Erectile Dysfunction (Impotence)
Erectile dysfunction (impotence) is very common, particularly in men over 40. It's usually nothing to worry about but see a GP if it keeps happening.
What is erectile dysfunction?
Erectile dysfunction (ED), often known as impotence, is a widespread issue, especially among older males. It can signify various underlying physical or psychological conditions.
The key symptom of erectile dysfunction is the continuous inability to obtain or maintain an erection adequate for satisfying sexual intercourse for a period of at least three months. In certain cases, it may also involve a diminished sexual desire (loss of libido).
Depending on the cause, achieving an erection at other times, like during sleep, may still be possible. While experiencing occasional difficulties in achieving an erection is typical, ongoing ED can lead to considerable emotional distress and relationship issues.
Your emotional state significantly influences the ability to achieve and sustain an erection. Feeling relaxed, self-assured, and sexually aroused is vital. Experiencing occasional issues with erections is normal, and it is not always a reason for concern. However, experiencing progressive or frequent ED during sexual activity is unusual and should be looked into.
Erection difficulties can stem from feelings of nervousness, anxiety, frustration, or tiredness. Consumption of alcohol and the use of drugs can also factor into these problems. Moreover, other medical issues or some medications and cancer treatments may lead to erectile dysfunction.
If erectile dysfunction continues, the emotional and psychological repercussions can be significant. It may result in stress, shame, reduced self-esteem, and can affect not only the individuals experiencing it but also their partners, leading to relationship challenges. Additionally, issues with achieving or retaining an erection could indicate a health issue that necessitates attention and might also be a risk factor for heart disease.
Erectile dysfunction is normally categorised by healthcare professionals into various types, these are:
- Vascular erectile dysfunction: Vascular erectile dysfunction (ED) is caused by issues with blood vessels that supply blood to the penis, which are essential for getting and maintaining an erection. It is the most common type of ED.
- Neurogenic erectile dysfunction: Neurogenic erectile dysfunction (ED) results from nerve issues that prevent signals from the brain from reaching the penis. It can be caused by trauma, pelvic surgery, radiation therapy, or neurological disorders like stroke, spinal stenosis, and multiple sclerosis (MS).
- Hormonal erectile dysfunction: Hormonal erectile dysfunction (ED) occurs due to testosterone deficiency or, in some cases, thyroid issues.
- Psychogenic erectile dysfunction: Psychogenic erectile dysfunction (ED) refers to psychological conditions that affect thoughts, feelings, or behavior, leading to ED.
How Erections Work
An erection happens through two main ways: reflex erection and psychogenic erection. Reflex erection occurs when the penile shaft is touched directly. Psychogenic erection happens from sexual or emotional thoughts.
Reflex erection involves nerves and the lower part of the spinal cord. Psychogenic erection involves the brain’s limbic system. For both types, a functioning nervous system is needed for a full erection.
During arousal, nerves release chemicals that increase blood flow to the penis. Blood enters two chambers in the penis called the corpus cavernosum. These chambers are made of spongy muscle tissue and are not empty. During an erection, these tissues relax and hold blood. This creates pressure, making the penis firm.
When a man has an orgasm, nerve signals cause the muscles in the penis to contract. This releases the blood back into circulation and the erection goes down.
Impotence can happen for several reasons, such as hormonal issues, nerve problems, poor blood flow to the penis, or psychological factors.
How common is erectile dysfunction?
Erectile dysfunction (ED) is the most common sexual health issue reported by men, particularly between the ages of 40 and 70, as they experience other health problems. Many men avoid seeking help due to feelings of embarrassment or shame. However, it’s important to realize that experiencing ED is nothing to be ashamed of; it may be your body’s way of signaling that something isn't right.
Having an open conversation with a healthcare provider about your symptoms and how they impact your quality of life is crucial. They can diagnose ED, identify its underlying causes, and recommend the most suitable treatment options for you.
Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles, and blood vessels. Erectile dysfunction can stem from issues related to any of these factors. Additionally, stress and mental health concerns can either cause erectile dysfunction or exacerbate it.
In some cases, the cause of erectile dysfunction may be both physical and mental. For example, a minor physical condition that slows down your sexual response might lead to anxiety about maintaining an erection. This anxiety can, in turn, contribute to erectile dysfunction.
