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Health Library - Erectile Dysfunction

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Erectile dysfunction (ED) means that you cannot get a proper erection. There are various causes. However, most cases are due to narrowing of the arteries that take blood to the penis. This is due to a build up of atheroma in these arteries. This is similar to the way the heart arteries are affected in people with heart disease. As with heart disease, smoking and heavy alcohol drinking are important risk factors. Most cases of ED can be treated. The common treatment is to take a tablet before you plan to have sex. There are also various other treatment options. If you have ED, you may also be advised on lifestyle factors and treatments to minimise your risk of developing heart disease.

What is erectile dysfunction?

Erectile dysfunction (ED) means that you cannot get and/or maintain an erection. In some cases the penis becomes partly erect, but not hard enough to have sex properly. In some cases, there is no swelling or fullness of the penis at all. ED is sometimes called impotence.

How common is erectile dysfunction?

Most men have odd times when they cannot get an erection. For example, you may not get an erection so easily if you are tired, stressed, distracted, or have drunk too much alcohol. For most men it is only temporary, and an erection occurs most times when you are sexually aroused. However, some men have persistent, or recurring, ED. It can occur at any age, but becomes more common with increasing age. About half of men between the age of 40 and 70 have ED. About 7 in 10 men aged 70 and above have ED.

How does an erection normally occur?

When you are sexually aroused, messages from your brain travel down nerves to your penis. Chemicals called 'neurotransmitters' are then released from the ends of the nerves in the penis. Stimulation of the penis can also cause local nerve endings to release neurotransmitter chemicals. The neurotransmitters which are released in the penis cause another chemical to be made called cyclic guanosine monophosphate (cGMP). An increase of cGMP causes the arteries in the penis to dilate (widen). This allows extra blood to flood into the penis. The rapid inflow of blood causes the penis to swell into an erection. The swollen inner part of the penis also 'presses' on the veins nearer to the skin surface of the penis. These veins normally drain the penis of blood. So, the flow of blood out of the penis is also restricted, which enhances the erection. The cGMP is soon converted into another inactive chemical. But, as you remain sexually aroused whilst having sex, your brain keeps sending nerve messages to the penis which makes more cGMP to maintain the erection. When the level of cGMP falls, the blood flow to the penis returns to normal, and the penis gradually returns to the non-erect state.

What causes erectile dysfunction?

There are several causes which tend to be grouped into 'physical' and 'psychological'.


Physical causes

About 8 in 10 cases of ED are due to a physical cause. If the ED is due to a physical cause, you are likely to still have a normal sex drive (libido). Causes include:

  • Reduced blood flow to the penis. Like in other parts of the body, the arteries which take blood to the penis can become narrowed. The blood flow may then not be enough to cause an erection. 'Risk factors' can increase your chance of 'narrowing of the arteries'. These include: getting older; high blood pressure; high cholesterol; smoking; diabetes.
  • Diseases which affect the nerves going to the penis. For example, multiple sclerosis, a stroke, etc.
  • Diabetes. This is one of the commonest causes of ED. Diabetes can affect blood vessels and nerves.
  • Injury to the nerves going to the penis. For example, spinal injury, following surgery to nearby structures, fractured pelvis, radiotherapy to the genital area, etc.
  • Side-effect of certain medicines. The most common are: some antidepressants; betablockers such as propranolol, atenolol etc; some diuretics ('water tablets'); cimetidine. Many other less commonly used tablets sometimes cause ED.
  • Alcohol and drug abuse.
  • Cycling. ED after long distance cycling is thought to be common. It is probably due to pressure on the nerves going to the penis from sitting on the saddle for long periods. This may affect the function of the nerve after the ride.
  • Hormone causes are rare. For example, a lack of a hormone called testosterone which is made in the testes.
  • Excessive outflow of blood from the penis through the veins ('venous leak'). This is rare but can be caused by various conditions of the penis.

In most cases due to physical causes (apart from injury or after surgery) the ED tends to develop slowly. So, you may have intermittent or partial ED for a while, which may gradually get worse. In some cases, ED causes poor self esteem, anxiety, and even depression. These reactions to ED can make the problem worse.

Psychological causes

Various psychological causes may cause you to develop ED. For example:

  • Stress. For example, due to a difficult work or home situation.
  • Anxiety.
  • Relationship difficulties.
  • Depression.

