Erectile Dysfunction

When a man becomes sexually aroused, his brain sends nerve signals to his penis causing an erection (the nerves increase the blood flow to the penis and the tissue expands and hardens). Erectile dysfunction, sometimes referred to as ED or impotence, is when a man cannot get or keep a firm enough erection to have satisfactory sex.  The term can also refer to a lack of sexual desire (a reduced libido). Erectile dysfunction treatment can help men achieve an erection and enjoy sex. Which treatment is best depends on what is causing the problem.

Erectile dysfunction is very common and is thought, in some way, to affect roughly 50% of all men aged 40-70. Erectile dysfunction is very different to issues with ejaculation (for example, premature ejaculation – where arousal, orgasm and ejaculation happen quickly.)

• Psychological: anxiety or stress, depression, relationship difficulties.
• Physical: any problem that relates to the nervous system or to circulation could cause erectile dysfunction, e.g. the narrowing of blood vessels leading to the penis (as a result of high blood pressure, high cholesterol, diabetes, or other factors), an injury or as a result of surgery. Changes in hormone levels can also cause ED.

It is also possible for some medicines to cause erectile dysfunction.

You might find that you sometimes experience difficulty getting an erection and other times find it very easy. For example, you might get an erection in the morning and when you masturbate, but not when you try to have sex with your partner. In this type of scenario, it is likely that the cause of your erectile dysfunction is psychological. It could be stress related, for example. If you can’t ever get an erection, under any circumstances, the causes of your impotence are probably physical.

• Vasculogenic conditions alter the flow of blood to the penis. Erectile dysfunction is closely linked to cardiovascular disease, so your doctor might start by looking at this. High blood pressure (hypertension) and diabetes can both cause ED. Diabetes is a condition caused by a surfeit of glucose in the blood that affects both the flow of blood to the penis and the nerve endings in your penis. It is therefore both a vasculogenic and a neurogenic condition.

• Neurogenic conditions involve your nervous system, i.e. your brain, nerves and spinal cord. Multiple Sclerosis, Parkinson’s disease, a spinal disorder or a stroke are examples of neurogenic conditions that can all result in ED.

• Hormonal conditions such as a change in your hormone levels, for example, as a result of an overactive thyroid, an underactive thyroid, Cushing’s syndrome or hypogonadism can all result in impotence.

• Anatomical conditions that result in changes to the physical structure of your penis, for example as a result of Peyronie’s disease, which affects the tissue of the penis, can cause erectile difficulties.

Erectile dysfunction can also be the result of psychological causes like depression and anxiety. Emotional issues can also affect whether you feel physically able to get and keep an erection. If you are having relationship problems or starting a new relationship, if you feel like you don’t know what you’re doing when it comes to sex, if you have had sexual issues in the past or have experienced sexual abuse, then you may find that you are experiencing erectile dysfunction. Counselling can help to resolve these issues.

It is possible to get erectile dysfunction that is caused by both physical and psychological factors. An example might be, if you have multiple sclerosis and find it difficult to get an erection, you may then be worried about this. The two factors together can lead to an episode of ED. 

If you drink alcohol heavily, take illegal drugs like heroin, cocaine or cannabis, or if you are very tired, this can result in erectile dysfunction, too. 

• Diuretics – cause your body to increase the amount of urine it produces. Commonly used to treat high blood pressure, heart failure and kidney problems.
• Antihypertensives – used to treat high blood pressure, e.g. beta-blockers.
• Fibrates – prescribed to decrease cholesterol levels.
• Antipsychotics – used for some mental health conditions, like schizophrenia.
• Antidepressants – prescribed to tackle depression or sometimes pain
• Corticosteroids – contain steroids (these are a type of hormone)
• H2-antagonists – for stomach ulcers
• Anticonvulsants – prescribed to people with epilepsy
• Antihistamines – used to manage allergies, like hay fever
• Anti-androgens – suppress androgens (male sex hormones)
• Cytotoxics – used in chemotherapy

If you’re worried that your medication is causing erectile dysfunction, speak to your GP as there might be other options that you could try. Don’t stop taking a medicine that your GP has prescribed without discussing it with a qualified professional though.

• Viagra (active ingredient: sildenafil)
• Viagra Connect (available Spring 2018)
• Tadalafil
• Cialis (active ingredient: tadalafil)
• Levitra (active ingredient: vardenafil)
• Spedra (active ingredient: avanafil)

The above list are erectile dysfunction treatments, of which Viagra and Levitra work for between four and eight hours after you take them. Cialis and Tadalafil last for longer – about a day and a half – so are more suited if you need a longer-lasting treatment, for example, over a full weekend.

All erectile dysfunction treatments start working within half an hour to an hour. The medication will work faster if you take it on an empty stomach. You can then eat an hour after taking it without affecting its effectiveness.  

You should talk to your doctor about which erectile dysfunction treatment might be best for you, depending on whether you have taken one before and how often you intend to have sex. 