How do I know my ED is physical and not mental?
It can be challenging to determine the causes of erectile dysfunction (ED). Healthcare providers now understand that many men experience underlying physical issues contributing to ED. For most patients, both physical and emotional factors can play a role. It's difficult to definitively rule out psychological influences on a man's ED.
The brain is crucial in the body's response; thus, anxiety about the ability to achieve an erection can hinder the process. This phenomenon is known as performance anxiety, which can be addressed through education and treatment.
Several factors can contribute to erectile dysfunction, some of which may only be temporary. However, for some men, the causes of ED may persist over an extended time. It is not uncommon for men to face occasional difficulties with erections. It is estimated that nearly one in five men in the general population experiences issues with achieving an erection at some point, whether infrequently or more consistently over a prolonged period.
ED can happen:
- Blood flow to the penis can often be restricted, or the nerves can be damaged, leading to various issues.
- With stress or emotional reasons.
- As an early warning sign of more serious illnesses such as atherosclerosis (hardening or blockage of arteries), heart disease, high blood pressure, or high blood sugar due to diabetes.
Understanding the causes of your erectile dysfunction (ED) is a vital step toward effective treatment and improved well-being. Remember, what’s good for your heart is often beneficial for your sexual health, too!
Physical
Common physical causes of erectile dysfunction include:
- Cardiovascular problems: High blood pressure, high cholesterol, heart disease, and stroke can restrict blood flow to the penis. Cardiovascular disease is a key risk factor for erectile dysfunction (ED), with nearly 50% of men with diagnosed coronary artery disease experiencing significant ED.
- Kidney disease: ED and chronic kidney disease share common mechanisms like vascular and hormonal dysfunction and may be linked to comorbidities such as hypertension and diabetes, which can contribute to ED.
- Endocrine conditions: Diabetes mellitus, hypogonadism, and hyperprolactinaemia can harm blood vessels and nerves, resulting in erectile dysfunction (ED). The longer and more severe the diabetes, the higher the risk of ED, partly due to the common occurrence of hypogonadism in men with long-term diabetes.
- Neurological conditions: Multiple sclerosis, Parkinson's disease, Epilepsy, spinal cord injuries can disrupt nerve signals to the penis.
- Hormonal imbalances: Low testosterone levels can lead to a decrease in libido and erectile function. This condition is often referred to as hypogonadism and can be associated with thyroid issues as well.
- Injuries: Injuries affecting the pelvis or spinal cord, such as pelvic fractures, can be particularly concerning if they damage the nerves or arteries responsible for erections.
- Operations & Medical Treatments: Treatments for prostate cancer or benign prostatic hyperplasia, such as post-transurethral resection of the prostate or radiation therapy for cancer, along with surgeries involving the pelvic area or spinal cord.
- Medications: Some medications, like certain antidepressants and blood pressure drugs, can have ED as a side effect. (antidepressants, antihypertensives, antipsychotics, opioids, medicines to treat high blood pressure, pain or prostate conditions and recreational drugs).
- Addictive / Recreational Drugs: These substances can affect and suppress the central nervous system. They may also cause severe damage to blood vessels, potentially leading to permanent erectile dysfunction. This includes amphetamines, barbiturates, cocaine, marijuana, methadone, nicotine, and opioids.
- Lifestyle factors: Smoking, excessive alcohol, lack of exercise, and obesity (BMI over 25) can harm erectile function. Adopting a healthier lifestyle can often reverse these effects. Many men in weight loss programs report improved erectile dysfunction within two years, and quitting smoking or drinking can yield faster results.
- Age: Erectile dysfunction can impact men of all ages, but aging significantly contributes to the issue. As men get older, the risk of cardiovascular diseases, hypertension, and other health conditions increases, which can lead to ED.
- Sleep Conditions: Poor sleep, including sleep disorders like sleep apnoea and insomnia, can negatively impact erectile function. Conversely, ED can also contribute to sleep problems.
- Circulatory Conditions: The circulatory system includes blood vessels that carry blood throughout the body. Adequate blood flow is necessary for the penis to become erect and stay that way. Valves close to maintain the erection, but they can malfunction. Clogged blood vessels, known as atherosclerosis, can also hinder blood flow.
