Rising to the occasion: What you need to know about erectile dysfunction

Demand for Viagra has soared since it went for sale over the counter a year ago.  But the drug must be seen as one of a range of treatment options for erectile dysfunction, say experts 
Rising to the occasion: What you need to know about erectile dysfunction

Some pharmacies have seen sales of Viagra double or triple since it became available over the counter

THE lives of men who struggle with erectile dysfunction (ED) were transformed in 1998, when sildenafil, commonly known as Viagra, became available as a prescription medicine in Ireland. Since January 2021, the drug can be bought over the counter with no need for a prescription from a GP.

Pharmacies are reporting significant increases in sales.

“Sales have doubled, if not tripled, in our pharmacies, since it became available over the counter,” says Conor Phelan, owner of Phelan’s Pharmacies. “We sell a lot online too.”

Ger Browne, of Carrigtwohill Pharmacy, reports sales up to four times higher than they were prior to Viagra becoming available over the counter.

At Keating’s Pharmacy, in Dooradoyle, Limerick, sales have also increased, with Eugene Doyle reporting an increase of up to 15%.

Some might conclude that any increase indicates a problem. If more men are buying Viagra, does this mean that they are relying on medication for everyday sex?

Pharmacists see it differently. Having Viagra available without prescription has given them more opportunities to talk to men about their general health.

“When men buy Viagra in a pharmacy or online through a pharmacy’s website, they are required to have a consultation with the pharmacist,” says Phelan.

“We talk to them confidentially to make sure the drug is safe and suitable for them, to check it’s not contraindicated by any of their other medication, and to ensure they don’t have an underlying heart condition. These questions start a conversation about health that these men might not have had otherwise.”

ED is not confined to older men

So, what is ED? Cork-based GP Dr Phil Kiernan offers two definitions.

“It’s when a man can’t achieve an erection or when he has an inability to achieve or sustain an adequate erection to achieve a satisfactory sexual performance,” he says.

Many more men struggle with ED than people think. “This condition is not new and it’s certainly not uncommon,” says Dr Kiernan.

“The incidence of ED increases with age, with up to 50% of men reporting having experienced it by the age of 50, according to research carried out by healthcare company Viatris in 2021.”

However, doctors and pharmacists say ED is not confined to older men. “Our customers cover the full spectrum from 18 to 80,” says Phelan.

Dr Kieran also treats a wide age range. “ED is a problem that can occur at any age. In the 30-to-40 age group, for example, I would expect up to 30% of men to have issues with getting or maintaining an erection. Yet, statistically speaking, age is the biggest contributing factor. The degenerative impact of age and the wear and tear of the body has an undeniable effect.”

Many men don’t see it that way. As part of their research in 2021, Viatris spoke to 511 men about their attitudes to ED. Half of them had experienced ED and 54% said they were embarrassed to discuss the topic with their partner, friends, or family members.

Even more worryingly, 40% believed that ED was not treatable and 38% said they would be reluctant to seek medical help for the condition.

What these men might not realise is that ED can be an important indicator of their overall health. Rather than immediately reaching for the Viagra, medical professionals want them to have their general health checked first.

The most common cause of ED is reduced blood flow to the penis and Viagra works by increasing that blood flow, so that there is enough to achieve and maintain a firm erection. But according to Dr Kiernan, if the blood vessels surrounding the penis are narrowed or damaged for some reason, it’s likely that blood vessels in the rest of the body are, too.

“ED could indicate underlying cardiovascular issues, such as heart disease or high blood pressure,” says Dr Kiernan.

“There are other potential causes too, with 90% of ED cases relating to underlying issues or medication. ED can be a sign of high cholesterol or diabetes. It can be related to declining levels of testosterone in the body. Any man suffering from ED should get their health checked for these issues.”

He advises men not to delay. “The longer it goes on, the more damage the underlying condition can do,” he says. “For example, untreated high blood pressure can damage the arteries and the heart, increasing your risk of stroke and heart attack.”

Cause 10% psychological

If 90% of ED cases have a physical basis, the other 10% have psychological causes. Áine Ward is a psychosexual psychotherapist at Insight Matters in Dublin. She works with men and couples of all ages dealing with ED and the stress, anxiety, and other underlying issues that can cause it.

“Generally with ED, if the problem is psychological, it’s fixable once the man and the couple are committed to fixing it,” she says.

There are plenty of potential obstacles. Ward has seen many men whose perception of themselves is rocked by their inability to perform penetrative sex. “Getting and maintaining an erection is something they believe they are supposed to be able to do naturally and automatically,” she says. “Not being able to do so can cause stress and anxiety and even make them question their own masculinity.”

The fact that some men are ashamed to talk about it can compound the problem. “Men don’t tend to discuss sex or sexual problems with their peers in the way women do,” says Ward. “They aren’t able to talk about it and living in a world where the common perception is that everyone has a great sex life, it’s easy for them to think that they are the only ones suffering from this problem.”

