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 12 years of this century – so much so that almost all patients nowadays can be assured of a return to fairly 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.
  • But these conditions have nothing to do with ED.
    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 they 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'. We have termed this 'condom collapse syndrome'.


      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. Alcohol, nicotine and other drugs can be factors, as can obesity.


      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 high proportion of cases, the problem is due to narrowing of the blood vessels that carry blood into the penis.

      Research, which was carried out in 2007, suggests that in some older men who have erection difficulties, there may also be deterioration in the arteries of the brain or the heart.

      In 2008, leading sex expert Dr Geoffrey Hackett said in the British Medical Journal, 'Erectile dysfunction is the manifestation of vascular disease in smaller arteries and can give a two to three year early warning of heart attack.'

      This doesn't mean that if you have erection problems, you're about to have either a stroke or a heart problem.

      But 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 and getting an adequate amount of exercise. Also, at all costs they should avoid smoking.

    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. However, it can occur particularly after severe injuries to the testicles or to the base of the brain.

    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

    • major surgery in the abdomen – particularly on the prostate gland.

    Less common physical causes include:

    • excessive drainage of blood from the veins of the penis (‘venous leak’)

    • diseases of the nervous system

    • injury to the spinal cord or brain

    • hormone problems, including excess production of a pituitary hormone called prolactin (this is rare).

    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 (for instance at Relate) may be very useful, but they aren'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-aiding drugs to help 'kick-start' the man back into action and boost his confidence. Not all doctors agree with me.

    The treatments for the type of ED that has a physical origin are listed below.

    Erection-aiding drugs

    Oral drugs, which help produce an erection in response to sexual stimulation, have revolutionised the treatment of ED over the last 15 years.

    They don't work for everybody, but they do work for the great majority – even in diabetes. They can also sometimes 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 now only 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.

    For a few men, it's not safe to use these drugs. Also, 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 or her, 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. In fact, there have been several recent cases of cruel scams, in which men were sold fake Viagra.

    The oral drugs currently available are:

    • Viagra tablets (sildenafil)

    • Cialis tablets (tadalafil)

    • Levitra tablets (vardenafil).


      Viagra (sildenafil)

      It widens the bloods vessels, so giving an erection – provided there is some sexual stimulation – such as rubbing.

      In most men, it works within an hour. The effect lasts for about four hours. (This doesn't mean the erection lasts for four hours, rather that an erection can be produced for up to four hours after taking a tablet.) It's 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.

      And it certainly does give you excellent stiffness. However, we're not convinced that it produces greater hardness than the other two drugs.

      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, but it only lasts a short time.

      Viagra is dangerous with certain heart drugs. It interacts with many medications. Do not drink grapefruit juice on the day of use, because that pushes up the blood level of the drug.

      In 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 neuropathy (NAION).

      It's apparent that a very small number of 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.

      Also, in 2007 concerns began to emerge about whether Viagra could cause deafness. In that year, the American Food & Drug Administration (FDA) told manufacturers of all three ED medicines to mention this possibility more prominently on their leaflets for patients.

      And in 2011, a well-argued study published in the respected British journal 'The Laryngoscope' showed that sudden deafness does indeed seem to occur occasionally in men who have recently taken Viagra or one of the other two medicines.

      Admittedly, only 47 cases had been reported worldwide, and a mere eight of these had been recorded in the UK. But there were 240 other possible cases in America.

      This type of deafness is called sudden sensorineural hearing loss (SSHL).

      It generally affects only one ear and mostly seems to happen within 24 hours of taking Viagra or one of the other ED medicines.

      As yet, no one has proved that this deafness is definitely due to Viagra, Cialis or Levitra. But if you suddenly lose your hearing after using one of these drugs, do NOT take any more until you have consulted an ear, nose and throat specialist.


      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, which means sex can be more spontaneous. Manufacturers claim it is not blocked by food.

      Side-effects are similar to those of Viagra, but it can also cause 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 phenobarbital.

      Cialis is very similar in structure to Viagra and there have been several reports of blindness occurring while on it. Also, it may be a cause of sudden deafness (please see above).


      Levitra (vardenafil)

      Works in same way. Side-effects and interactions are similar to those of Viagra. Not as long-lasting as Cialis. There have been a very few reports of blindness and deafness (see above).

      Please note the alleged relationship between these three drugs and blindness or deafness is still the subject of argument – and litigation. A 'cause and effect' has still not been proved.

    The above three drugs are supposed to be 'prescription-only' in the UK and most other countries.

    However, in 2012 Lloyds and other large British high street chemists are offering a service through which a man can obtain Viagra directly from a pharmacy after undergoing some basic tests and filling in a health questionnaire. There's a back-up from online doctors, but you do not usually meet them face-to-face.

    Also, it is now very easy to buy Viagra, Cialis and Levitra through the internet, but I really do NOT recommend this – particularly because criminals have been making a fortune by selling fake tablets on the net.

    There is another oral anti-ED drug called 'Uprima', but it was withdrawn from sale in Britain during 2006 – probably for commercial reasons. It's now almost impossible to obtain it.

    What other drug treatments for ED are there?

    It's also possible to give erection-inducing agents by:

    • injections into the penis, which usually involve the drug alprostadil (Caverject)

    • pellets inserted down the urinary pipe. These also contain alprostadil (Muse).

    These methods have become less popular since the increasing availability of oral drugs, but they suit a small 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 that 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 (in fair-skinned men) blue-looking.

      Quite a lot of men do use vacuum pumps, as shown by the fact that there are currently no less than 11 different vacuum devices available for prescription by doctors.

      However, as is the case with other treatments for erectile dysfunction, you can only obtain them free on the NHS from your GP if you have one of a short list of physical disorders, which were specified by the then Minister of Health back in 1999. The commonest of these disorders is diabetes.

      If you don't have one of those disorders, the cost of buying a vacuum cylinder is generally in excess of £100.


      Rings

      Specially-designed rings that 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.

      Again, your GP can prescribe these rings, but you would only get them free if you have one of the disorders on the above-mentioned NHS list. Otherwise, the current cost of penile rings is between £10 and £40.


      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 therefore 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's 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 very 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 that 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 overwork, 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 sometimes be helpful in various ways to ED sufferers and their partners.

    The Sexual Advice Association(formerly the Sexual Dysfunction Association) Tel: 0207 486 7262. Provides information only - not treatment.

    The Institute of Psychosexual Medicine Tel: 020 7580 0631.

    Family Planning Association (FPA) Helpline Tel: 0845 122 8690.

    Brook Advisory Centres For Young People Tel: 0808 802 1234.

    Relate Tel: 0300 100 1234.

    Relationships Scotland Tel: 0845 119 2020.

    Relate Northern Ireland Tel: 0289 032 3454.

    The College of Sexual and Relationship Therapists (COSRT) Tel: 0208 543 2707.

    Other people also read:

    ED treatments: a variety of effective treatment options is now available.

    Premature ejaculation: find out what causes it.

    Blood pressure measurement: what is measured?

    Checking yourself for testicular cancer: why self-examine?


    Last updated 07.12.2012

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