- Anatomical Issues: Peyronie's disease, which can cause pain during sex, a bent penis, a shorter penis with erection, or a lump or bump on the penis.
- Cycling: Cycling has many health benefits, but it can sometimes cause erectile dysfunction (ED) due to pressure on the perineum and nerve compression. If you cycle over three hours a week, consider taking a break.
Psychological
The brain is essential for sexual arousal, which is the initial step in achieving an erection. A fulfilling sexual experience requires both the mind and body to work in harmony. Emotional or relationship issues can lead to or exacerbate erectile dysfunction (ED). Factors that can hinder sexual feelings and contribute to erectile dysfunction include:
- Stress and anxiety: Can interfere with the body's ability to respond to sexual stimulation.
- Depression: Can lower libido and negatively impact erectile function.
- Embarrassment or low self-esteem
- Relationship problems: Can create tension and anxiety around sex.
- Performance anxiety: Concerns about sexual performance can create a self-fulfilling prophecy of erectile dysfunction (ED).
What are the symptoms of erectile dysfunction?
Erectile dysfunction (ED) can significantly affect the emotional well-being of both men and their partners. Many men avoid seeking treatment due to feelings of embarrassment, which leads to many cases of ED remaining untreated.
While experiencing difficulties in getting an erection occasionally is normal, symptoms of erectile dysfunction are persistent and often worsen over time. They might include:
- Trouble getting an erection: Only sometimes being able to get an erection before sexual intercourse.
- Trouble keeping an erection: Experiencing difficulty in maintaining an erection during sexual intercourse.
- Complete inability to get an erection.
- Requiring a lot of stimulation to maintain an erection.
- Loss of sex drive: Embarrassment or depression can cause a lack of interest in sex.
- Premature or Delayed Ejaculation: Other sexual problems are often related, such as ejaculating sooner than you want or ejaculating later than you want.
Erectile dysfunction feels different for everyone, but here are some things you may be experiencing:
- Lack of confidence
- Worried about your future
- Less attractive
- Ashamed
- Worried about your health
- Embarrassed
- Scared about talking to a doctor or medical professional
- Frustrated that this is happening to you
Erectile dysfunction is a personal issue, which can make it difficult to discuss. If you’re concerned about it, consider talking to a trusted friend or family member, as long as they’re comfortable discussing the topic.
If you are experiencing frequent or persistent problems with erectile dysfunction, it's important to speak with a healthcare professional, even if it feels awkward. In many cases, addressing an underlying condition can resolve erectile dysfunction. A doctor can help determine the root cause and suggest suitable treatment options, which may include medication, therapy, or lifestyle changes.
If you prefer not to visit your general practitioner (GP), sexual health clinics can also help with sexual health concerns. They provide the same treatments you would receive at your GP's office, and many clinics offer walk-in services that do not require an appointment. Additionally, these clinics often provide test results more quickly than standard GP practices.
How is erectile dysfunction diagnosed?
One of the first steps is to differentiate whether your erectile dysfunction (ED) is due to physical or psychological reasons. This involves answering questions about your health history and lifestyle.
Your healthcare provider will also ask about your personal and sexual history. While these questions may make you feel embarrassed or awkward, it is important to be honest with your provider. This honesty helps them quickly identify the cause of your ED and determine the best treatment options for you.
General questions may include:
- Are you currently taking any medications: Including prescription drugs, over-the-counter drugs, herbal supplements, dietary supplements and recreational drugs?
- Lifestyle factors: Do you smoke? How much alcohol do you drink? What is your exercise regime?
- Questions about current or previous medical conditions: Have you had surgery or radiation therapy in the pelvic area? Do you have any urinary problems? Do you have other health problems (treated or untreated)?
- Questions About Stress and Emotional Health: Has a healthcare provider ever diagnosed you with depression or anxiety? Do you often feel stressed? Are you experiencing any relationship problems? The provider may also ask to talk with your sexual partner. Your partner may be able to offer additional insight on potential causes.
They will also ask you questions specific to your ED symptoms like:
- How long have you had these symptoms? Did they start slowly or all at once?
