow you to feel more at ease in mentioning it to your doctor. By opening up this discussion, which is confidential, your doctor can help you in a number of ways.
Your doctor can check your health and any current medications for likely side effects. If psychological reasons are suspected, your doctor can advise you on the appropriate action and help you access counselling services you (and your partner) may benefit from.
If your erection problems have a medical cause, your doctor can explain the treatment options, the techniques needed to make them work and their suitability for your needs in the light of your overall health.
Oral medications
The drugs sildenafil, tadalafil and vardenafil (also called PDE5 inhibitors) ‘prime’ the penis by allowing the blood vessels to relax, while another drug apomorphine acts by enhancing the brain’s response during arousal.
These tablets usually allow an erection to occur, but only when the man is stimulated or aroused. They can, however, cause headaches, dizziness and nausea, and PDE5 inhibitors can cause flushing or rarely some visual disturbance. Men with certain heart conditions or those taking nitrates for angina can’t use PDE5 inhibitors as this combination has proved fatal in some circumstances.
Self-injection
Injecting a prostaglandin drug into the base of the penis allows most men to get an erection, which may last beyond ejaculation. Some men may be put off by this method, but the injector devices are simple and convenient to use and the procedure is virtually painless.
Available treatments are summarised below. Your doctor can advise you on the benefits and drawbacks of each.
psychological counselling (whether or not there is a medical cause)
oral tablets
self-injection or penile insertion of a drug
vacuum pump devices
rigid or inflatable surgical penile implants
testosterone replacement (only for men with low levels of this hormone