FAQs on erectile dysfunction

Erectile dysfunction, not getting it up or whatever you want to call it – 90% of men who have it never seek treatment. Health24 answers the questions many men would hesitate to ask their doctor.

What is erectile dysfunction?
Erectile dysfunction (previously called impotence) is the inability to get or maintain an erection sufficient to ensure satisfactory sex for both partners.

Can young men get erectile dysfunction?
Yes, but it appears much more frequently in older men. Current statistics are not available for South Africa, but in America about 10% of men are believed to be affected. Incidence rises with age: about 5% of men at the age of 40 and between 15 and 25% of men at the age of 65 suffer from erectile dysfunction, and the percentage grows to 70% as men reach 80. As men age, they typically report some loss of sexual desire as well, although neither loss of desire nor erectile dysfunction is an unavoidable feature of ageing.

Is ED physical or psychological?
It can be both, but most often the cause is physical. A firm erection is the result of a whole series of psychological and physical events. If a problem occurs at any step in the process, the erection may be absent, insufficient or short-lived. There is therefore a range of possible causes of erectile disorder. These can be grouped into two general types: physical (related to the blood vessels and/or nerves) and psychological. Most erection problems are due to a combination of these factors. Until the early 1990s, most cases of erectile dysfunction were thought to be of psychological origin, but new research has shown that the causes are physical in 85 to 90% of cases.

Is it normal to get ED?
Yes, it is, in the sense that many men have erectile problems, especially at times of great changes in their lives. In fact it is probably more widespread than people realise, as proven by the popularity of anti-impotence drugs on the market. It is estimated that men with erectile problems wait an average of five years before going to the doctor. It should not be ignored, as erectile problems often point to other physical problems, such as diabetes.

What makes an erection problem occur?
An erection begins with sensory and mental stimulation. Impulses from the brain travelling down the spinal column and impulses from the nerves in the penis relax smooth muscles in two spongy cylinders that run the length of the penis, parallel to the urethra (the conduit for urine and semen). When the impulses cause the muscles to relax, blood flows into spaces in the spongy tissue, and this pressure makes the penis swell out. A membrane surrounding the cylinders helps to trap the blood in the penis and maintain the erection. The penis returns to its flaccid state if the muscles contract, stopping the inflow of blood and opening outflow channels.

An erection problem can occur if any of the events in this sequence are disrupted: the problem may involve mental processes, nerve impulses, or responses in muscles, fibrous tissue, veins and arteries in the penis.

What are the physical causes of ED?
The most common cause of erectile dysfunction is damage to arteries, smooth muscles and fibrous tissues.

• Problems with the blood vessels (vascular problems) make up 48% of erection problems.
• Problems with the nerves (neurological problems): 14%
• Problems with the structure of the penis or surrounding tissues: 3%

These problems can in turn be caused by a variety of factors:

• Disease: illnesses account for 70% of erectile dysfunction. These may include diabetes, kidney disease, and multiple sclerosis. Atherosclerosis or "hardening of the arteries" can prevent adequate blood from entering the penis.
• Injury to the penis, spinal cord, prostate, bladder or pelvis: such injury can be the result of sports or car accidents, or even riding on hard bicycle seats.
• Complications of surgery or radiation (for example, for prostate cancer): these can interfere with nerve impulses or blood flow to the penis. When the nervous system cannot transmit arousal signals, or when the blood vessels in the penis cannot fill or stay filled with blood, you cannot have an erection.
• Side effects of common medication: these include drugs taken for high blood pressure, antidepressants, antihistamines, tranquillisers, appetite suppressants, and the ulcer drug cimetidine.
• Substance abuse: chronic use of alcohol, marijuana or other drugs often causes impotence, which may be aggravated by decreased sexual drive. Excessive tobacco use can also block penile arteries.
• Hormonal factors, such as low testosterone levels
• Zinc deficiency

Erection problems in men over 50 are more likely to have physical causes.