- How often are you able to get erections?
- How firm are your erections?
- How long are you able to maintain an erection?
- Do you have problems with ejaculation or orgasm (climax)? Do you lose your erection because you ejaculate sooner than you would like?
- What exactly happened when you first had erectile dysfunction symptoms?
- Do or did you experience erections at night or during the morning?
- Do your erections vary at different times, such as when having intercourse, during oral stimulation, or while masturbating?
- Do you have problems with sex drive or arousal?
- How is this problem changing the way you enjoy sex?
- Do you have painful with erections, feel a lump or bump in the penis or have penile curvature?
Understanding your history of erectile dysfunction (ED) will help your healthcare provider determine whether your issues are related to your sexual desire, erectile function, ejaculation, or orgasm (climax). Some questions may feel private or even embarrassing, but rest assured that your doctor is a professional. Your honest responses are essential for identifying the cause of your condition and finding the most effective treatment.
In many cases, the diagnosis can be made based on your reported symptoms. However, some situations may require a physical examination, focusing on your genitals to check your penis and testicles for any abnormalities. Depending on your age and risk factors, the exam may also assess your heart and circulatory system, including checking your heart rate, peripheral pulses, and blood pressure. Additionally, if warranted by your age and family history, your doctor may perform a rectal exam to evaluate your prostate. Rest assured, these tests are not painful.
Laboratory tests may be conducted to rule out more serious underlying conditions. Your healthcare provider might order specific tests to confirm their diagnosis and identify the cause of your erectile dysfunction. These tests will vary based on what your provider suspects.Your provider may order:
Blood tests (like full blood count, Liver function tests, lipid panels, kidney function test, thyroid test and testosterone tests). Urinalysis (urine test).
- Penile Doppler ultrasound to check blood flow.
- Tests that measure if the nerves in your penis respond to vibrations.
- Drugs that temporarily make your penis erect (vasoactive injection).
- Pelvic x-rays like arteriography, MRI or CT scanning can be arranged if there is history of trauma or cancer.
Before the test, your provider will take the time to explain what to expect and will be there to answer any questions you might have. Your comfort is important, so please know that if you feel uneasy at any point, you are completely free to decide not to proceed with the test. Your well-being comes first.
Once a diagnosis of erectile dysfunction has been made, clinicians have a variety of treatment options to consider. The choice of treatment depends on the underlying cause of the condition. Possible treatments include medications, vacuum pumps, lifestyle changes, and counseling. In more severe cases, surgical intervention may be recommended.
Typically, non-invasive treatments are tried first, as many well-known options for erectile dysfunction are effective and safe. However, it is important to discuss potential side effects of each treatment option with your healthcare provider.
Lifestyle Changes
The treatment for erectile dysfunction (ED) begins with focusing on your heart and vascular health. Your doctor may highlight certain risk factors that can be modified or improved. Additionally, you may be presented with alternatives to your current medications. Remember, never stop or change your prescription drugs without first consulting your healthcare provider.
Some basic treatments can include simple lifestyle changes like the following:
- Eat a healthy diet and lose weight if you're overweight
- Quit smoking: For men with mild ED, quitting smoking can lead to improvement after several months.
- Increase physical activity and exercise regularly: Engaging in vigorous cardiovascular exercise for at least 45 minutes, three times a week, may help reverse some cases of mild erectile dysfunction. Cardiovascular exercises can include brisk walking, jogging, swimming, and jumping rope.
- Reduce Alcohol Intake: do not drink more than 14 units of alcohol a week
- Changes to your existing medication routine: If your erectile dysfunction is a side effect of a prescribed medication, alternative options may be available. Always consult your health care provider before stopping or changing any prescribed drugs.
Medication
The main treatments for erectile dysfunction (ED) involve medications that enhance blood flow to the penis, known as PDE-5 inhibitors.
Oral medications such as sildenafil (Viagra), tadalafil (Cialis), avanafil (Spedra), and vardenafil (Levitra) can effectively improve blood flow, making it easier to achieve and maintain an erection.
Sildenafil can be obtained with a prescription or over-the-counter, while other ED medications require a prescription. For best results, these pills should be taken one to two hours before sexual activity and need normal nerve function to work effectively.
