Erectile dysfunction (impotence)

Written by Dr David Delvin, GP and family planning specialist

The outlook for men with erectile dysfunction (ED) has improved enormously in the first seven years of this century – so much so that almost all patients nowadays can be assured of a return to successful intercourse. Many of these males feel that the new treatments for erection difficulty (formerly known as ‘impotence’ or ‘impotency’) have transformed their lives. What is erectile dysfunction? Term watch Many people confuse erectile dysfunction with: · premature ejaculation which is 'coming too quickly'. · retarded ejaculation (delayed ejaculation) which is an inability of the man to reach a climax. First, let’s define the problem. ED means an inability to get a good enough erection to achieve satisfactory intercourse. Some sufferers can’t get a hard-on at all; others get one but it isn’t firm enough to penetrate the partner; and others can manage penetration for a bit, but then lose it. Why does ED occur? ED is very common, and it occurs for a variety of reasons and at different ages. Teenagers and young men In younger males, the most frequent cause is anxiety – particularly nervousness about having sex, about causing a pregnancy, or about using a condom. A lot of men in this age group complain that they ‘can’t get on with a condom’ because as soon as they try to put it on, they lose their ‘stiffy'. Middle age Common causes in this age group are overwork, stress, guilt and bereavement (ED often happens when a widowed man tries to form a new sexual relationship). A few cases are due to diabetes. Post-middle age In this group of men, ED gets commoner with increasing age. Nonetheless, 70 per cent of all 70-year-olds are sexually potent. It is now clear that in a very high proportion of cases, the problem is due to deterioration in the blood vessels that carry blood into the penis. Research being carried out in 2007 suggests that in addition there may often be deterioration in the arteries of the brain or the heart. Therefore older men with ED should take care to protect themselves against strokes and heart attacks – for example by keeping their blood pressure and cholesterol down. You may be surprised to see that I have not listed ‘lack of hormones’ as a common cause of ED. In fact, lack of male hormone is pretty rare. If you are tempted to go to one of the many private clinics that make a habit of diagnosing ‘male hormone deficiency', and then charging huge sums of money for testosterone treatment, I suggest you think twice! What is an erection? An erection occurs when blood is pumped into the penis and stays there, making it hard. It generally happens because a guy is thinking about sex, or because his penis is being stimulated - or both. The result is that signals go down the nerves that lead from his spinal cord to his genitals. They tell the blood vessels which supply the penis to open up. Blood flows in and the organ ‘blows up’ like a balloon. A valve mechanism near the base of the penis keeps the blood from flowing out again – a least, until sex is over. As you can see, getting an erection is a complex process. It’s awfully easy for various factors to interfere with it - for instance, worry, tiredness, too much alcohol or in later life, narrowing of the blood vessels. Nicotine is now known to narrow those vital blood vessels – which is why ED is much commoner in smokers. But often, there is nothing physically wrong with men who develop ED. Are many cases due to psychological causes? Yes, particularly in the young. In general, erectile dysfunction is quite likely to be psychological rather than physical if the man: is still waking with morning erections can still get a good erection by masturbation. Common psychological causes of erection difficulties include: nerves - especially about performing guilt - notably if you’re trying to have sex with somebody else’s wife relationship problems - especially if you’re no longer keen on your partner latent gayness - for instance, if you’re a basically gay guy, trying to have sex with a woman depression exhaustion. In a lot of cases, ED turns out to be due to a mixture of psychological and physical causes. What physical causes are there? Common physical causes include: deterioration of the arteries – this is a physical change which is common in older men, including those with high blood pressure diabetes smoking excessive drinking (hence the phrase ‘Brewer’s droop’) being obese and out-of-condition side-effects of certain drugs, notably ones for blood pressure and depression effects of recreational drugs, like cocaine. Less common physical causes include: excessive drainage of blood from the penis (‘venous leak’) diseases of the nervous system injury to the spinal cord major surgery in the abdomen, particularly