What are the psychological causes of ED?
Psychological problems, such as anxiety, interfere with the erection process by distracting the man from things that would normally arouse him. These problems cause between 10 and 40% of erectile dysfunction. Even in cases where the underlying problem is physical, these factors can play an important secondary role, for example when a man who has had some erectile difficulty starts to anticipate and fear sexual failure. As a result, psychological factors play some causal role in at least 80% of cases of erectile dysfunction. These factors include:

• Depression: erectile dysfunction is twice as likely among men suffering from depression as it is among those without depressive symptoms.
• Relationship problems: a man who loses sexual interest in or desire for a particular partner may develop erection problems.
• Anxiety and stress, including that caused by major life changes.
• Grief and other reactions to major loss: recently widowed men may have erection problems.
• Low self-esteem
• Erection problems in men under 50 are more likely to be due to psychological causes.

Does ED sometimes clear up by itself?
Yes, it does. Especially if it was the result of a stressful situation which has been resolved, or an injury that has healed.

What is priapism?
In layman's terms, an erection that won't subside. This can be caused by anti-impotence drugs. This condition can be dangerous and can cause permanent damage to your penis. If an erection lasts for more than four hours, you need to get to a doctor immediately.

If I do go the doctor, what will happen?
Determining the cause of erection problems is often the key to reversing them. Since both physical and psychological factors are often involved, it can be complicated to make an exact diagnosis.

As part of the initial evaluation, your doctor may do the following:

• History taking. He may ask about your sex life, diseases you’ve had and drugs prescribed to you. This will enable him to review risk factors.
• A complete physical exam (including the abdomen, penis, prostate, rectum, and testicles). If the penis does not respond as expected to certain touch stimuli, there may be a problem with the nervous system. Abnormal secondary sex characteristics, such as loss of armpit or pubic hair, can suggest problems in the endocrine system affecting hormone levels. A circulatory problem might be indicated by, for example, an aneurysm in the abdomen (such as disease of the large artery, the aorta, which supplies blood to the abdomen and lower limbs).
• Routine lab tests. These include blood counts, urine analysis, lipid profile, and measurement of liver enzymes and creatinine (a waste product of protein metabolism). If sexual desire is low, the levels of testosterone in the blood may be measured to determine if there are any endocrine abnormalities.
• Nocturnal penile tumescence testing. This test, which monitors if you have erections while asleep, can often help to determine whether the cause is predominantly psychological or physical. Physically healthy men have involuntary erections in their sleep; if these occur, the cause is more likely to be psychological. However, these tests are not completely reliable, and have not been standardised. The modern era of effective oral treatment has reduced the indications for penile tumescence testing drastically.
• Tests to evaluate the penile arteries and veins. This includes the use of medication to assess erections, ultrasound and angiography (a radiographic technique for examining the anatomy of a blood vessel).
• Extensive nervous system tests. These are not well standardised and are generally done only at major medical centres.
• Psychological evaluation. This may be recommended when a major psychological cause is suspected.

You and your doctor will use the results of the examination and tests to develop a treatment plan that may include medications, other non-surgical treatments or surgery.

What treatments are available for ED?
Treatment for erectile dysfunction depends on whether the problem is caused by psychological or physical factors, or a combination of these. Even if erectile dysfunction has a physical cause, it often has adverse psychological effects that make the problem worse and treatment more complicated. The following treatments have a reasonable chance of success:

• Oral medication.
• Medication you can inject or insert into the penis to get an erection.
• Alteration of existing medication for other conditions.
• Vacuum devices.
• Penile implants.
• Psychotherapy or behavioural therapy – even when the erection problem has physical causes.

The least invasive treatment should be considered first. Non-surgical treatments work for 60-70% of men and may make surgery unnecessary. Although treatments like injections are effective more than 80% of the time, up to 60% of men may eventually drop out of treatment. Sometimes, once men can get an erection again, they realise they have overestimated its importance in their relationships. They may decide that the nuisance or cost of the treatment is not worth the effort.

Is there home treatment for ED?
If you only experience occasional episodes of erectile dysfunction, you may be able to treat it at home without a doctor's help.

• Some of the causes of erection failure are within your control, such as stress, smoking, and alcohol use.
• Talk to your partner. Often sharing your worries about sexual performance with your partner can break a vicious cycle of anxiety. You may find out that your partner does not view the problem as seriously as you do. This may leave you freer to enjoy sexual activity instead of consciously tracking your performance.
• Make some time together to enjoy simple sensual pleasure, such as caressing and massaging without the goal of having sexual intercourse or even an erection. You may discover new kinds of sexual pleasure while you reserve intercourse for another occasion when you are more at ease.
• Sexual problems are often the result of underlying emotional problems you and your partner may experience. Are you angry with him or her? Are you worried about rejection? Talk openly about these feelings and try to resolve conflicts. At the same time you might want to reassure your partner that erectile dysfunction very seldom arises from lack of sexual interest.
• Pelvic-floor exercises (similar to Kegel exercises) may be helpful in some men with erection problems. These exercises have no risks.
• Don't be embarrassed about seeking professional help if home strategies don’t help and erection problems are persistent and troublesome.

