Share this article:

Dealing with Erectile Dysfunction

Erectile dysfunction (ED) is an extremely embarrassing problem, one that many men find very difficult to discuss with their partners, let alone with their doctors. Often men feel isolated, and the negative and profound effect on their self-image can start the beginnings of vicious circle of ignoring the problem. Erectile dysfunction is actually very common, effecting 22%(1) of men aged between 40 and 49. Fortunately, in many cases, ED can be easily treated.

What is erectile dysfunction?

Erectile dysfunction is defined as the inability to achieve or maintain an erection good enough for penetrative sex. To understand the causes of ED, it is important to understand how a normal erection is achieved. An erection involves a complex cascade of changes. Sexual stimulation leads to a significant increase in arterial blood flow into a special tissue within the penis known as the corpora cavernosa. As the corpora cavernosa swells, the penis hardens and lengthens. The venous system (vessels returning blood to the heart from the penis) then begins to narrow, helping to maintain the erection.

Both psychological and physical problems can lead to problems within this process and cause erectile dysfunction. Understanding the cause of an individual's dysfunction is crucial for ensuring correct treatment. It is also necessary to examine the cause as a means of possibly preventing other medical problems (such as issues with the nerves and blood supply).

Psychosexual Causes

Psychosexual causes are the most common reason for erectile dysfunction and are attributed to 90% of instances (2). Those suffering with ED related to psychosexual causes, may still be able to achieve a morning erection and may be able to masturbate. When a physical cause is the culprit, this is usually not the case. Psychosexual causes can include issues like:

Stress
Depression
Generalised anxiety
Performance anxiety
Loss of attraction to partner

Often, men do have an idea of why they might be having problems achieving an erection. Nevertheless, a doctor will often take a detailed confidential history and examination. They will first try to narrow down the cause of the erectile dysfunction to psychosexual or physical causes in order to help their patient.

Physical Causes

Even if the history indicates a psychological cause, most doctors will carry out a detailed examination and blood profile to exclude physical causes. It is of the utmost importance for a doctor to determine if there are any physical causes for the patient's erectile dysfunction, as the ED may be an early presenting symptom of conditions like diabetes, high blood pressure or heart disease (3). Some research has shown that ED may present in up to two years earlier as an early warning symptom of heart disease. Certain lifestyle factors can also cause erectile dysfunction:

Smoking
Obesity
Increased alcohol consumption
Recreational drug use (heroin, cocaine, ecstasy or marijuana)
Prescribed medications

Other examples of physical problems that may cause erectile dysfunction are surgery and injuries involving the lower spine or prostate. Traumas to these areas can cause damage to the nerves that are crucial in helping to achieve an erection.

Treatment Options

The doctor will tailor the treatment according to the cause. In psychosexual causes, drugs may be of assistance; however, the primary concern is helping the patient reconcile their psychological issues relating to the ED. For conditions like depression and anxiety, this may involve the following:

Cognitive behavioral therapy
Relationship counseling
Psychosexual counseling

In conditions like depression, which are often treated with medication, sometimes the medicines may actually cause or worsen erectile dysfunction. Even if this is the case, one should never stop their medication suddenly, even if they suspect it as the cause of their ED. Always consult a doctor first.

Medication

Drugs like Viagra® and Cialis® have revolutionised the lives of those suffering from ED, helping many people to live more sexually fulfilling lives. The medications can be used in both psychosexual and physical causes. Both drugs work by increasing the blood flow into the penis, mimicking the normal erectile process.

A common misconception is that by taking Viagra® or Cialis®, the patient will experience an instant erection. There still needs to be sexual arousal for an erection to occur. In addition, these drugs must be taken to 30 minutes to an hour before sexual activity, and therefore can ruin spontaneity. Doctors will often start patient on a low dose. Upon first taking the drug, the erection may not be hard enough for penetration. With continued discussion with the GP, however, the correct dose will be determined.

To tackle the issue of spontaneity, new drugs are being developed which will allow patients to only take one tablet per week and still allow for an erection whenever sexually stimulated.

Despite their success and wide spread use, there are still some areas of caution when considering these drugs. If you have heart disease or are taking blood pressure medication, the doctor will have to take this into consideration. Drugs like Viagra® may interact with cardiac medication. If you have recently had a heart attack, then this medication is not advisable. Viagra® can be taken by cardiac patients, but only if they are not on nitrates or nicorandil. If unsuitable for Viagra® and similar drugs, there are alternatives like Apomorphine, which can be taken with most cardiac medications. This should always be discussed with your doctor first, or in an ED clinic.

Injections

Injections of drugs like alprostadil (also known as Caverjet®, Viridal® Duo) into the penis are also available as a treatment option. Alprostadil can also be inserted using a special applicator (MUSE®) into the urethra (the tube from which you pass urine). Alprostadil is a chemical that helps relax smooth muscle in the penis, encouraging blood flow, and allowing the penis to become engorged, and hence erect, on sexual arousal.

The injections require the patient to be trained in its use. The treatment dose limits use of the injection to 2-3 per week, with at least 24 hours drug free period between doses.

Who on the NHS is eligible for these medications and injections?

Unfortunately, medication treatments (medicines and injections) for erectile dysfunction are not available to everyone on the NHS. Unless you are in one of the following groups, a private prescription from your doctor will be necessary:

Diabetes
Multiple sclerosis
Parkinson's disease
Poliomyelitis
Prostate cancer
Prostatectomy (including TURP)
Radical pelvic surgery
Renal failure treated by dialysis or transplants
Severe pelvic injury
Single gene neurological disease
Spinal cord injury
Spina bifida

In the UK, NHS treatments are also available for those being treated for erectile dysfunction prior to 14^th September 1998. On the NHS, treatment is normally limited to one treatment dose per week.

Vacuum Erection Devices

Vacuum devices involve the placement of a tube around the penis. A vaccum is then created around the penis to encourage blood flow in to the corpora caverosa. A ring is then placed at the base of the penis to prevent blood leaving, helping to maintain the erection. These devices are often used where medication hasn't proved effective. Evidence suggests that 60% of men find this device satisfactory.

Surgery

Surgery is usually reserved for patients where medical therapy, including the use of vacuum erection devices, has not worked adequately. There two main surgical routes:

Inflatable prosthesis
Malleable rods

Malleable rods are surgically inserted in to the penis and act as adjustable scaffolding. When an erection is required, the rods are simply adjusted to bring the penis into an erect position. The disadvantage is a constantly semi rigid penis. Surgeons tend to prefer the inflatable prosthesis, as the penis can be completely flaccid. Additionally, when required, the prosthesis may be inflated using easily concealed pumps. Both technologies have their pros and cons.

Further information

For further information, speak to your doctor or urologist. Most doctors are trained to deal with these issues in a sensitive and caring manner. You may also wish to visit the Sexual Dysfunction Association (SDA) website. The SDA is a support group that helps sufferers and their partners deal with male and female sexual problems and raises awareness about the extent to which these problems affect peoples' lives.

Sources

1. McVary, K.T. Erectile dysfunction. The New England Journal of Medicine, 357(24), 2007, pp. 2472-2481.

2. Feldman, H.A, Goldstein, I, Hatzichristou, D.G, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study, Journal of Urology, 1994;151(1), 1994, pp. 54-61

Author: Dr Shazan Chughtai, MB BS

Editor: Dr Ahmed Farooq, BMedSci, BDS, MJDF (RCS Eng)

Advertisement Area