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Erectile dysfunction

Erectile dysfunction, also known as ED and impotence, is the frequent inability to achieve or maintain an erection sufficient for sexual activity to take place. It can be an early sign of heart problems that need treatment.

If you have erectile dysfunction, it’s likely that you often have difficulty getting an erection or keeping one for long enough to have penetrative sex.

Erectile dysfunction is one of the most common sexual problems and affects up to 20 men in every 100. You’re more likely to get it as you get older. It’s important to see your GP because erectile dysfunction can be a sign of a problem with your heart and blood flow around your body.

It’s important to be aware that erectile dysfunction isn’t the same as problems with ejaculation or orgasm. If you have erectile dysfunction, you may be able to ejaculate even if you’re not able to have penetrative sex.

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  • Diagnosis Diagnosis of erectile dysfunction

    It’s a good idea to see your GP if you’re consistently having problems getting an erection. Not being able to get an erection occasionally is common and doesn’t mean that you will have persistent problems in the future.

    Your GP will ask you about your symptoms and lifestyle, such as whether you smoke and how much alcohol you drink, and examine you. This may involve an examination of your penis, scrotum or prostate gland.

    Your GP is also likely to check your weight and waist circumference, as well as measuring your blood pressure and heart rate. This helps to indicate how healthy your blood flow is and whether you’re at risk of diabetes or heart disease, which are often associated with erectile dysfunction. Your GP may arrange a blood test to check the levels of glucose (sugar), cholesterol and other hormones, such as testosterone, in your blood.

  • Treatment Treatment of erectile dysfunction

    Self-help

    Making some changes to your lifestyle may help to prevent your erectile dysfunction from getting worse. The following may help.

    • If you smoke, try to stop. Ask your GP for information about help and support that is available to you.
    • If you’re overweight, lose excess weight.
    • Do regular physical activity. Aim for 150 minutes of moderate exercise over a week in bouts of 10 minutes or more.
    • Eat a low-fat, high-fibre diet, including at least five portions of fruit and vegetables a day and two portions of fish (one oily) a week.
    • Drink alcohol in moderation. The recommended daily limit for men is three to four units, with at least two alcohol-free days per week.
    • Try to reduce stress where possible.
    • If you cycle for more than three hours a week, your GP may advise you to stop for a while to see if your condition improves. However, there is no good evidence to show that cycling leads to erectile dysfunction.

    Medicines

    If your GP thinks that prescription medicines you’re taking for other conditions may be causing or contributing to your erectile dysfunction, he or she will discuss possible alternatives with you. Don’t stop taking any medicines that are prescribed to you before speaking to your GP.

    Your GP may prescribe you a type of medicine called a phosphodiesterase-5 inhibitor. These medicines increase the blood flow to your penis and can help you to get and sustain an erection. They don’t increase your sex drive so you will still need sexual stimulation. The medicines enable you to have an erection for several hours.

    The most common phosphodiesterase-5 inhibitors are:

    • sildenafil (Viagra)
    • tadalafil (Cialis)
    • vardenafil (Levitra)

    Phosphodiesterase-5 inhibitors may cause side-effects, including headaches, feeling sick, vomiting and indigestion.

    You won’t be prescribed these medicines if you’re taking medicines that contain nitrates, for example glyceryl trinitrate (GTN) for angina. Your GP may also not prescribe them if you have heart disease.

    It’s now possible for you to buy some of these medicines over the counter in pharmacies, following a consultation with a pharmacist. Be careful if you’re considering buying medicines on the internet, particularly prescription medicines. Speak to your GP about the provider first.

    If phosphodiesterase-5 inhibitor medicines don’t work for you, or you can’t be prescribed them, your GP may offer you a medicine called alprostadil. This is a synthetic (man-made) hormone that stimulates blood flow to your penis. Alprostadil can be injected directly into your penis or a small pellet can be inserted inside the opening at the tip of your penis. A new cream containing alprostadil has been developed and authorised for use in Canada. However, it hasn’t yet been approved or licensed for use anywhere else and there is no evidence available about its long-term effectiveness or safety.

    If your erectile dysfunction is caused by a problem with your hormones, your GP may prescribe you testosterone replacement therapy.

    Non-surgical treatments

    You may wish to try using a vacuum erection device if medicines haven’t worked or you can’t be prescribed them. This is a device that pumps air out from around your penis to create a vacuum. This draws blood into your penis, leading to an erection. You can use these with a constriction band that traps the blood inside your penis, which helps to maintain your erection.