The man’s relationship with his partner can suffer as a result. “Self-esteem issues can quickly come into play,” says Ward. “Men’s self-esteem can plummet if they feel they can’t perform sexually, and partners can begin to wonder if this is an indicator that they are no longer sexually attractive to them.”

If the couple can’t talk about the issue, sex can disappear very quickly. “I’ve worked with couples who go to bed at different times in order to avoid the issue of sex altogether,” says Ms Ward. “By avoiding sex, they can end up avoiding each other and intimacy can be lost over time.”

While sildenafil can help couples resolve some of the problems relating to ED, Ward cautions against becoming too dependent. “Drugs like Viagra have their uses and they boost men’s confidence, but they don’t really address the underlying problems,” she says.

“They can also take the romance out of sex, as you have to take the drugs 30 minutes or an hour before sex and be ready to go once it takes effect. This can be hard on both members of the couple, with the man’s partner often feeling under pressure to perform once the drug has kicked in.”

This pressure to perform can also be driven by porn. This is something Ward often sees with younger clients. “Porn is all about performance and I have seen a connection between the use of porn and low self-esteem and a lack of confidence around sexual partners,” she says. “That feeling of not being good enough, not measuring up, can cause ED.”

The stark contrast between porn and real-life sexual encounters is another factor. “Real life is so much messier than the fantasy,” says Ward.

“This can have an impact on desire and arousal circuits. In porn too, the focus is on the end result, not on sexual intimacy. Men who watch a lot of porn and who then struggle with ED often become spectators of their own penis, concentrating on it working rather than on engaging with the body and mind of their partner.”

All of these issues can be resolved with help.“At the beginning, my job is to get the man on friendly terms with his penis again, as so many of my clients begin to see their penis as their enemy,” says Ward.“Then, I share techniques in how to gain control of it and get, hold, and let go of an erection. I also share other things that he and his partner can do to maintain sexual intimacy and strengthen their relationship.”

Ward says couples can emerge stronger at the end of the process. “They have worked through something as a team and are more connected and together,” she says.

Whether it’s caused by a psychological issue or by an underlying medical problem, ED is usually treatable.

Medication, such as Viagra, is one of those treatment options and having it available as an over-the-counter medicine for the past year has changed things for men who suffer from this problem. Importantly, the drug being more visible in pharmacies is reducing the embarrassment factor.

“That’s still there, but it’s waning,” says Phelan. “Men are recognising that this is a normal part of the human condition, and they are less shy about speaking to us about it.”

This can only be seen as good news, says Dr Kiernan. “Before this, men who were reluctant to talk about ED sometimes resorted to buying from the internet rather than going to see their GPs and we know we can’t trust medical products we buy online,” he says.

“Now that men are buying from pharmacies, they have access to safe, reputable products. Their pharmacists also have the opportunity to open conversations and if they have concerns, to encourage men to see their doctors. This is so important for letting men know that help is available for both ED and its underlying causes.”

10 things you need to know about ED

1. You are not alone if you suffer from ED — one-in-two men will experience it by the age of 50.

2. Mention it to your GP as it may be linked to an underlying condition. Your ED could be a symptom of heart disease, high cholesterol, high blood pressure, or diabetes.

3. ED can also be caused by hormonal issues such as low levels of testosterone.

It can be a side effect of some medications. It can also be an issue for some men following prostate surgery. Psychological factors such as anxiety, depression, fatigue, and stress can play a part too.

4. Some studies have found that ED is up to twice as high in men who smoke cannabis on a recreational basis.

5. There are a number of steps all men can take to address ED and to restore full function. Addressing any underlying medical conditions under the supervision of your GP is the first step.

6. Stopping smoking, cigarettes and cannabis, is another. “Not smoking is the single biggest and the best thing you can do for your health, and especially for erectile dysfunction,” says GP Dr Phil Kiernan.

7. Regular exercise will help too, as it increases the function of the cardiovascular system and the production of testosterone. Don’t spend too long on a bike though as the seat puts pressure on the area between the genitals and the anus, temporarily slowing the blood flow, which can contribute to ED.

8. Eat a balanced diet that contains heart-healthy foods such as beans, peas, lentils, olive oil, fish and nuts like walnuts and brazil nuts. Avoid highly- processed foods. All of this will help keep your weight in check as overweight men are known to be more likely to suffer from ED because their blood vessels are damaged, and their blood flow is affected.

9. Drink alcohol moderately. “It’s known to be a factor in ED,” says Dr Kiernan.

10. Medication such as sildenafil can be very effective when used safely. In cases that are not caused by any treatable underlying conditions and that don’t respond to commonly available medication, there are other options including injectable therapies, vacuum pumps, and penile implants. Treatment options are increasing all the time.

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