Erectile dysfunction (ED) is the inability to get and maintain an erection that is sufficient for satisfactory sexual intercourse. ED is also known as impotence.
How common is erectile dysfunction?
ED is a very common condition, particularly in older men. It is estimated that half of all men between 40 and 70 years of age will experience ED at least once.
ED can have a range of causes, both physical and psychological. Possible physical causes include:
- heart disease,
- high blood pressure (hypertension), and
- hormonal problems.
Possible psychological causes of ED include:
- depression, and
- relationship problems.
Many men will experience episodes of ED that improve without the need for treatment. Sometimes, persistent ED can be the result of a more serious underlying health condition, such as heart disease. In such cases, treatment will be needed to treat the underlying condition.
Other causes include head injury, which can result in low levels of production of the hormone testosterone. Treatment of testosterone can treat ED when it is caused by head injury.
Generally, the prognosis for ED is good. Some men will just need to make some lifestyle changes, such as losing weight and taking regular exercise. Other men may need to take medication such as sildenafil (known as Viagra).
Symptoms of erectile dysfunction
Sometimes, erectile dysfunction (ED) only occurs in certain situations.
For example, you may be able to obtain an erection during masturbation, or you may find that you sometimes wake up with an erection. However, you may be unable to obtain an erection when you are with your sexual partner.
In these circumstances, it is likely that the underlying cause of ED is primarily psychological. However, if you are unable to obtain an erection under any circumstances, it is likely that the underlying cause is primarily physical.
When to seek medical advice
It is recommended that you see your GP if ED persists for more than several weeks. Although many websites offer treatments for ED, their use is not recommended. This is because many of the medications that are offered by these sites are counterfeit and could be dangerous.
Even if the medications that are offered by websites are genuine, such as sildenafil (Viagra), these tablets are not suitable for everyone. Therefore, you should only take medication for ED that has been specifically prescribed for you by your GP.
If you have ED, your GP should assess your general state of health because the condition can be the first sign of more serious health conditions, such as heart disease.
Causes of erectile dysfunction
To understand more about the possible causes of erectile dysfunction (ED) it is useful to know how erections occur.
When you become sexually aroused, your brain sends signals to the nerves in your penis. The nerves increase the blood flow to your penis, causing the tissue to expand and harden.
Therefore, anything that interferes with your nervous system, or the circulation of your blood, can potentially lead to ED.
Psychological factors, such as stress, or depression, can also reduce your libido (your interest in sex) making it harder for your brain to trigger an erection. Changes in hormonal levels can also affect your libido.
Physical causes of erectile dysfunction
There are four main types of health condition that can cause ED. These are described below.
- Vasculogenic – health conditions that can affect the flow of blood to your penis.
- Neurogenic – health conditions that can affect your nervous system.
- Hormonal – health conditions that can affect your hormone levels.
- Anatomical – health conditions that can affect the physical structure of your penis.
Examples of vasuclogenic conditions include:
- heart disease,
- arteriosclerosis – hardening of the arteries,
- high blood pressure (hypertension), and
- diabetes – which can affect both the blood supply and the nerve endings in your penis, so it also a neurogenic condition.
Examples of neurogenic conditions include:
- multiple sclerosis,
- Parkinson’s disease,
- spinal injury, or disorder, and
Examples of hormonal conditions include:
- hypogonadism – a condition that affects the production of the hormone testosterone,
- over-active thyroid gland (hyperthyroidism),
- under-active thyroid gland (hypothyroidism), and
- Cushing’s syndrome – a condition that affects the production of a hormone called cortisol.
Examples of anatomical conditions include:
- Peyronie’s disease – a condition that affects the tissue of the penis, and
- hypospadias – a congenital condition that causes the urethra (the urine tube) to develop abnormally.
Medicinal causes of erectile dysfunction
In some men, a number of medicines can cause ED, including those that are listed below.
- Diuretics – medicines that increase the production of urine, and are often used to treat high blood pressure (hypertension), heart failure, and kidney disease.
- Antihypertensives – medicines, such as beta-blockers, that are used to treat high blood pressure (hypertension).
- Fibrates – medicines that are used to lower cholesterol levels.
- Immunosuppressants – medicines that are used suppress the immune system.
- H2-antagonists – medicines that are used to treat stomach ulcers.