If you are taking nitrates for your heart, you should not take any PDE5 inhibitors. Always consult your healthcare provider before using a PDE5 inhibitor to understand how it may affect your health.
PDE5 inhibitors typically have mild side effects that are short-lived. If you have any concerns, it is advisable to consult your clinician.
Vacuum Pumps
Vacuum pumps are devices designed to create a vacuum that draws blood into the penis, resulting in an erection. The pump consists of a plastic tube that fits over the penis, forming a seal against the skin. By operating a pump at the other end of the tube, a low-pressure vacuum is created around the erectile tissue, leading to an erection. After achieving an erection, an elastic ring can be placed at the base of the penis to hold the blood in, maintaining the erection for up to 30 minutes.
These devices are effective for most men and can be used when medications are unsuitable or ineffective. They typically produce results almost immediately, but they may not be available on the NHS. It’s advisable to consult a doctor about obtaining a vacuum pump.
Penile injections or Urethral Therapies
If oral medications are ineffective, there are alternative treatments that can be considered. Your clinician may suggest a different type of medication that is applied directly to the penis. This can be done through an injection (known as intracavernosal injection, or "ICI"), a pellet administered through the urethra (referred to as "IU therapy"), or a cream. Some of these options can also be combined with other treatments to enhance effectiveness.
Testosterone replacement therapy
In rare instances where a low sex drive and low blood levels of testosterone contribute to erectile dysfunction (ED), testosterone therapy may help restore normal erections or enhance the effectiveness of ED medications, such as PDE5 inhibitors. This therapy typically begins to show results in about four weeks and is available in various forms, including gels, injections, patches, and pellets.
Penile low-intensity focused shockwave therapy (LiSWT)
This non-invasive treatment improves blood flow by using sound waves. It can take two months to see improvement.
psychological support
Cognitive Behavioral Therapy (CBT) and various other therapeutic approaches can effectively target the psychological factors that contribute to erectile dysfunction (ED). Common issues such as anxiety, depression, and relationship dynamics often play a significant role in the experience of ED.
For those seeking help, it is important to note that accessing these services through the NHS may involve lengthy waiting times, potentially delaying treatment. Alternatively, individuals may choose to pursue private counseling or therapy, allowing for a more immediate and personalized approach to their mental health and wellness. Engaging with a qualified counselor or therapist can provide tailored strategies to address underlying emotional or relational factors, thereby improving overall sexual health and well-being.
Surgical Treatment
There are two main types of surgery for erectile dysfunction (ED):
- Penile Vascular Surgery: This is typically an option for younger men with ED caused by trauma or localized arterial disease. The goal is to restore blood flow to the penis, either through revascularization to improve arterial flow or venous surgery to correct leakage. This method is not recommended for older men with hardened arteries.
- Penile Implants: For older males who haven't found success with oral medications or injections, penile implants are a common next step. This involves placing a device in the penis that allows for erections without affecting sensation, urination, or orgasm.
There are two types of implants:
- Semi-Rigid Implants: These flexible rods provide firmness for penetration and can be bent for urination or sex.
- Inflatable Implants: These consist of fluid-filled cylinders connected to a pump in the scrotum. Activating the pump inflates the cylinders, creating a natural-looking erection. These implants allow men to control firmness and, in some cases, size, while maintaining normal sensation during orgasm.
What is the Surgery Like?
Penile implants are typically placed under anesthesia. If a patient has a systemic, skin, or urinary tract infection, the surgery should be postponed until all infections are adequately treated. Additionally, if a man is taking blood thinners, he should consult a medical professional about the possibility of stopping these medications before elective surgery and during the healing process.
A small cut is usually made either above the penis, where it meets the abdomen, or below the penis, where it connects to the scrotum. No tissue is taken out during this procedure, and there is usually little bleeding. After the surgery, the patient may go home the same day or stay in the hospital for one night.
In the first one to two weeks following the surgery, patients may experience pain that can be managed with narcotic pain relief medications. After the first week, over-the-counter pain relievers such as acetaminophen or ibuprofen can be used as alternatives. Discomfort, bruising, and swelling may persist for a few weeks. During the first month, men should limit their physical activity, and the surgeon will provide guidelines on when and how much exercise can be safely resumed.