    If your erectile dysfunction is caused by a psychological problem, you may benefit from a talking therapy. This could be psychosexual counselling or cognitive behavioural therapy (CBT). Your GP may recommend that you try this as well as prescribing medicines for you.

    Psychosexual counselling is a type of therapy you can do alone or with your partner if you have one and he or she is willing. It involves discussing any sexual or emotional issues that may be contributing to your erectile dysfunction. The counsellor may also give you some practical advice about sex, such as foreplay techniques and how to use other treatments for erectile dysfunction.

    CBT is a talking therapy in which you work with a trained therapist to challenge negative thoughts, feelings and behaviour. CBT may help you to address problems such as anxiety or depression if these are contributing to your erectile dysfunction.

    Surgery

    You may be able to have surgery to increase the blood flow to your penis or have a penile implant inserted – this involves inserting a cylinder down the centre of your penis to make it rigid. However, this is very rarely needed. Ask your GP for more information.

    Complementary therapies

    Some complementary therapies, such as acupuncture or herbal remedies, claim to treat erectile dysfunction. However, there is little clinical evidence to prove this. Some herbal remedies may contain ingredients, including prescription-only medicines, that can affect other medicines and cause side-effects. Always speak to your pharmacist or GP before trying any complementary therapies.

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  • Causes Causes of erectile dysfunction

    There a number of reasons why you may have erectile dysfunction.

    Physical causes

    A number of conditions may cause erectile dysfunction, including:

    • high blood pressure
    • high cholesterol
    • diabetes
    • multiple sclerosis
    • Parkinson’s disease
    • stroke
    • treatment for prostate problems, such as an operation to remove your prostate gland or radiation to your pelvic area
    • a problem with your hormones (chemicals occurring naturally in your body), such as hypogonadism, which causes low levels of testosterone
    • Peyronie’s disease – a condition that causes your penis to curve when it’s erect

    Psychological causes

    Psychological problems can affect your ability to get and keep erections. These include:

    • feeling anxious, guilty or depressed
    • performance anxiety
    • stress at work or home
    • relationship problems
    • unresolved issues about sexual orientation
    • sexual boredom

    Lifestyle causes

    Many factors to do with your lifestyle can influence your ability to get and keep erections. These include:

    • smoking
    • drinking excessive amounts of alcohol
    • taking illegal drugs, such as cannabis
    • being physically inactive

    Medicines

    The side-effects of some medicines, such as treatments for high blood pressure and certain antidepressants, can cause erectile dysfunction. Medicines can also affect your sex drive or cause problems with ejaculation and orgasm.

  • FAQs FAQs

    Is there a link between erectile dysfunction and heart disease?

    Answer

    Yes, one of the main causes of heart disease is the build-up of fatty deposits. These can narrow and may eventually block the arteries that supply your heart with blood. This process is known as atherosclerosis and can also affect the blood vessels that take blood to your penis. A lack of blood getting to your penis can cause erectile dysfunction.

    Explanation

    One of the most common causes of erectile dysfunction is a problem with the blood flow to your penis. Increased atherosclerosis as you get older can reduce the amount that is able to enter it. Finding it difficult to get an erection is often one of the first signs that your arteries are becoming narrowed because the blood vessels that supply your penis with blood are smaller than those that supply your heart with blood.

    If you’re having problems getting an erection, see your GP. He or she can assess your risk of developing heart disease in the future. Your GP may check the levels of cholesterol and glucose (sugar) in your blood as well as your blood pressure, and ask about your lifestyle, for example whether you smoke and how active you are.

    Your GP may recommend you make changes to your lifestyle, such as trying to lose excess weight or stopping smoking. This will help reduce your risk of heart disease and may improve your erectile dysfunction.

    Can you tell me more about the medicines available to treat erectile dysfunction?

    Answer

    The main medicines available to treat erectile dysfunction are called phosphodiesterase type-5 inhibitors. There are three varieties and they all work in a similar way and are equally effective, but their effects last for different lengths of time.

    Explanation

    The three phosphodiesterase type-5 inhibitors are sildenafil, vardenafil and tadalafil. They work by increasing the blood flow to your penis, which gives you an erection. They don’t increase your sex drive so you will still need sexual stimulation.

    Phosphodiesterase type-5 inhibitors usually start to work within 30 minutes and one hour of taking them. The effects of sildenafil and vardenafil last for about four hours whereas tadalafil lasts for 24 to 48 hours, sometimes longer.

    You may need to try different doses until you find the one that works for you. Don’t take more than the maximum recommended dose as it won’t make the tablet any more effective but it will increase your risk of side-effects. Don’t take more than one dose in a day.

