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Erectile dysfunction

Key points about erectile dysfunction

Erectile dysfunction is also known as impotence.
It means you can't maintain an erect enough penis for satisfactory sexual intercourse.
Many men have erection problems at times and the chance of this happening increases with age.
Erectile dysfunction is not a disease, but a symptom of some other problem, either physical or psychological or a mixture of both.
There are several solutions, but recognising the problem and talking about it with your doctor are the key first steps.

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Getting an erection is a complicated process. During an erection, the blood vessels that let blood into your penis relax and widen (dilate). This lets more blood in, which causes the sponge-like tissues of your penis to swell and harden. Your thoughts and senses (touch, hearing, smell and sight) influence a part of your 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-system mechanisms such as touch reflexes are 2 ways you can get an erection.

Image credit: 123rf

Some estimates indicate that about 40% of men over the age of 40 will have erection problems at times.

Symptoms of erection problems include:

being unable to get an erection
experiencing a partial erection
having an erection of a shorter than usual duration.

Erectile dysfunction occurs when sexual stimulation or arousal does not result in enough blood flow to your penis, even though you may still have the urge. For some men there is a physical or medical reason for this. For others the problem is related to thoughts or emotions.

Even when there is an initial physical reason, when this has passed you may still feel anxious about having sex and this can add to the problem.

Alcohol, smoking and recreational drugs

Smoking, drinking alcohol and the use of recreational drugs such as narcotics, stimulants and hallucinogens can all affect sexual function. Chemicals from smoking can interfere with blood flow to your penis and damage the lining of the blood vessels or lead to atherosclerosis (hardening of the arteries). It can also affect the smooth muscle tissue that needs to relax to allow blood to flow in.

Short-term use of alcohol affects sexual desire, reduces performance and delays orgasm and ejaculation.

Medical reasons

Medical cause	Description
Hormone imbalance	Hormone imbalance is a cause of erectile dysfunction in about 7 out of 100 men. Some hormonal conditions that affect erectile function are thyroid disease, acromegaly, low testosterone, cortisol abnormalities and high prolactin.
Nerve damage	Nerve damage can lead to reduced sensitivity or reduced signals to your penis to release the chemicals that cause erection. Nerve damage can be caused by spinal cord injury, multiple sclerosis and Parkinson's disease. Pelvic trauma from an accident or pelvic surgery, including some cancer operations on your prostate, bladder or bowel, may result in nerve damage leading to erectile dysfunction. Stroke can also lead to erectile dysfunction.
Blood vessel disease	Blood vessels often become narrowed and hardened with increasing age. This reduces blood supply to your penis. Diseases that affect blood vessels include diabetes, hypertension and high cholesterol .
Other conditions	Obesity (due to multiple reasons such as low testosterone and inflammation), obstructive sleep apnoea, prolonged cycling (damage to pudendal nerve), low physical activity and chronic kidney disease can all affect erectile function.

Medicines

Some medicines, including over-the-counter medicines, can cause sexual problems, including getting and maintaining an erection. Medication is a common cause of erectile dysfunction for 25 out of 100 men using medication. This varies depending on the person and type of medication.

Medicines known to cause sexual problems in some people
Some antidepressants, particularly SSRIs Antipsychotics Some medicines for heart problems, particularly thiazide diuretics and spironolactone – beta blockers only have a small increased risk of erectile dysfunction (5 per 1000) Some anti-epileptic medicines	Opioids such as morphine, oxycodone (thought to be due to reducing testosterone levels) Anti-androgens Some treatments for cancer Some medicines for bladder and prostate problems Corticosteroids such as prednisone, dexamethasone

If you are taking a medicine and are worried about its effects, don't stop taking it suddenly. Instead discuss this with your doctor or pharmacist. There might be a different medicine you can take that is less likely to cause sexual problems. Read more about medicines and sexual problems.

Psychological reasons

There are a range of psychological factors affecting erection including:

existing values or attitudes towards sex
stress, guilt, depression or fatigue
performance-related anxiety about your performance during sex
traumatic past experiences including sexual abuse
poor body image
relationship problems (possible anger, power or control issues with your partner)
problems with intimacy and communication
intercourse less than once per week (twice the risk of developing erectile dysfunction).

Pornography consumption is not generally a cause.