If you find that PDE-5 inhibitors don’t work, you might want to consider whether you waited long enough for the erectile dysfunction treatment to kick in, whether you waited too long for the medication to kick in, whether you had a high enough dose, and whether you felt sexually aroused. You still need to feel sexually stimulated to get an erection when taking an erectile dysfunction treatment.

You can get all three types of PDE-5 inhibitors on prescription from your NHS GP, but in some cases you’ll be asked to pay the full cost of the medication (£17-£30 for 4 tablets depending on the pharmacy’s pricing). If you have: diabetes, multiple sclerosis, Parkinson’s disease, polio, prostate cancer, a severe pelvic or spinal injury, spina bifida, or certain genetic conditions, then you may be entitled to an NHS prescription for PDE-5 inhibitors. 

Likewise, if you have had one of the following medical treatments, then you may also be entitled to an NHS prescription for erectile dysfunction treatment: pelvic surgery, surgical removal of the prostate gland (prostatectomy), dialysis for kidney failure, a kidney transplant. 

If a specialist centre decides that erectile dysfunction is negatively affecting your daily life, mood/behaviour, or your relationships, then they may also prescribe treatment on the NHS.

If you were getting treated for impotence before or on September 14 1998 then you may also be entitled to an NHS prescription (eligibility for impotence treatment was redefined in 1999, and people who were receiving treatment prior to that date are often still allowed to get it on prescription).

There are different types of treatment depending on the causes of your erectile dysfunction.

The most common types of treatment include:

• Lifestyle changes
• Complementary therapies
• Pelvic Floor Muscle exercises
• Psychological therapies: cognitive behavioural therapy
• psychosexual therapy, sensate focus, counselling
• Medication: Viagra, Cialis, Levitra and Alprostadil
• A vacuum pump
• Hormone therapy
• Surgery

How to treat erectile dysfunction with lifestyles changes

You can often improve the erectile problems by switching to live a healthier lifestyle.

Some changes that you can make yourself include:

• Quit smoking
• Exercise often
• Don’t drink too much alcohol
• Don’t take drugs
• Try to lower your stress levels
• Lose weight (if you need to)

Treating erectile dysfunction due to underlying health issues

If you are suffering from erectile dysfunction as a result of an underlying health condition, you’ll usually need to treat the underlying condition first, before you embark upon a course of treatment for impotence. You may then find that by treating the underlying condition, this solves the problem of your erectile dysfunction too. Speak to your doctor about the fact that you are struggling with ED as well as your underlying condition, so that they can factor this into your treatment plan. 

If you are taking medication for another condition and you think that this is causing erectile dysfunction, have a chat with your doctor about it. It may be that they can suggest an alternative type of medication. Make sure that you talked to your doctor or healthcare professional before you stop taking any medication that you’ve been prescribed. 

Psychological Treatment Options

Counselling can be very helpful for people who have erectile dysfunction that is caused by psychological problems like anxiety or depression. Another type of treatment for people who have ED that has a psychological cause is called Sensate Focus. 

Sensate focus is a type of sex therapy. You and your partner agree not to have sex for a set period of time. During this time, you can still touch each other, but you agree not to touch each others’ genitals (or a woman’s breasts). During the agreed timeframe, you then set aside time to spend together as a couple to explore each others’ bodies without having sex. Clothed or naked, you can massage each other, explore touch, and stroke each other. Once the agreed timeframe has passed, you can then start to touch each others’ genitals, you can start to use your mouth as a way of exploring each others’ bodies through kissing or licking your partner, for example. Gradually, you can then build up to penetrative sex together. If you would like to read a bit more about Sensate Focus or about sex therapy in general, the College of Sexual and Relationship Therapists website is very useful: http://www.cosrt.org.uk/information-for-members-of-the-public/tips-for-sexual-wellbeing/

Psychosexual counselling is a talking therapy. It has mixed results and can take a while to work, but many people find it really helps. It provides space for you and your partner to talk about any issues that might contribute to or cause your erectile dysfunction. The aim of talking it through is to help you feel less worried or anxious, so that you can overcome your problems. The counsellor can also offer advice on sex, like practical foreplay techniques and how you might like to incorporate other treatments for erectile dysfunction into your plans to improve your sex life. The NHS offers advice on good sex which includes practical tips on arousal. You can read this on the NHS website: http://www.nhs.uk/LiveWell/Goodsex/Pages/Goodsexhome.aspx

Cognitive Behavioural Therapy can also be helpful in treating impotence. Cognitive Behavioural Therapy explores the link between the way we think and how we feel. It aims to change the way you think about and react to a situation, to help you feel happier. A CBT therapist can work with you to identify factors that are contributing to your erectile dysfunction. They will look for unhelpful thoughts or thought patterns that might be linked to: your self esteem, your sexuality or your personal relationships. With the therapist, you can then work to change these by practicing different ways of thinking. 

Complementary therapies

Like acupuncture claim to improve impotence. The evidence of whether this is effective is limited. If you decide to try to treat your erectile difficulties with complementary therapies, speak to your doctor first because sometimes they can interact with other medicines. 