Most men can typically begin engaging in sexual activity with their penile implants by eight weeks after surgery. If swelling or pain continues, the use of the implant may need to be postponed. The surgeon or a healthcare professional in the surgeon's office will guide the patient on how to inflate and deflate the implant.
As with any surgical procedure, there are risks associated with prosthetic surgery, and patients are thoroughly counselled before undergoing the procedure. If there is a post-operative infection, the implant will likely need to be removed. While the devices are generally reliable, mechanical malfunctions can occur, and if this happens, the device or a part of it may require surgical replacement. It is important to note that if a penile prosthesis is removed, other non-surgical treatments may no longer be effective.
Is erectile dysfunction a sign of prostate cancer?
ED is not a common symptom of prostate cancer, but treatment for some advanced cases may lead to ED.
Will ED go away on its own?
ED is unlikely to resolve itself without lifestyle changes or treatment.
What can I expect if I have erectile dysfunction?
The outlook for erectile dysfunction (ED) is positive, as it is a highly treatable condition. Although some underlying causes of ED may not have cures, numerous treatment options can assist you in achieving and maintaining an erection firm enough for sexual activity.
Can ED be prevented?
Certain lifestyle changes can help lower your risk of developing erectile dysfunction, including:
- Reducing your cholesterol.
- Being more physically active, especially doing cardiovascular exercises like running, jogging or bicycling.
- Maintaining a healthy weight for you.
- Getting high-quality sleep.
- Eating healthy foods with low saturated fats, such as fruits, vegetables and whole grains.
- Stopping smoking.
- Reducing or stopping drinking.
- Taking care of your mental health and finding effective methods of dealing with stress and anxiety.
Can I combine treatment options?
It is common to combine treatments but always consult your healthcare provider first. Drug therapy can occasionally cause prolonged erections, which can be dangerous. Be sure to ask your doctor for proper instructions.
I had no symptoms until I started this new medication, what should I do?
Avoid stopping or changing prescription medications without consulting your healthcare provider. Some medications can cause erectile dysfunction (ED), but may be necessary for your health. If you believe a specific drug is causing ED, discuss alternatives with your provider. If a change isn't possible, there are effective ED treatments available.
What can I do if I have erectile dysfunction?
The most crucial step in addressing sexual issues is the willingness to discuss them openly. Erectile dysfunction is a common concern, and your local general practitioner (GP) and staff at sexual health clinics are trained professionals ready to assist you. Don’t let embarrassment prevent you from seeking help.
When should I go to the ER?
If you are taking medication for erectile dysfunction and experience an erection that is painful and lasts for more than two to four hours, go to your nearest emergency room immediately. This condition, known as priapism, can lead to permanent damage to your penis if left untreated.
What can I do if my partner has erectile dysfunction?
Erectile dysfunction can be a challenging and sensitive topic for many people, and it’s important to approach it with compassion and understanding. If your partner is facing this issue, here are some ways you can offer your support and show that you care:
- Encourage open communication: Express to your partner that you value their feelings and well-being. Choose suitable times for discussions that won't make them feel vulnerable.
- Remind your partner that they are not alone: Erectile dysfunction (ED) is common, and treatment options are available. Therapists and support groups can assist your partner in processing their feelings.
- Encourage healthy habits: Emphasize the advantages of regular exercise, nutritious foods, and reducing substances that may contribute to erectile dysfunction.
- Educate yourself: Being informed about erectile dysfunction and its treatment options shows your support and commitment to navigating this journey together. Your partner will truly appreciate your knowledge and understanding.
- Offer to go with your partner to their appointments: You can assist your partner by asking questions, taking notes, and sharing information with a healthcare provider to aid in making a diagnosis. If they prefer to see the provider alone, respect their privacy.
- Convey your emotions through different methods: Intimacy between partners can be fostered in ways beyond sexual intercourse. You can demonstrate your care for your partner through simple physical gestures, such as holding hands or giving back rubs. Spending quality time together, sharing kisses, writing thoughtful notes, being patient, and actively listening are all effective ways to strengthen your connection.
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