Do smoking or alcohol affect this condition?
Yes, they both do. Smoking causes damage to blood vessels and this slows blood flow to the penis. In one study it was found that male smokers with high blood pressure and/or other risk factors were more than twice as likely to have complete ED than those who didn't smoke. If you drink alcohol, it’s best to have no more than two drinks a day. Alcohol slows down your central nervous system and can make it more difficult for you to get an erection.

What medication is available to treat ED?
Erectile dysfunction, whether caused by blood vessel (vascular), hormonal, nervous system, or psychological problems, can be treated with a range of prescription drug therapies.

Drug therapy can have various goals:

• Increase of blood flow into the penis (erection-producing medications)
• Reduction of performance anxiety by ensuring successful erections
• Adjustment or replacement of medication taken for other conditions. If such drugs affect your erections, your doctor may review them in an attempt to reduce side effects. Never adjust your dosage without consulting your doctor.
• Correction of abnormal hormone levels through testosterone replacement therapy. Abnormal hormone levels, however, are a rare cause of erection problems.
• See the section on medication under "Understanding erectile dysfunction" for more information on various types of medication used to treat this condition.

Can surgery correct ED?
Surgery for erection problems is frequently chosen when non-surgical treatments and psychotherapy have not been effective. Surgical approaches include penile implants, which can be very successful and produce satisfactory results in 80 to 90% of men, and repairs to the vascular system in the penis. So what does surgery entail?

• A bendable rod can be implanted into the penis. This makes the penis rigid enough to have sex, yet leaves it flexible enough to be tucked away in your pants unobtrusively.
• A cylinder may be implanted that extends when fluid from a reservoir tucked under the abdominal muscle is pumped into it. This is done by manually squeezing a small pump that is connected to the reservoir and implanted into the scrotum.

While implants mean that you can avoid using drugs, they do require surgery and all the risks normally related to surgery: adverse reaction to anaesthesia, possible blood loss, and infection. About two percent of implants have to be removed as a result of infection. In 5-10% of cases there may be mechanical failure of the device, in which case a second operation is necessary for repair or removal. Urologists perform most penile implants, and cost can range from about R6 000 to more than R20 000, depending on the type of implant.

Surgery to repair or remove blood vessels of the penis may be appropriate in the case of a young man who suffers erectile dysfunction as a result of injury, such as a car accident. In older men, it tends to be more difficult to repair damaged blood vessels, as damage may be extensive. These specialised blood vessel repair (revascularisation) operations should be done by specially trained urologic surgeons.

How do vacuum pumps work?
Vacuum devices are small pumps attached to a cylinder you fit around your penis. Air is pumped out of the cylinder to create a vacuum, and the lowered pressure increases blood flow into the penis. The blood is trapped by rolling a special rubber ring down to the base of the penis.

More fashionable versions of these rings, made from metal or studded leather, can also be bought from sex shops, if it appeals to you to make the intervention less clinical in this way. The pumps are useful for all types of erection problems (physical, psychological, or a combination of both). Vacuum pumps are generally safe, simple to operate and can be used as often as desired. However, improper use can damage your penis and so they must be used under a doctor's care. While you may need to interrupt foreplay to use them, you can also incorporate use of the pump into erotic play, making it less medical and more natural.

Can ED be prevented?
Many erection problems can be prevented or even reversed by a more relaxed approach to sex and by rediscovering sensuality. Sexual intimacy is a form of communication. If you and your partner talk about your lovemaking, it will help reduce your stress and anxiety, so that your sexual activity becomes more relaxed. Many people avoid talking about problems in their sexual relationship. It may gradually become more difficult to get and maintain an erection as you get older. However, foreplay and the right environment can increase your ability to have an erection, regardless of your age.

(Compiled by Susan Erasmus, Health24, updated September 2012)

(Source: all information from Health24's Erectile Dysfunction Centre)