Erectile dysfunction: signs and treatment

Erectile dysfunction (ED), one of the common signs of the andropause (a condition linked to low testosterone) is diagnosed as the difficulty to have or maintain an erection firm enough and long enough to have sex and the problem has persisted for three months or more.¹ It’s a subject that can be uncomfortable to talk about but ED is a surprisingly common condition particularly amongst men over 40. Research suggests it is something which affects over half of all men between the ages of 40 and 70 to some degree (that’s around 4.3 million men in the UK) and it is becoming more common amongst younger men.^2,3 The problem is often short-lived and usually fixable but the emotional and psychological ramifications can be huge – affecting not just the individual it is happening to but also his partner. Experiencing erectile dysfunction can feel embarrassing and emasculating and lead to a loss of confidence and self-esteem potentially causing anxiety and depression and that can impinge severely on quality of life. Experiencing ED is not just a sexual issue either but can be a genuine warning sign of chronic conditions such as heart disease and type 2 diabetes and seeking treatment for ED could potentially lead to the diagnosis of an underlying issue. This is why it needs to be taken seriously and shouldn’t be ignored in the hope it will just right itself.

Signs and symptoms of erectile dysfunction

Difficulty getting or maintaining an erection.
Being able to get an erection sometimes but not every time you want to have sex.
Weak erections during masturbation.
Decreased incidence of spontaneous erections (for instance, when you wake up).
A general decrease in sex drive and/ interest in sex or in fantasising about it.

Potential causes of erectile dysfunction

Age – whilst ageing does not necessarily cause ED erectile dysfunction does get increasingly common after the age of 40.⁴

Diabetes – men who have diabetes are two to three times more likely to develop ED than men who don’t and can develop it 10 to 15 years earlier than men without the condition.⁵ One third of diabetic men will have hypogonadism (a condition in which blood levels of testosterone are lower than average).⁶ Good diabetes care and management can help to treat ED and prevent it happening again.

Cardiovascular issues – Erectile Dysfunction is often a sign of impaired blood flow which can indicate a problem with cardiovascular health. Erectile problems can be a sign of narrowing of the arteries leading to impaired blood flow to the penis - so making it harder to have or keep an erection.⁷ Studies linking ED with cardiovascular risk show the strongest association with men in their 40s and 50s.⁸ Other cardiovascular risk factors include being overweight or obese, having diagnosed high cholesterol or type 2 diabetes. Any lifestyle changes you can make (see below) that can improve your heart health should, in turn, improve your penis/erectile health. It should be pointed out that if you have been diagnosed with heart disease and have ED it may not be safe for you to take certain medications to treat it (such as Viagra) along with the medications you are taking to treat heart disease so always take advice from your doctor.

Stress – none of us can avoid stress completely but if you are going through a particularly tough or traumatic time it is understandable that your sex drive might take a bit of a nosedive. This can be a short-lived problem, or it could get worse over time. There’s no test to determine whether stress or trauma could be the cause of your ED but signs that indicate it may be stress-related could be that you still have spontaneous erections when you wake up in the morning but find it harder to sustain an erection during sex. Similarly, if you go away on holiday and find you can more easily maintain an erection to enjoy sex then this is likely to point to a stress-related ED problem.

‘Performance anxiety’ – men tend to be taught from a very early age that a big part of their identity revolves around their sexuality and ability to have sex. Having ED can understandably shatter that sense of who they are and commonly creates a sense of emasculation. Having to admit to their partner it is a problem becomes yet another dilemma. If they avoid discussing it with their partner s/he is likely to take it personally - thinking you don’t find them attractive or even take it as a sign you are cheating on them. This can obviously create tensions within the relationship and then lead to more anxiety about being able to perform. Similarly for men getting involved with a new sexual partner this can raise the same anxieties, creating an ongoing vicious cycle of distress, reduced confidence and of feeling ‘less of a man’.

Low testosterone – Studies suggest that men with low testosterone, also referred to as hypogonadism,⁹ have higher rates of ED and cardiovascular disease than men with normal levels but it shouldn’t be assumed that a shortage of this hormone is automatically to blame for erectile dysfunction. Plenty of men with low testosterone have no trouble gaining an erection and having high levels of testosterone doesn’t make you immune from ED.¹⁰ However, low testosterone can contribute to fatigue, weight gain, low mood, and decreased libido resulting in less interest in sex and fantasising about it.

Pornography – evidence suggesting that excessive use of pornography is linked to erectile dysfunction is limited. However, research presented at the European Association of Urology Virtual Congress in 2020 suggests it may lead to increased cases of erectile dysfunction and the more porn watched the higher the incidence. Porn-induced ED can also cause problems in the sense that men may feel guilt and shame about using it and can need more extreme pornography to get the level of arousal they need to get, and maintain, an erection.¹¹ Plus relying heavily on porn can desensitise a man to actual sexual encounters increasing the risk of ED with a partner. This then becomes a psychological problem rather than anything to do with hormones or other health issues.

