Men who have a problem with their sexual performance may be reluctant to talk with their doctor, seeing it as an embarrassing issue.
However, doctors are used to dealing with potentially embarrassing issues in private consultations; and, erectile dysfunction is now well understood, and there are various treatments available.
This article offers helpful information for people experiencing this problem, or those close to them.
- Erectile dysfunction is defined as persistent difficulty achieving and maintaining an erection sufficient to have sex.
- Causes are usually medical but can also be psychological.
- Organic causes are usually the result of an underlying medical condition affecting the blood vessels or nerves supplying the penis.
- Numerous prescription drugs, recreational drugs, alcohol, and smoking, can all cause erectile dysfunction.
What is erectile dysfunction?
A man is considered to have erectile dysfunction if he regularly finds it difficult getting or keeping a firm enough erection to be able to have sex, or if it interferes with other sexual activity.
Most men have occasionally experienced some difficulty with their penis becoming hard or staying firm.
However, erectile dysfunction is only considered a concern if satisfactory sexual performance has been impossible on a number of occasions for some time.
Broadly, two forms of erectile dysfunction can affect men's sex lives - the main cause is either medical or psychosocial.
- Medical - these are illnesses or anatomical changes that prevent the penis from becoming or staying erect.
- Psychosocial - this refers to psychological influences on sexual performance; it might include problems within a relationship or stress at work.
It is important to note that there can be overlap between medical and psychosocial causes. For instance, if a man is obese, blood flow changes can affect his ability to maintain an erection (a medical cause); he may also have low self-esteem, which can also impact erectile function (psychosocial cause).
Treatments for erectile dysfunction
The good news is that there are many treatments for erectile dysfunction, and most men will find a solution that works for them. Treatments include:
Drug treatments for erectile dysfunction
Men can take a group of drugs called PDE-5 (phosphodiesterase-5) inhibitors.
Most of these pills are taken 30-60 minutes before sex - the best known being the blue-colored pill sildenafil (Viagra). Other options are:
- vardenafil (Levitra)
- tadalafil (taken as a once-daily pill; Cialis)
- avanafil (Stendra)
PDE-5 inhibitors are only available on prescription. A doctor will check for heart conditions and ask about other medications being taken before prescribing.
Side-effects associated with PDE-5 inhibitors include:
Less commonly used drug options include prostaglandin E1, which is applied locally, into the penis (either injected into it or inserted down the opening into the urethra).
Most men prefer a pill, however, so these locally acting drugs tend to be reserved for men who cannot take oral treatment.
Online pharmacies selling drugs for erectile dysfunction
It is possible to buy treatment over the internet for erectile dysfunction; however, it is advisable to exercise caution.
The Food and Drug Administration has a consumer safety guide about this, including a recommendation to check that the online pharmacy:
- Is located in the U.S. and licensed (check the list maintained by the National Association of Boards of Pharmacy).
- Has a licensed pharmacist to answer questions.
- Requires a prescription.
- Offers direct contact with a person who can discuss any problems.
The FDA also offers tips for spotting the dangers of an unsafe website, including watching out for the following clues:
- There is no way to contact the website by phone.
- Prices are dramatically lower than those offered by legal online pharmacies.
- Prescription drugs are offered without requiring a prescription - which is illegal.
- Personal information is not protected.
The FDA adds that these illegal sites may send drugs of unknown quality and origin, even sending the wrong drug or a dangerous product.
Vacuum erection devices are a mechanical way of producing an erection for men who do not want or cannot use drug treatments, or find they are not working.
The penis is made rigid by the use of a vacuum pump sealed around it that draws up blood - this is prevented from then leaving the penis by the use of an accompanying band.
The lack of spontaneity with the use of vacuum devices means that many men find other treatments for erectile dysfunction preferable.
There are several surgical treatment options:
- Penile implants - these are a final option reserved for men who have not had any success with drug treatments and other non-invasive options.
- Vascular surgery - another surgical option for some men is vascular surgery, which attempts to correct some blood vessel causes of erectile dysfunction.
Surgery is a last resort and will only be used in the most extreme cases. Recovery time varies, but success rates are high.
Do dietary supplements and alternative treatments for erectile dysfunction work?
The short answer is "no."
No guidelines followed by doctors, nor any established sources of evidence, support the use of dietary supplements for erectile dysfunction, such as herbal pills.
