Erectile dysfunction, or impotence, is common, especially in older men. But there are treatments that work.
If you suffer from erectile dysfunction, you’re not alone. Erectile dysfunction is estimated to affect around one in five Australian men over age 40 to some extent, while about one in 10 men are completely unable to have an erection.
Erectile dysfunction is largely a disease of the older man. By age 70, about seven in 10 men will have some degree of erectile dysfunction.
Erectile dysfunction is the persistent inability to achieve and/or maintain an erection sufficient for satisfactory sexual activity.
Getting an erection depends on a good blood and nerve supply to the penis. A sexual stimulus activates nerves that dilate blood vessels, allowing more blood to flow into the network of veins in two expandable sponge-like shafts in the penis called the corpora cavernosa. Valves prevent the blood flowing back out so the penis stays hard until after either ejaculation or the removal of the sexual stimulus.
Causes of erectile dysfunction include physical problems, lifestyle factors and psychological factors. In some men the cause is unknown.
In most men, erectile dysfunction is caused by a physical problem. Damage to nerves supplying the penis from prostate cancer (or other surgery in the area such as bladder or bowel surgery) or diabetesare common physical causes of erectile dysfunction.
Other physical conditions that are related to development of erectile dysfunction include problems such as heart and blood vessel disease, high blood pressure, kidney failure, high cholesterol and sleep apnoea.
Sometimes erectile dysfunction can be a side effect of certain medications, like blood pressure or cholesterol-lowering drugs, diuretics, antidepressants and epilepsy medications. If you think medication may be contributing to erectile dysfunction talk to your doctor, they may be able to help. It is important to keep taking your medication until you have seen the doctor.
Lifestyle factors such as smoking, lack of sleep, excessive alcohol consumption and obesity can also contribute to erectile dysfunction.
Recreational drugs such as alcohol, tobacco, marijuana, cocaine, heroin, barbiturates, and amphetamines can cause erectile dysfunction because they depress the brain’s response to a sexual stimulus. A heavy alcohol intake and smoking can also cause erectile dysfunction by damaging the nerves and arteries of the penis.
Psychological factors can also play a part for around 1 in 10 men with erectile dysfunction. Stress, caused by things like problems at work or financial worries as well as depression, anxiety and other psychiatric conditions can also produce erectile dysfunction, as can anxiety about sexual performance (commonly called performance anxiety).
Erectile dysfunction may also be a symptom of a relationship that’s not working due to sexual boredom, tension or anger, or lack of intimacy and communication between partners.
A clue that the cause is psychological rather than physical is if the man still gets an erection on waking or is able to get one when masturbating.
In some cases, erectile dysfunction results from a combination of physical, lifestyle and psychological causes. It’s important to see your doctor so you can get an accurate diagnosis of what is causing the problem and appropriate treatment.
There have been many advances in the treatment of erectile dysfunction. Most men can be helped, but because there are many different causes and treatments available, the best option for you should be worked out in consultation with your doctor.
In men whose erectile dysfunction stems from a physical cause, treating the underlying cause, such as heart disease, is important for your overall health. Changing medications can also be considered if erectile dysfunction is a side effect of a drug.
It’s also important to address lifestyle factors such as moderating alcohol intake, stopping smoking, and exercising regularly.
Medication. Oral medications are commonly used for erectile dysfunction. These drugs – a class of medication known as phosphodiesterase inhibitors, (PDE5 inhibitors) work by enhancing the erectile response to normal sexual stimulation. They do not treat the underlying cause of erectile dysfunction however. You may need other treatment for these conditions. There appears to be no difference in effectiveness across the three drugs.
These medications are usually taken ‘on-demand’, when sexual activity is desired and planned. They need to be taken at least one hour before sex. After a large meal or after drinking a lot of alcohol they can be slow to be absorbed, so take even longer to have an effect. More recently, a low-dose version of one of these medications has become available for regular daily use, which for some men allows more spontaneous sexual activity. PDE5 inhibitors may have side effects including facial flushing, nasal congestion, headaches and indigestion.
There have been some deaths during sexual intercourse in men taking these drugs, but this is thought to have been due to the physical exertion during sex, not the drugs themselves. So if a man has heart disease, his doctor needs to assess how fit he is before prescribing these drugs. Erectile dysfunction drugs can’t be used in men with heart disease who are on nitrate therapy (sprays, tablets or patches) or men who use amyl nitrite ‘poppers’ as this can cause a severe drop in blood pressure.
These medications can help up to seven in 10 men attain and maintain an erection. They only work if you are sexually excited and will not increase your sex drive. They don’t improve a man’s performance, libido or attractiveness and do not help if there isn’t an erectile problem to begin with.
For men who don’t respond to (or can’t take) medication for erectile dysfunction, there is a range of other treatments to consider.
Devices: Some treatments involve using a device, such as a vacuum pump placed over the penis to draw blood into it, with a rubber ring fitted around the base of the penis to stop the blood draining out and so keeping the penis engorged. But these devices can be cumbersome, and they take time to learn how to use. They need to be fitted and a doctor needs to explain how to use them.
Penile injections: Before the arrival of newer medications, this used to be the most popular and effective treatment. It involves the man or his partner injecting a drug that relaxes the blood vessels in the penis, allowing them to expand and fill with blood. It can create an erection within five to 10 minutes which lasts for up to one hour. Men must be taught how to do it and to use the right dose – too much can cause a painful erection that lasts for hours. There are also possible complications from repeated injections, such as bleeding and scarring. But many men have used them successfully for years.
Penile prosthesis: This is a device that is surgically implanted into the penis. It’s inflated with saline to enlarge the penis. Because it’s not reversible, it’s usually a last-resort treatment if other treatments haven’t worked.
Surgery: In a few men surgery can be used to correct defects in blood vessels in the penis. It’s not always successful and the surgery often needs to be redone.
Psychotherapy: Psychotherapy or counseling from a GP, psychologist or psychiatrist can help if the underlying cause is psychological. Counseling (for both partners) may help solve a relationship problem, and can also help a man whose confidence is low because of an underlying physical cause.
Low-intensity extracorporeal shock wave therapy: This has been proposed as a new non-invasive treatment for erectile dysfunction caused by problems with blood vessels. Shock wave machines are available in some medical practices in Australia. Although there is some evidence that it may help a proportion of men with erectile dysfunction, more research is needed before clear recommendations on its use can be made.
The impotence industry
Some people claim that erectile dysfunction is a result of the natural reduction in testosterone levels that occurs as a man ages – they call it the ‘male menopause’. They say testosterone replacement with tablets or injections will help. This is not accurate. Low testosterone levels can lead to problems with getting and keeping an erection, but it is not a common cause of erectile dysfunction. Testosterone is not a therapy for erectile dysfunction unless androgen deficiency (low testosterone) has been diagnosed by a doctor. Even then, testosterone replacement will not always help the erectile dysfunction.
Other clinics sell various concoctions of unspecified drugs, often as nasal spays or puffers. However, there is no scientific evidence for their effectiveness and safety.
Even the manufacturers of effective treatments have been accused of aggressively marketing them to men who don’t need them. So ignore those billboards, late-night TV ads and the spam. Anyone who has persistent difficulty getting and/or keeping an erection should see a GP, who may refer them to a specialist andrologist or urologist if necessary.
The best chance for a man to avoid problems with erectile dysfunction is to stay fit and healthy: eat a high-fibre diet low in saturated fats and sugars, exercise regularly, don’t smoke and moderate alcohol intake.