There is often a vicious cycle linking performance anxiety and erectile dysfunction. If you still have erections at times and the problem started rapidly (except after surgery), this usually means psychological reasons are involved.

Other sexual problems	Description
Low libido	Erectile dysfunction may lead to low libido. However, most people with erectile dysfunction do not complain of low libido. Libido tends to reduce with age. Many of the causes are the same as for erectile dysfunction.
Premature ejaculation	Some men with premature ejaculation also have erectile dysfunction, but most do not. Other than psychological factors, partner factors, especially vaginismus (excessive female pelvic floor contraction), can be a cause. Some men with erectile dysfunction may “rush” sexual intercourse in order to avoid losing their erection. The main treatments are the start-stop technique, the squeeze technique and having more sexual intercourse. SSRIs can be used as a treatment in order to delay ejaculation. Topical anaesthetics and counselling can also be used.
Other types of sexual problems in men	Delayed ejaculation and retrograde ejaculation are other conditions that men can experience.

Many men are unhappy with their ability to get or maintain an erection, but only 5% of these men seek help. This is because most 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 help you to feel more at ease in mentioning it to your doctor. Your doctor is used to talking about these issues. By opening up this discussion, which is confidential, your doctor can help you in a number of ways.

They can check your health and any current medications for likely side effects. If psychological reasons are suspected, your doctor can advise you on what would help, including helping you access counselling services you (and your partner) may benefit from.

Tests by your doctor may include:

a physical examination, which may include your genitals and prostate gland
checking your medications for side effects
blood and urine tests for hormones, blood lipids, thyroid, liver and kidney function and diabetes.

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 based on your overall health.

There are several treatments for erectile dysfunction. Your doctor can advise you on the benefits and drawbacks of each.

Lifestyle changes

Lifestyle changes are one of the most effective treatments. Weight loss, increased physical activity, cutting out smoking, getting enough sleep and reducing alcohol can all have a big effect on erectile dysfunction. If you have obstructive sleep apnoea, make sure you are using your CPAP machine.

Psychological counselling

This can be useful even if there is a medical cause, as it gives you a chance to talk about how you feel about having erectile dysfunction. If there is an underlying psychological reason for the difficulty, this is a safe place to explore what this might be and what you can do about it. This is generally not available as a funded service and you would normally need to pay for this privately. If you have been sexually abused, then you may be able to access free counselling through ACC.

Sensate focus exercises

Sensate focus exercises are intimacy exercises you do with your partner. Sensate focus is about setting the stage for sensuality rather than sexuality, focusing on touch and being touched, and being mindful during the experience. The exercises are progressed in steps starting from non-genital touching. Read more about sensate focus exercises.(external link)

Tablets (taken by mouth)

Tablets for erectile dysfunction are called phosphodiesterase-5 (PDE5) inhibitors such as sildenafil (Viagra, Silvasta, Vedafil), tadalafil (Cialis) and vardenafil (Levitra). These medicines usually enable an erection by relaxing the blood vessels in your penis, but only when you are stimulated or aroused. They are all similarly effective. Read more about PDE5 inhibitors and frequently asked questions about their use.

Self-injection

If the tablets mentioned above don't work, then injecting a medicine called Caverject into the base of your penis is another option. It 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. Your doctor or sexual health specialist needs to show you in person how to use it safely.

Other possible treatments

For some men, vacuum pump devices, rigid or inflatable surgical penile implants or testosterone replacement (only for men with unequivocally low levels of this hormone) may also be options. Constriction bands at the base of the penis can be a treatment option for men with non-sustained erections. Discuss these options with your doctor.

Do herbal products work?

Many herbal products such as horny goat weed, ginkgo, yohimbe and ginseng claim to improve sexual function. There is no sound evidence that these herbal products work well for erectile dysfunction. They have not been well studied or tested. Since some erectile dysfunction is related to psychological problems, herbal products may help with anxiety, which may indirectly help sexual function.

Some herbal products and supplements can cause side effects or interact with other medicines. Talk to your doctor or pharmacist before you try an alternative treatment for erectile dysfunction, especially if you're taking medications or you have a chronic health problem such as heart disease or diabetes.

Most ageing men manage to get erections, but to do so requires 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, stopping smoking and reducing the stress in your life.