In addition to there being no evidence in favor of non-prescription alternatives for ED, the FDA has warned of hidden risks of "treatments" sold online for erectile dysfunction.
What causes erectile dysfunction?
Normal erectile function can be affected by problems with any of the following systems:
- blood flow
- nerve supply
Physical causes of erectile dysfunction
It is always worth consulting a physician about persistent erection problems, as it could be caused by a serious medical condition.
Whether the cause is simple or serious, a proper diagnosis can help to address any underlying medical issues and help resolve sexual difficulties.
The following list summarizes many of the most common physical or organic causes of erectile dysfunction:
- Heart disease and narrowing of blood vessels.
- High blood pressure.
- High cholesterol.
- Obesity and metabolic syndrome.
- Parkinson's disease.
- Multiple sclerosis.
- Hormonal disorders including thyroid conditions and testosterone deficiency (hypogonadism).
- Structural or anatomical disorder of the penis, such as Peyronie disease.
- Smoking, alcoholism, and substance abuse, including cocaine use.
- Treatments for prostate disease.
- Surgical complications.
- Injuries in the pelvic area or spinal cord.
- Radiation therapy to the pelvic region.
Atherosclerosis is a common cause of blood flow problems. Atherosclerosis causes a narrowing or clogging of arteries in the penis, preventing the necessary blood flow to the penis to produce an erection.
Numerous prescription medications can also cause erectile dysfunction, including those below (anyone taking prescription medications should consult their doctor before stopping or changing their medications):
- Drugs to control high blood pressure.
- Heart medications such as digoxin.
- Some diuretics (known as 'water pills' that increase urine output).
- Drugs that act on the central nervous system (on the brain or spinal cord), including some sleeping pills and amphetamines.
- Anxiety treatments (anxiolytics).
- Antidepressants, including monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants.
- Opioid painkillers.
- Some cancer drugs, including chemotherapeutic agents.
- Prostate treatment drugs.
- Hormone drugs.
- The peptic ulcer medication cimetidine.
Physical causes account for 90 percent of erectile dysfunction cases, with psychological causes much less common.
Psychological causes of erectile dysfunction
In rare cases, a man may always have had erectile dysfunction - having never achieved an erection. This is called primary ED and the cause is almost always psychological if there is no obvious anatomical deformity or physiological issue. Such psychological factors can include:
- fear of intimacy
- severe anxiety
Most cases of erectile dysfunction are 'secondary,' i.e. erectile function has been normal, but is now problematic. Causes of a new and persistent problem are usually physical; less commonly, psychological factors cause or contribute to erectile dysfunction, with such factors ranging from treatable mental health illnesses, to everyday emotional states that most people experience at some time or another.
Does riding a bicycle cause erectile dysfunction?
Questions remain over the effects on men's health of riding a bicycle (saddle effects).
Some research has raised concerns that men who regularly cycle for long hours could have a higher risk of erectile dysfunction, in addition to other men's health issues such as infertility and prostate cancer.
The most recent study to investigate this found that there was no link between riding a bike and erectile dysfunction, but it did find an association between longer hours of cycling and the risk of prostate cancer.
Prostate disease and erectile dysfunction
Prostate cancer does not cause erectile dysfunction; however, prostate surgery to remove the cancer and radiation therapy to treat prostate cancer can cause erectile dysfunction.
Treatment of non-cancerous, benign prostate disease can also cause ED.
Tests and diagnosis for erectile dysfunction
The numerous potential causes of erectile dysfunction means that a doctor will typically ask a lot of questions and arrange for blood tests to be performed. Such tests can check for heart problems, diabetes, and low testosterone, among other things. The doctor will also carry out a physical examination, including of the genitals.
Before considering a diagnosis of erectile dysfunction that requires treatment, a doctor will look for symptoms that have persisted for at least 3 months.
Once a patient's history has been established, a doctor will then undertake further investigation. One simple test, known as the 'postage stamp test,' can be helpful in determining if there is a medical cause of erectile dysfunction rather than a psychological one.
This test checks for the presence of erections at night - men usually have 3-5 a night - by seeing if postage stamps applied around the penis before sleep have snapped off overnight. Other tests of nocturnal erection include the Poten test and Snap-Gauge test. These methods provide limited information but can help guide a doctor's choice of further tests.