- Anticonvulsants – medicines that are used to treat epilepsy.
If you are concerned that a prescribed medication is causing ED, you should speak to your GP about it because an alternative medication may be available.
However, do not stop taking a prescribed medication without first consulting with your GP.
Psychological causes of erectile dysfunction
Possible psychological causes of ED include:
- stress, and
- unresolved relationship problems with your partner.
ED can often have both physical and psychological causes. For example, if you have diabetes, it may be difficult for you to get an erection, which may cause you to become anxious about the situation. The combination of diabetes and anxiety may lead to an episode of ED.
Other causes of erectile dysfunction
Other possible causes of ED include:
- tiredness, and
- using illegal drugs, such as cannabis, or cocaine.
Sometimes, cycling can also be a cause of ED. People who spend more than three hours a week cycling may experience ED due to the saddle placing pressure on the nerves in their penis.
Diagnosing erectile dysfunction
Before diagnosing erectile dysfunction (ED), your GP will ask you about your symptoms, your overall physical and mental health, your alcohol consumption, whether you take drugs, and whether you are currently taking any medication.
Your GP will also want to know whether your ED is permanent, or only occurs when you are attempting to have sex with your partner. The former suggests that there is an underlying physical cause, and the latter suggests an underlying psychological cause.
Your GP may carry out a physical examination of your penis to rule out any possible anatomical causes, such as Peyronie’s disease.
Blood tests may also be used to check for possible underlying health conditions. For example, abnormal hormone levels could suggest a hormonal condition, such as an under-active thyroid (hypothyroidism), or high glucose levels could suggest diabetes.
A blood pressure test is usually carried out to check if you have high blood pressure (hypertension).
Further testing for ED is usually only required if you are unusually young to be experiencing ED. This is because ED is relatively rare in men who are under 40 years of age.
Your GP may also recommend further testing if they think that you may have a more serious underlying health condition, such as heart disease, or arteriosclerosis. Some of these tests are outlined below.
An ultrasound scanner can be used to build up a more detailed picture of the blood vessels inside your penis.
Intracavernous injection test
An intracavernous injection test involves injecting a synthetic hormone into your penis in order to increase the blood flow to your penis. If the injection fails to produce an erection, it may indicate that there is a problem with the blood supply to your penis.
Cavernosometry involves injecting a special dye into the blood vessels of your penis. The dye is then studied on a scanner and can help show how the blood is moving through your penis, and whether there are any blockages, or abnormalities, in the blood vessels.
Nocturnal tumescence test
Most healthy men experience erections when they are sleeping, so a nocturnal tumescence test involves spending a night in hospital. During the test, a piece of perforated tape is tied to the base of your penis. If you have an erection during the night, the tape will break.
A nocturnal tumescence test is useful for determining whether ED is due to physical or psychological causes.
Treating erectile dysfunction
In use since the 1970s, a penile implant is a medical device that is implanted into the penis during an outpatient surgical procedure. The device is entirely contained within the body. To operate, one squeezes and releases the pump in the scrotum to achieve an erection.
Vacuum Erection Devices
In use since the 1980s, a vacuum erection device consists of a hollow plastic tube, a vacuum pump, and a tension ring. The tube, placed over the penis, creates a vacuum that pulls blood into the penis. Once an erection is achieved, an elastic tension ring is placed at the base of the penis to help maintain the erection.
In use since the 1980s, injection therapy uses a needle to inject medication directly into the base or side of the penis. These medications can create an erection by improving blood flow into the penis.
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The symptoms of ED can often be improved by using some self-help techniques, and making associated life style changes. These include:
- losing weight (if you are overweight),
- giving up smoking (if you smoke),
- moderating your consumption of alcohol,
- not using illegal drugs, and
- taking regular exercise.
If you do a lot of cycling (more than three hours a week), and you are experiencing ED, you may want to spend a trial period without riding your bike in order to see if it improves your symptoms.
PDE-5 inhibitors are one of the most widely used and effective types of medication used to treat ED. They work by temporally increasing the blood flow to your penis.
In England, three PDE-5 inhibitors are available for the treatment of ED. These are:
- sildenafil – which is sold under the brand name Viagra,
- tadalafil- which is sold under the brand name Cialis, and
- vardenafil – which is sold under the brand name Levitra.