prostate operations hormone problems, including excess production of a pituitary hormone called prolactin. What should I do if I'm having potency problems? If you have difficulty getting an erection, seek help. Don’t suffer in silence – as so many men do! Also, don’t hide it from your partner. A lot of guys behave like this, and very often the result is that the other person decides that she is being scorned, or that ‘he doesn’t love me any more'. Your first move should be to consult your GP. If for any reason you don’t want to do that, then contact another medical/relationships agency, such as the ones listed at the end of this article. Please don’t do daft things like: buying yourself some pills or potion off the Internet signing up with some clinic that asks you for £1,000 deposit going to a prostitute to see if she can cure you deciding that your life is over (it isn’t). What will happen when I see a doctor or therapist? If you go to a doctor, he should take a full history of your problem, and then examine you to see if there are any physical causes for your ED. A therapist or counsellor isn’t able to do physical examinations, nor can they prescribe drugs. The doctor should also do a test for diabetes and possibly other lab tests as well. After that, he may well be able to give you some indication of the likely cause of your ED. If he can’t, then ask if can refer you to someone who can give you further help. Once the cause(s) of your erectile dysfunction has been identified, you can get treatment. What treatments are now available? Treatment depends on the cause of the ED. For instance, psychological causes may require: commonsense advice to one or both partners counselling psychotherapy relationship counselling. Personally, I feel that in some cases of psychologically-induced ED, it’s worth trying erection-inducing drugs to help ‘kick-start’ the man back into action and boost his confidence. Not all doctors agree with me. The treatments for ED that has a physical origin are listed below. Erection-inducing drugs Oral drugs which induce erection have revolutionised the treatment of ED over the last eight years. They don’t work for everybody, but they do work for the majority – even in diabetes. They can also help people with neurological and spinal problems. Also, the choice of available drugs means that if one particular drug doesn’t suit you, it’s well worth trying one of the others. There are three orally-administered drugs available in the UK. They all have side-effects, only a few of which we can list here. For more information, read the package insert leaflet, and if in doubt ask your doctor. It is not safe for some people to use these drugs, and some medications interact dangerously with them. Therefore, before going on any of these pills you should always see a doctor, talk things over with him, and have a physical check-up. Do not buy erection drugs by mail-order, or from chaps you meet in pubs! They may not be the right thing. The oral drugs currently available are: Viagra tablets (sildenafil). Cialis tablets (tadalafil) Levitra tablets (vardenafil) Viagra (sildenafil) Widens the bloods vessels, so giving an erection - provided the penis is rubbed. In most men, works within an hour. Effect lasts for about four hours. Easily blocked by food in the stomach. Viagra still remains the world’s most popular ED drug. At the Vienna International Sexology conference of December 2006 which we attended, it was claimed that its continuing popularity is due to the ‘hardness ‘ of the erections it produces. The most common side-effects are headache, visual disturbances, blocked nose, flushed face, indigestion, palpitations - and dizziness after getting out of bed too quickly! Blue vision occurs at higher doses. Viagra is very dangerous with certain heart drugs. Interacts with many medications. Do not drink grapefruit juice on day of use. At the beginning of April 2005, a report from the University of Minnesota suggested that a small group of men have suffered blindness as a result of Viagra use. It was claimed that the drug may rarely cause a serious eye condition called ‘non-arteritic ischaemic optic atrophy.’ In 2007, it became apparent that about half a dozen British men have suffered similar eye problems. If you are taking Viagra, you should ask your doctor to keep you informed of any further research on this development. Cialis (tadalafil) Works in the same way as Viagra. Now popular with a lot of men, because its effects last so long – at least 12 hours in most cases. Manufacturers claim it is not blocked by food. Side-effects similar to those of Viagra, but also causes back pain and muscle pain. Interactions with other drugs and with grapefruit juice are similar to those of Viagra, but also clashes with the antibiotic clarithromycin and the sedative phenobarbitone. Cialis is very similar in structure to Viagra, but so far (2007) there have been no reports of blindness on Cialis. Levitra (vardenafil) Works in same way. Side-effects and interactions are similar to those of Viagra. Not as long-lasting as Cialis. So far, there have been no reports of blindness. The above three drugs are supposed to be ‘prescription-only’ in the UK and most other countries. However, in Manchester during early 2007, Boots the chemists opened three centres where men can obtain Viagra (for a fee) after careful counselling from a pharmacist. There is back-up from a group of private doctors. If this scheme turns out to be a success, then Viagra and similar drugs may become more widely available over the counter. Uprima There is another oral anti-ED drug called ‘Uprima’, but it was withdrawn from sale in Britain during 2006 – probably for commercial reasons. What other drug treatments for ED are there? It’s also possible to give erection-inducing agents by: injections into the penis. pellets inserted down the urinary pipe. These methods have become less popular since the increasing availability of oral drugs, but they suit a minority of men. You have to be quite brave to give yourself a jab in the penis. For details of side-effects, consult your GP. What mechanical aids are there for ED? There are a number of devices that can help men to achieve a better erection and to have successful sex. Vacuum pumps. A pump is a cylinder which you put over your penis. You then pump out the air. That should ‘suck’ your penis into an erection – which, however, tends to be a bit cold and blue-looking. Rings Specially-designed rings which fit round the base of the male organ are often used with vacuum pumps. However, they can be tried on their own. The idea is that the ring helps stop the blood from flowing out of the penis. External splints These are supposed to prop the penis up during sex. Not awfully successful, in my view. Vibrators Although vibrators aren’t often prescribed by doctors (and certainly not on the NHS), I have found that they can be quite useful in urging a lethargic penis into life. Some vibrating devices such as the Penisator actually clip round the male organ. In December 2006, at the Vienna conference, it was reported that vibrators are surprisingly effective in helping men with spinal injuries to achieve an orgasm – and thus to have children. What about surgery? In the 1990s there was great hope that surgery would cure a lot of men who had ED. Unfortunately, it hasn’t worked out like that, and it is fairly rare to see a man whose erection problems have been put right by a surgical operation. The types of surgery which are available for ED are as follows. Curing a venous leak. As we’ve indicated above, a few men lose their erections because blood leaks out of the penis through a leakage in the veins. Occasionally, this leak only occurs in certain sex positions. Where a leak can be clearly pin-pointed by special X-rays, a urologist may be able to operate in order to improve matters. Insertion of internal splints. A skilled urologist can insert artificial splints inside the body of the penis. With the simplest type of splint (which is just a firm rod), the man lifts the organ into a vertical position when he wants to have intercourse. There are more sophisticated (and much more expensive) internal splints which you or your partner can inflate when you wish to make love. Some couples report being very pleased with these. But if anything goes wrong with the surgery – for instance, infection or bleeding, you could be in some trouble. Summing up Erectile dysfunction is usually treatable these days. However, it’s important to first establish what the cause is. Very often, there are several causes, including both physical and psychological factors. Commonsense measures will often help – for instance, cutting down on stress, alcohol or smoking, getting more sleep, or stopping any medications which interfere with erection. Your GP should assist you in these areas. If he can’t, then talk to one of the organisations listed below. Further help The following can be helpful in various ways to ED sufferers and their partners: The Sexual Dysfunction Association (formerly The Impotence Association) Tel: 0870 7743571. Institute of Psychosexual Medicine Tel: 020 7580 0631. Family Planning Association (fpa)/Sexual Health Direct Tel: 0845 310 1334. Brook Advisory Centres For Young People Tel: 08000 185 023. Website: http://www.brook.org.uk. Relate Tel:01788 573 241. Couple Counselling Scotland (now called Relate Scotland but their website is still currently to be found under its old name). Tel: 0131 55 61 52 7. Website: www.couplecounselling.org British Association for Sexual and Relationship Therapy (BASRT) Tel:020 8543 2707.