Hard facts: Facing up to the truth about erectile dysfunction

Erectile dysfunction can affect 40%-55% of men over the age of 40. Don’t be shy about talking to your GP about the problem, writes Dr Phil Kieran.

Fri, 15 Jun, 2018 - 01:00

Erectile dysfunction can affect 40%-55% of men over the age of 40. Don’t be shy about talking to your GP about the problem, writes Dr Phil Kieran.

ONE of the most successful drugs of all time is used to treat a problem which most of us would rather ignore than discuss with our doctor. Despite the fact this problem is so common it has featured as a storyline in almost every TV sitcom, I rarely see people become as uncomfortable as they do just before they bring up the issue of erectile dysfunction.

Erectile dysfunction (ED) is a common problem, which will affect 40%-55% of men over the age of 40. It can be as short-lived as a few weeks or in some cases can be difficult to remedy.

Sexual arousal is a complex process that we can all take for granted until there is a problem, but before we reach for the Viagra there’s a bit more detail to look into.

How does it happen?

Signals travel from your brain down to the penis and cause blood vessels in the top of the penis to enlarge while at the same time constricting the outflow tract at the base of the penis. This increases pressure, causing the penis to elongate and become hard. For this to happen the mind must be in the right place, the blood supply must be functioning well, there needs to be enough testosterone in the blood supply, and the nerves need to transmit the signals effectively.

Issues can arise in the mind (psychogenic ED), in the nerve supply (neurogenic ED), or in the blood supply (vascular or hormonal ED) and the treatment for each will differ.

In younger men, a common problem is psychogenic ED (although this only accounts for 10% of the overall numbers). Fatigue because our lives are too busy can leave a lot of us without the physical or mental energy needed. Depression and anxiety will also cause significant problems, hampering the libido and the physical ability to achieve and maintain an erection. This can often be a self-reinforcing problem as increasing the pressure we put on ourselves makes erections even more difficult to achieve. You could call it performance anxiety.

I remember a consultation years ago where a young man told me his partner said she would leave him unless the problem was fixed quickly. I was only working in that practice for a short period so I don’t know how it worked out in the end but with that level of pressure, I’m not too optimistic.

Let it flow

Vascular problems are a common cause as the small blood vessels that do the work down there are easily damaged by untreated high blood pressure, smoking, or conditions which damage the blood vessels such as high cholesterol and diabetes. In fact, one of the first tests that will likely be done when you discuss erectile dysfunction with your GP is a fasting blood sugar to screen for diabetes. Thankfully, with effective treatment of either of these conditions, ED can improve.

Neurogenic ED can occur as a consequence of diabetes and in those cases can be difficult to treat, which is another reason to try and keep diabetes well controlled if you have it.

Apart from diabetes, neurogenic ED is mostly as a result of spinal injury or degenerative neurological conditions such as MS.

What about medication?

People always think of medication as a solution to ED but it is much more important from a medical point of view to try and treat the causes of ED rather than just throwing medication at the patient and missing their diabetes until they have a stroke or heart attack.

From a lifestyle point of view, regular exercise (although not too long on a bike), keeping weight at a healthy level, and stopping smoking can go a long way to fixing the problem.

Medication can be effective in ED treatment. It works by helping the blood vessels in the penis expand and, depending on the medication, there are different timings to take it. The most common drug (sildenafil) is taken 30-60 minutes before sex. Because it works on the blood vessels themselves, it has no effect on your libido, so if that is the root problem, no amount of medication is going to help. Counselling can be effective.

The most common side-effects of these drugs are runny nose, facial flushing, and low blood pressure. This can cause headaches, feeling faint, and, if mixed with other drugs, can be disastrous.

Sildenafil is one of the most commonly purchased drugs online and it is quite dangerous as you don’t know what dose or what quality of medication you are getting. For anyone with a heart condition who is on a nitrate containing medication (Imdur or nitrate spray for angina), this type of medication can be fatal. I personally think taking unprescribed medication bought online without medical advice is asking for trouble.

For the vast majority of patients, a simple trial of medication will sort out the problem. Also, for most people, the need for medication will also, thankfully, be shortlived and they will regain unassisted erections when the underlying medical cause is treated.

For some, however, the problem can be more resistant, not caused by any treatable underlying medical condition and not responsive to medication. For these people I will refer them to a urologist (a specialist in the genito-urinary system). There are other options such as various medications, injections directly into the penis (not as terrifying as it sounds, I have been told), or even prosthetic devices which can be pumped up to achieve an erection.

For most people, although erections probably won’t come as easily as they did in their late teens or early 20s, erectile dysfunction will not cause a problem. For those who do suffer from it at some stage, there are a number of treatments which can effectively help the problem and restore full function.

Most importantly talk to your GP. They have discussed this with hundreds of patients and there is no need to feel uncomfortable. It is common and important.