Sildenafil, tadalafil, and vardenafil
Sildenafil and vardenafil work for about four hours and they are designed to work ‘on demand’. Tadalafil is taken once every 24 hours (but not every day) and may last for longer than 24 hours, such as over the weekend.
Sildenafil and vardenafil should be taken an hour before sexual activity, but you should be aware that it may take longer to notice their effects if they are taken with food. Tadalafil should be taken at least 30 minutes before sexual activity.
When not to take PDE-5 Inhibitors
PDE-5 inhibitors are not recommended for people who are at high risk of coronary heart disease.
PDE-5 inhibitors should never be used if you are also taking medicines that contain organic nitrates because the combination of the two substances can be extremely dangerous for your heart.
Medicines that contain organic nitrates are often used to treat angina.
You should also not use PDE-5 inhibitors if you take the recreational drug, amyl nitrate, more commonly known as ‘poppers’.
Side effects of PDE-5 inhibitors
Side effects of PDE-5 inhibitors are rare and, when they do occur, they are usually mild. Possible side effects include:
- hot flushes,
- a blocked, or runny, nose,
- back pain, and
- disturbances to your vision.
Availability of PDE-5 inhibitors
PDE-5 inhibitors are usually only made available on a NHS prescription if you have one of the following health conditions:
- multiple sclerosis,
- Parkinson’s disease,
- prostate cancer,
- severe pelvic, or spinal injury,
- spina bifida, and
- certain genetic conditions, such as Huntington’s disease.
People who have received, or are receiving, certain medical treatments may also be able to get PDE-5 inhibitors on a NHS prescription. These treatments are listed below.
- Pelvic surgery – which is often used to remove tumours, or to treat conditions such as incontinence.
- Surgical removal of the prostate gland (prostatectomy) – which is often used to treat prostate cancer.
- Dialysis for kidney failure.
- Kidney transplant
In certain circumstances, some specialist centres may offer PDE-5 inhibitors on a NHS prescription – for example, if ED is causing you severe distress.
However, you may have to pay a full prescription charge for a course of PDE-5 inhibitors. The exact price will depend on the dosage and your local pharmacy but, on average, four PDE-5 tablets cost in the region of £15-30.
Treatment for ED is not usually covered by private medical insurance.
If a hormonal condition is causing ED, you may be referred to an endocrinologist. An endocrinologist is a health professional who specialises in the treatment of hormonal conditions.
Many hormonal conditions can be treated using injections of synthetic hormones that help maintain normal hormone levels.
A penis pump is another method of treatment for ED. It is a simple tube that is connected to a pump. You place your penis in the tube and pump out all of the air. This creates a vacuum which causes the blood to rush to your penis. You then place a rubber ring around the base of your penis in order to keep the blood in place, allowing you to maintain an erection for around 30 minutes.
If your ED does not respond to treatment, or you are unable, or unwilling, to use PDE-5 inhibitors, or a penis pump, you may be given a medicine called alprostadil. Alprostadil is a synthetic hormone that helps to stimulate blood flow to the penis. Alprostadil can be injected directly into your penis, or a small tablet can be placed inside your urethra (urine tube).
Alprostadil will usually produce an erection that lasts for between 5-30 minutes.
Surgery for ED is usually only recommended if there is clear evidence of a blockage to the blood supply of the penis, or if all other treatment methods have failed.
If there is a blockage to your penis’s blood supply, it may be possible for the surgeon to unblock the blood vessels and restore a normal supply of blood.
An alternative surgical method involves placing inflatable implants into your penis, which you can then activate as required. Penile implants are not usually available on the NHS.
If the cause of ED is thought to be primarily psychological, you may be referred for psychosexual counselling.
Psychosexual counselling is a form of relationship therapy where you and your partner can discuss any sexual, or emotional issues, or concerns, that you have that may be contributing to your ED.
The counsellor can also provide you with some practical advice about sex, such as foreplay techniques, and how to make effective use of other treatments for ED in order to improve your sex life.
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) is another form of counselling that may be useful if you have ED. CBT is based on the principle that the way we feel is partly dependent on the way we think about things.
Therefore, unhelpful, or unrealistic, thoughts and assumptions about issues such as self-esteem, sexuality, and your personal relationships, may be contributing to ED.
In this situation, the CBT therapist would encourage you to adopt more realistic and helpful thoughts about these types of issues and assumptions.