Typically, the ED develops quite suddenly if it is a symptom of a mental health problem. The ED may resolve when your mental state improves. For example, if your anxiety or depression eases. However, some people become even more anxious or depressed when they develop ED. They do not realise it is a reaction to their mental health problem. This can make matters worse and lead to a 'vicious circle' of worsening anxiety and persisting ED.

As a rule, a psychological cause is more likely for the ED than a physical cause if there are times when you can get a good erection, even though most of the time you cannot. (For example, if you can get an erection by masturbating, or wake up in the morning with an erection.)

Erectile dysfunction, heart disease and other vascular diseases

Although ED can be caused by various conditions, about 7 in 10 cases are due to narrowing of the small arteries in the penis. This causes reduced blood flow to the penis. This is the same problem that can occur in other blood vessels. For example, narrowing of the blood vessels in the heart (the coronary arteries) is a cause of angina and other heart problems. Narrowing of blood vessels to the brain is a risk factor for having a stroke. Narrowing of blood vessels in the legs can cause peripheral vascular disease.

The root cause of the narrowing of the arteries is caused by atheroma. Atheroma is like fatty patches or 'plaques' that develop within the inside lining of arteries. (This is similar to water pipes that get 'furred up' with scale.) Plaques of atheroma may gradually form over a number of years in one or more places in the body, commonly in arteries going to the heart, brain, legs and penis. In time, these can become bigger and cause enough narrowing of one or more of the arteries to cause symptoms and problems.

Certain 'risk factors' increase the risk of more atheroma forming which can make atheroma-related conditions worse. Risk factors that can be modified and may help to prevent atheroma-related conditions from getting worse are:

  • Smoking. Smoking is one of the biggest risk factors for developing heart disease. Smoking also roughly doubles your chance of developing ED. Young smokers may not be aware that they have a much greater risk of developing ED by middle age compared to non-smokers. If you smoke, you should make every effort to stop.
  • High blood pressure. Make sure your blood pressure is checked at least once a year. If it is high it can be treated.
  • If you are overweight, losing some weight is advised.
  • A high cholesterol. This can be treated if it is high.
  • Inactivity. We should all aim to do some moderate physical activity on most days of the week for at least 30 minutes. For example, brisk walking, swimming, cycling, dancing, gardening, etc.
  • Diet. You should aim to eat a healthy diet. 
  • Alcohol excess.
  • Diabetes. If you have diabetes, good control of the blood sugar level and blood pressure can help to minimise the impact of diabetes on the blood vessels.

Note: ED caused by narrowed arteries commonly develops several years before any symptoms or problems develop due to narrowing of the coronary arteries (or other arteries). Therefore, ED is thought of as an 'early warning signal' that heart disease (or other cardiovascular diseases) may develop. This is why some of the tests listed below may be advised if you develop ED. Also, you are likely to be advised by your doctor on how to modify any 'risk factors' listed above with the aim of preventing heart disease from developing.

What should I do if I develop persistent erectile dysfunction?

It is best to have a consultation with your doctor. He or she is likely to discuss the problem, go over any medication you may be taking, and do a physical examination. This can help to identify, or rule out, possible underlying causes. Before treatment, your doctor may suggest some tests.

What tests may be done?

Depending on your symptoms, likely cause of the ED, age, etc, your doctor may suggest that you have some tests. These are mainly to check up on any 'risk factors' listed above which increase the risk of developing narrowing of the arteries. Tests may include:

  • A blood test to check the level of cholesterol and other 'lipids'.
  • Blood sugar level.
  • A check of you blood pressure.
  • A heart tracing (ECG).
  • Other heart tests are sometimes done, where appropriate, if heart disease is suspected.

Occasionally, ED is due to a hormone problem. This is more likely if you have a low sex drive (libido) in addition to ED. In this situation a blood test to check the level of testosterone or prolactin may be advised.

What are the treatment options?

A referral to a specialist is sometimes needed for assessment and treatment. However, GPs are now treating more cases of ED than previously as the treatment options have improved in recent years. The following gives a brief summary of treatment options. There is a good chance of success with treatment. There are pros and cons of each treatment, and your doctor will advise further. 

Medication (tablets taken by mouth)

In 1998, the first tablet to treat ED was launched. This made a huge impact on the treatment of ED. There are now three different tablets licensed in the UK to treat ED.