Pelvic Floor Muscle Exercises

The pelvic floor muscles are grouped under the bladder, around the rectum and at the base of the penis. The exercises strengthen and train the muscles used to urinate and to control the anus (back passage). There is some evidence to suggest that for some people, exercising these muscles can improve erectile dysfunction. If you think this might help you, have a chat with your GP who might refer you to a physiotherapist so that you learn how to do the exercises correctly. 

The vacuum pump

A vacuum pump is made up of a clear plastic tube connected to a hand or battery activated pump. You put your penis into the tube and pump out all of the air. This increases the blood flow to your penis so that you can get and sustain an erection. You then put a rubber ring around the base of your penis to keep the blood there. Using this, you will be able to sustain an erection for about 30 minutes. It can take a bit of practice to get used to using the pump properly, but 90% of men who used it found that they were able to sustain an erection (regardless of the cause of their impotence).

Cautions

You shouldn’t use the vacuum pump if you have a bleeding disorder or take anti-coagulant (blood thinning) drugs. Under a third of people find that they experience side effects of pain or bruising using the pump. If you qualify for erectile dysfunction treatment on the NHS, then you might also be able to get a pump, but normally most people have to buy their own. You can get advice on using pumps and other topics from the Sexual Advice Association: http://www.sda.uk.net/advice.php

Alprostadil

If you find that your erectile dysfunction is not responding to your course of treatment, or if you can’t use Viagra, Cialis, Levitra or the vacuum pump, then your doctor might suggest you try Alprostadil (a synthetic hormone that increases the flow of blood to the penis given either as injection into the penis or as a pellet placed inside the urethra). You can be trained in how to inject or insert the pellet of Alprostadil. It usually takes effect within five to fifteen minutes. The length of time that the erection lasts for varies with the dose. If your partner is pregnant, you’ll need to use a condom during sex. 

Alprostadil when placed in the urethra is effective in 2 out of 3 men with ED. Alprostadil injections worked for just over 8 out of 10 men who found that Viagra, Cialis and Levitra didn’t work for them.

Cautions, risks, side effects, interactions

Men with the following conditions should not use Alprostadil:

• men at risk of priapism, e.g. if you have sickle cell anaemia
• men using other erectile dysfunction medications
• men with a penile implant
• men who have been told to avoid sexual activity

Men with the following conditions should not use Alprostadil:

• some men with anatomical problems with their penis; or
• some men with infections of their penis.

Alprostadil can cause the following side effects: changes in your blood pressure, dizziness, headache, pain in your penis, urethral burning or bleeding, reactions at the site of the injection, such as swelling. You should always read the patient information leaflet.

Hormone therapy

If your doctor thinks that your erectile dysfunction is related to your hormones, chances are you will be referred to a hormone specialist (an endocrinologist) who will look to rebalance your hormone levels (probably with a series of hormone injections.)

Surgery

Surgery is a last resort for treating impotence. It is normally only recommended for younger men who have seriously injured their pelvic area or men who have an anatomical problem with their penis. 

It used to be the case that if a man had a blockage in the blood vessels leading to the penis, then surgery could be used as a way to unblock these to allow the blood to flow again. However, evidence shows that this surgery is often not successful in the longer term, so it is now rarely used to treat this problem.  

Penile implants are another type of surgery. This is not normally available on the NHS, but about 75% of men who have it are satisfied with it.

• Semi-rigid implants – can be appropriate for older men who don’t have regular sex
• Inflatable implants – made up of two or three parts that are inflated to maintain a more natural erection. They are often very expensive.

About 5% of men who have penile implants experience mechanical issues with the implants within five years.

Side Effects and Warnings

Men who have cardiovascular disease including conditions like coronary heart disease, should use PDE-5 inhibitors with caution. Speak to your doctor if this applies to you. Sex can be a good way to improve your cardiovascular health, but you need to ensure that you are fit enough to take the medication safely.

If you have an anatomical issue with your penis, like Peyronie’s Disease, again you need to consult your doctor to see if it is safe for you to take an erectile dysfunction treatment. 

If you are taking medicines (for example, to treat angina) or using recreational drugs (such as butyl nitrate, also known as poppers) that contain nitrates, then you must not take PDE-5 inhibitors. Using the two drugs together can be very dangerous for your heart. 

If you suffer from priapism (a painful erection that lasts several hours), or if you are taking long-lasting alpha-blockers (a type of medication used to treat high blood pressure), then, again, you need to be very cautious about taking any erectile dysfunction treatment, so speak to your doctor first. 

Unless your doctor has said you can, do not take PDE-5 inhibitors if you:

• have been told not to have sex, not to engage in sexual activity /actions that widen your blood vessels;
• have low blood pressure (hypotension);
• have had a stroke lately;
• have unstable angina;
• have had a heart attack; or
• have a history of non-arteritic anterior ischaemic optic neuropathy (this condition causes a sudden loss of vision).

Side effects of PDE-5 inhibitors include:

• pain in your back/muscles/head; 
• migraines;
• getting flushed/going red;
• indigestion;
• feeling and or being sick;
• getting a blocked or runny nose
• vision disturbances.