Drugs – commonly prescribed drugs including beta blockers and some diuretics, antidepressants such as SSRIs, anti-androgens used for treating prostate cancer and medications used for high blood pressure, anxiety and epilepsy are known to cause issues with ED. Recreational drugs such as cocaine, heroin, anabolic steroids and alcohol can also potentially lead to short-term problems with ED.

Gut health – the link between the gut microbiome and erectile dysfunction is increasingly being studied and it seems that a flourishing and thriving balance of gut bacteria can help to regulate hormones - particularly levels of androgens, including testosterone. In short, if your gut health is compromised your body’s ability to manage these hormones can also be compromised. A healthy gut is also better able to absorb nutrient more effectively which are needed for good health generally. Poor gut health is also associated with conditions such as IBS which can affect libido. A recent study by Peruvian scientists found that men with IBS were twice as likely to experience erectile dysfunction. The researchers theorised this may be because men have their confidence knocked by the often embarrassing symptoms of IBS like cramps, bloating, flatulence, diarrhoea and constipation.¹²

Treatment options for erectile dysfunction

How you treat erectile dysfunction depends on its cause. Making strategic lifestyle changes may be all that is needed. These can be done in conjunction with using some medications (say, Viagra) in the short term to help restore confidence and/or any feelings of inadequacy. So what should you do if you have ED?

Track your symptoms – logging your symptoms over time logging your symptoms using an app can help to establish what is going on with you. Documenting them is also useful for providing details to take to your GP.

See your GP or health practitioner – it can be difficult to reach out for help and many men can feel embarrassed and ashamed by their ED but the earlier you get treatment the better. Talking to your doctor will help to unravel whether the problem is psychological, stress-driven or physical and what potential treatment or course of action is needed. You will also likely be assessed for common heart disease risks such as high blood pressure, elevated cholesterol levels and diabetes.

Lifestyle changes – if you have a poor diet, smoke, take recreational drugs, drink alcohol often, don’t sleep well, rarely exercise and/or cope badly with stress overturning some of those habits could resolve your ED and hopefully stop it from returning. Losing weight if you need to should also improve symptoms as will finding ways to manage stress that work for you. Significantly these lifestyle modifications should also reduce your risk of conditions like stroke, type 2 diabetes and heart disease. Any measures you take to improve your gut health by eating a diverse range of nutrient dense and fibre-rich foods such as vegetables and fruit, pulses, wholegrains, lean protein and including both prebiotic (such as garlic, onions, leeks, Jerusalem artichokes) and probiotic (including live natural yogurt, kefir, miso, sourdough bread) foods should help. Taking a probiotic supplement may also prove beneficial. There are also foods which can naturally help to boost testosterone production in men.

Topical gels –such as Eroxon® are available over the counter without prescription and work quickly to achieve an erection by increasing blood flow to the penis. Within minutes of the gel being applied to the head of the penis it creates a cooling sensation followed by a gradual warming one which causes the penis to fill with blood and become erect. This is a treatment that can safely be used if you are on other medications, are unable to take oral ED medication such as PDE5 inhibitors (see below) and can also be easily incorporated as part of foreplay making it seem less like a medical intervention and more like fun.

PDE5 inhibitors – these are drugs such as Viagra and Cialis which enhance the effects of nitric oxide, a natural chemical in the body that widens the blood vessels and increases blood flow to the penis. They are taken around an hour or two before sex – so this can make sexual spontaneity a slight issue but PDE5 inhibitors are a quick and effective treatment which can be used in the short term to increase quality of life whilst working out the real underlying cause of the problem. For men who are in general good health and who may suffer from performance anxiety-related ED or substance/alcohol-induced ED these treatments tend to work very well. When men get their erectile function back their confidence improves and their anxiety tends to dissipate. These drugs are now available over the counter in pharmacists and are generally very helpful in the short term. If you have been diagnosed with low blood pressure or heart problems such as angina and are taking nitrates to deal with it is not safe to take PDE5 drugs like Viagra at the same time as these can cause your blood pressure to drop suddenly.

Vacuum/penis pump – sometimes also referred to as vacuum erection assistant devices, these are pumps which are used to increase blood flow to the penis.¹³ You put your penis into a plastic cylinder from which the air is drawn out using a pump action. This creates a vacuum action causing the penis to fill with blood and become hard. You then slide a ‘constriction’ ring over your penis to maintain the blood supply. It is recommended that you do not keep the ring on your penis for more than half an hour but this is a treatment with a low risk of side effects.

Alprostadil – this is a vasodilator treatment which works by widening blood vessels to improve blood flow to the penis. It is available as an injection treatment, an implant implanted in the urethra or a cream.¹⁴

Testosterone Replacement Therapy (TRT) - Testosterone replacement therapy (TRT) may be prescribed if you have had your hormone levels checked by a doctor and have an official diagnosis of low testosterone and this is thought to be contributing to your ED. TRT is available in gel form or given as an injection (either by a nurse, doctor or in some cases, yourself).¹⁵ Benefits also include improving sex drive as well as mood and muscle mass.

Counselling – if the problem has been going on for some time or the problem is deemed more of a psychological one than a physical one you (and your partner) might benefit from counselling or psychosexual therapy.

References

Dr Nathan Spence

GP

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