  • Three of the tablets work by increasing the blood flow to your penis. They do this by affecting the chemicals involved in dilating (widening) the blood vessels when you are sexually aroused (described above). They are sildenafil (trade name Viagra), tadalafil (trade name Cialis), and vardenafil (trade name Levitra). You take a dose before you plan to have sex. Because of the way they work, these medicines are called phosphodiesterase type 5 inhibitors (PDE5 inhibitors).

None of these tablets will cause an erection unless you are sexually aroused. There is a good chance that a medicine will work (about an 8 in 10 chance of it working well). However, they do not work in every case. There are pros and cons for each of the above, and your doctor will advise. For example, you may not be able to take certain tablets for ED if you have certain other medical conditions, or take certain other medicines. For example, you should not take a PDE5 inhibitor if you take nitrate medicines (including GTN) which are often used to treat angina.

Erection-aiding drugs

Oral drugs which help produce an erection in response to sexual stimulation 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 now only three orally-administered drugs available in the UK. They all have side effects, only a few of which are listed 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 have a consultation with a doctor. 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 there is some sexual stimulation. In most men, works within an hour. 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.) Easily blocked by food in the stomach.

Viagra still remains the world's most popular ED drug. 

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. 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.

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.

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


Pelvic floor muscle exercises

The pelvic floor muscles are a group of muscles that wrap around the underside of the bladder and rectum. One of these muscles (the bulbocavernosus muscle) also partly wraps around the base of the penis. This is involved with preventing blood escaping during an erection, (as well as being active during ejaculation, and when emptying the urethra of urine when finishing at the toilet).


Injection treatment
This was the most common treatment before tablets became available. It usually works very well. You are taught how to inject a medicine into the base of the penis. This causes increased blood flow, and an erection usually develops within 15 minutes. (Unlike with tablets, the erection occurs whether of not you are sexually aroused.)


Urethral medication
You can place a small pellet into the end of the urethra (the tube which passes urine and opens at the end of the penis). The pellet contains a similar medicine to that used for the injection treatment. The medicine is quickly absorbed into the penis to cause an erection, usually within 10-15 minutes.


Vacuum devices
There are several different devices. Basically, you put your penis into a plastic container. A pump then sucks out the air from the container to create a vacuum. This causes blood to be drawn into the penis and cause an erection. When erect, a rubber band is placed at the base of the penis to maintain the erection. The plastic container is then taken off the penis and the penis remains erect until the rubber band is removed (which must be removed within 30 minutes).


Penile prosthesis
A surgeon can insert a 'rod' permanently into the penis. The most sophisticated (expensive) type can be inflated with an inbuilt pump to cause an erection. The more basic type keeps the penis rigid all the time.


Treating an underlying cause
For example, treating depression, anxiety, changing medication, cutting back on drinking lots of alcohol, or treating certain rare hormone conditions may cure the associated ED.


Lifestyle and other advice
As mentioned above, ED is often a marker that heart disease or other cardiovascular diseases may soon develop. Therefore, you should review your lifestyle to see if any changes can be made to minimise the risk of developing these problems. For example, stop smoking if you are a smoker, take regular exercise, eat a healthy diet, etc. For details, see separate leaflet called 'Preventing Cardiovascular Diseases'. Also, your doctor may prescribe a statin drug if your risk of developing cardiovascular disease is high.


Counselling
Sometimes 'couple counselling', or sex therapy is useful. These are most useful if certain psychological problems are the cause of, or the result of, ED. In some cases, sex therapy is used in addition to another treatment option.


Treatment for erectile dysfunction on the NHS
The Department of Health states, "From 1 July 1999 only those patients suffering from one of the specified medical conditions are eligible to receive drug treatments for impotence on the NHS. Other men can receive a private prescription from their own GP."

The specified medical conditions are: diabetes; multiple sclerosis; Parkinson's disease; poliomyelitis; prostate cancer; prostatectomy (an operation to remove the prostate gland); radical pelvic surgery; renal failure treated by dialysis or transplant; severe pelvic injury; single gene neurological disease; spinal cord injury and spina bifida.

Therefore, unless you have one of the above conditions, you have to pay the full cost of any tablets prescribed to treat ED. This policy may be reviewed by the Department of Health in the future.


References
Dr David Delvin, NetDoctor, Patient UK, Guidelines on erectile dysfunction, European Association of Urology (2005), Drugs for Erectile Dysfunction (Factfile), British Heart Foundation (June 2005), Sexual Dysfunction Association, British Association for Sexual and Relationship Therapy (BASRT).

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