Erectile dysfunction

Erectile dysfunction means having difficulty getting or keeping an erection firm enough for satisfying sexual activity. It’s a common issue, especially as men get older, and can affect intimacy and quality of life. About 50% of men 50 years of age or older, and 80% of those 80 or over, have some problems with erections. 

Erectile dysfunction isn't a disease, but a symptom of an underlying problem. It could be physical, psychological or a mixture of both. Cardiovascular disease, hypertension, high cholesterol and diabetes are risk factors for erectile dysfunction. Other contributors include smoking, drinking alcohol, using recreational drugs and some medications. 

There are several treatments for erectile dysfunction but recognising the problem, and talking about it with your healthcare provider, are the key first steps.

Image credit: Freepik

Erectile dysfunction occurs when sexual stimulation or arousal doesn’t result in enough blood flow to your penis, even though you may still have the urge for sexual activity. For some men there’s a physical or medical reason for this. For others, the problem is related to thoughts or emotions. If your erectile dysfunction has a physical cause, you may still feel anxious about having sex after the problem has resolved and this anxiety can continue to affect your performance.

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). Smoking can also affect the smooth muscle of your penis 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

Some medical conditions can cause erectile dysfunction.

• Blood vessel disease: Blood vessels often become narrowed and hardened as you get older and this reduces the blood supply to your penis. You’re at increased risk of erectile dysfunction if you have conditions that affect your blood vessels. These include: cardiovascular disease, diabetes, hypertension and high cholesterol.
• Nerve damage: Nerve damage can reduce sensation or the signals needed for an erection. Causes include stroke, spinal cord injury, multiple sclerosis, Parkinson's disease and trauma to your pelvic area from accidents or surgeries (including cancer operations on your prostate, bladder or bowel).  
• Hormone imbalance: Conditions that affect erectile function include thyroid disease, acromegaly (where there’s a tumour in your pituitary gland producing too much growth hormone), low testosterone, Cushing’s syndrome and high prolactin levels.
• Other conditions: Obesity (due to factors such as low testosterone and inflammation), obstructive sleep apnoea, prolonged cycling (which can damage the nerve to your genital area), low physical activity and chronic kidney disease. Problems in the penis itself – due to scarring or hardening of the penis tissue can also affect erectile function.      

Medicines 

Some medicines, including over-the-counter medicines, can cause sexual problems including erectile dysfunction.

Medicines known to cause sexual problems for some people include:

• antidepressants
• antipsychotics
• high blood pressure medicines
• some anti-seizure medications
• treatments for cancer
• medicines for bladder and prostate problems
• corticosteroids.

If you’re taking a medicine and you're worried about its effects, don't stop taking it suddenly. Instead, talk to your your healthcare provider or pharmacist about it. There might be a different medicine you can take that's less likely to cause sexual problems. Read more about medicines and sexual problems.

Psychological reasons

There are a range of psychological factors that can affect your ability to get an erection, including:

• your values or attitudes towards sex
• stress, guilt, depression or fatigue
• 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
• having intercourse less than once a week – this doubles the risk of developing erectile dysfunction.

Pornography consumption isn't usually a cause of erectile dysfunction.

It’s common for worry about sexual performance to make erectile problems worse. This can start a cycle where anxiety causes trouble with erections, which then leads to more anxiety. If you sometimes still get erections and your difficulty started suddenly (except after surgery), it usually suggests that things such as stress, worries or feelings are playing a part.

Symptoms of erection problems include:

• being unable to get an erection
• having a partial erection
• having an erection for less time than usual.

Erectile dysfunction can be caused by physical health problems, such as heart disease or diabetes, but psychological issues such as stress and anxiety are common. Health professionals understand both issues and will work with you to identify the cause of your problem. Remember, any conversation you have with your healthcare provider is confidential.

They check for possible underlying conditions and also the medicines you’re taking to see if these may be causing the problem. Erection problems can be an early sign of more serious health issues, such as diabetes and heart disease, so they may suggest tests to check for these as well.

Tests by your healthcare provider may include:

• a physical examination which may include examination of your genitals and, depending on your history, a prostate gland, heart health or nervous system check
• blood and urine tests for hormones, blood lipids, thyroid, liver and kidney function and diabetes.

There are several treatments for erectile dysfunction. Your healthcare provider can advise you on what might be helpful for you.

Lifestyle changes

Lifestyle changes are one of the most effective treatments. The following can all improve erectile dysfunction:

• Weight loss.
• Being more physically active.
• Cutting out smoking.
• Getting enough sleep.
• Reducing alcohol.

 If you have obstructive sleep apnoea, make sure you're using your CPAP machine.

Treating underlying conditions

If you have underlying conditions that are causing or contributing to erectile dysfunction (eg, cardiovascular disease, high blood pressure, high cholesterol, anxiety, depression, diabetes or thyroid disease) these will need to be treated and well managed.

Your healthcare provider may consider reducing the dose or changing any medicine that may be contributing to erectile dysfunction.

Psychological counselling 

This can be useful even if there’s a medical cause for your erectile dysfunction, as it gives you a chance to talk about how you feel about having erectile dysfunction. If there’s an underlying psychological reason for the difficulty, counselling gives you a chance to explore what this might be and what you can do about it. Counselling from a psychologist, counsellor or sex therapist is generally not available as a funded service and you would normally need to pay for this yourself. A health improvement practitioner or health coach may be able to help if these services are provided at your medical centre. 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 are taken before sex and help you get an erection by relaxing the blood vessels in your penis, but only when you're stimulated or aroused. They're all equally effective.

You shouldn't take these medicines if you're taking nitrate medicine such as isosorbide mononitrate or a glyceryl trinitrate spray for chest pain or other heart conditions. This is because there's a risk of a dangerous drop in blood pressure.

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 healthcare provider or sexual health specialist needs to show you in person how to use it safely.

Other treatments

For some men, vacuum pump devices, rigid or inflatable surgical penile implants or testosterone replacement (only for men with low levels of this hormone) may also be options. Constriction bands at the base of the penis can be a treatment option if you have trouble keeping an erection during sexual activity. You can discuss these options with your healthcare provider. 

Do herbal products work?

Many herbal products such as horny goat weed, ginkgo, yohimbe and ginseng claim to improve sexual function. 

Currently, there’s not enough evidence that these herbal products work well for erectile dysfunction. 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 healthcare provider or pharmacist before you try an alternative treatment for erectile dysfunction. This is particularly important  if you're taking any medicines or have a chronic health problem such as heart disease or diabetes. 

Making lifestyle changes, such as losing weight, stopping smoking or reducing stress in your life, can help if you have erectile dysfunction – read more in the treatment section above.

Erectile dysfunction is often a sign that you’re at higher risk of developing heart disease or other cardiovascular diseases, and making these lifestyle changes will also help to keep your heart healthy.

Most ageing men manage to get erections, but to do so requires more stimulation. It’s up to you to decide whether your 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.

Apps reviewed by Healthify

You may find it useful to look at some alcohol use apps, quit smoking apps, depression apps and anger management apps. 

It can be difficult for both of you if your partner has erectile dysfunction, but being supportive of your partner is important when addressing the difficulty.

Read information about erectile dysfunction as this will help your own understanding of the condition and make it easier to have conversations with your partner.

Let your partner know that it’s not something to be ashamed of, and it doesn’t change the way you feel about them. Talk sensitively about how you both feel and discuss possible solutions together. Encourage them to see their healthcare provider and ask if they’d like you to go with them so you can both be part of finding a solution.

If you find it’s difficult to talk about the problem together, seeing a couples counsellor may be helpful.