    You may not be able to take these medicines for the following reasons:

    • You are taking other treatments for erectile dysfunction
    • You are taking medicines called nitrates, such as glyceryl trinitrate (GTN) for angina – this can lead to a potentially very dangerous drop in blood pressure
    • You take recreational drugs called poppers (amyl nitrate) – these may also cause a severe drop in blood pressure
    • You have been told that being sexually active may cause you problems, for example if you have certain serious heart problems, such as a recent heart attack or stroke

    Speak to your GP before taking phosphodiesterase type-5 inhibitors.

    An alternative medicine for treating erectile dysfunction is alprostadil. This is a synthetic (man-made) hormone that stimulates blood flow to your penis. Alprostadil can be injected directly into your penis or a small pellet can be placed inside the opening at the tip of your penis to give you an erection.

    A new cream containing alprostadil has been developed and authorised for use in Canada. However, it hasn’t yet been approved or licensed for use anywhere else and there is no evidence available about its long-term effectiveness or safety. Talk to your GP for more information.

    How do vacuum pumps work?

    Answer

    A vacuum erection device pumps out the air from around your penis and so draws blood into it. Vacuum devices are an effective way of getting an erection and they often have very few side-effects.

    Explanation

    A vacuum erection device usually consists of a clear plastic cylinder and a pump that is hand or battery operated. You place your penis into the cylinder and press firmly down against your body to create an air-tight seal. Once a vacuum is created your penis becomes filled with blood. When you’re ready for sexual intercourse, you can place a plastic ring around the base of your penis. This traps blood in your penis and enables your erection to be maintained. Don’t use a vacuum erection device for more than 30 minutes as it can get very uncomfortable.

    Most men find the device effective but it may take several weeks to learn how to use it. You may develop side-effects, such as bruising, and it also means it’s not possible to be spontaneous.

    Speak to your GP to find out if vacuum erection devices may be suitable for you.

    Can hypopituitarism caused by a serious head injury lead to erectile dysfunction?

    Answer

    It’s possible that an underactive pituitary gland (hypopituitarism) that developed after a serious head injury can lead to erectile dysfunction. However, this is rare. Hypopituitarism can lead to reduced production of certain hormones (chemicals occurring naturally in your body) called gonadotrophins that trigger the release of the male sex hormone testosterone.

    Explanation

    If you have a condition known as hypopituitarism, your pituitary gland doesn’t produce enough of the hormones it usually releases. Your pituitary gland produces a number of hormones including those involved with reproduction, sexual characteristics and fertility. These are called gonadotrophins.

    If your pituitary gland doesn’t produce enough gonadotrophins, it can lead to a condition known as hypogonadism. In men this can cause symptoms including less hair on the face and body, a reduced sex drive and erectile dysfunction.

    Hypopituitarism can develop for a number of reasons including a tumour, taking certain medicines, being exposed to radiation or a serious head injury that causes damage to the pituitary gland. Therefore, it’s possible that if you have had a serious head injury, even if it happened some years ago, you may be at risk of erectile dysfunction.

    Speak to your GP if you’re concerned that a past injury to your head may be causing you sexual problems.

  • Resources Resources

    Further information

    Sources

    • Erectile dysfunction. BMJ Best Practice. www.bestpractice.bmj.com, published July 2012
    • Elliott SL. Hot topics in erectile dysfunction. B C Med J 2011; 53(9):480–86. www.bcmj.org
    • Simon C, Everitt H, Kendrick T. Oxford handbook of general practice. 2nd ed. Oxford: Oxford University Press; 2005: 702–03
    • Erectile dysfunction. Medscape. www.emedicine.medscape.com, published August 2013
    • Erectile dysfunction. NICE Clinical Knowledge Summaries. cks.nice.org.uk, published January 2013
    • Erectile dysfunction. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). www.kidney.niddk.nih.gov, published March 2012
    • Erectile dysfunction (impotence). The British Association of Urological Surgeons. www.baus.org.uk, accessed 11 September 2013
    • Joint Formulary Committee. British National Formulary (online). London: BMJ Group and Pharmaceutical Press. www.medicinescomplete.com, accessed 11 September 2013
    • Sex therapy is also known as psychosexual therapy, or PST for short. Sexual Advice Association. www.sda.uk.net, published July 2011
    • Cognitive behavioural therapy. Royal College of Psychiatrists. www.rcpsych.ac.uk, published July 2013
    • Erectile dysfunction. (Impotence). The Merck Manuals. www.merckmanuals.com, published February 2013
    • Hypogonadism in men. BMJ Best Practice. www.bestpractice.bmj.com, published April 2013
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