Erectile dysfunction (impotence)

What is it?

The persistent or recurrent inability to achieve or maintain an erection good enough to complete your chosen sexual activity satisfactorily, whether that's masturbation, oral sex or vaginal or anal intercourse.

The occasional inability to achieve a satisfactory erection doesn't normally constitute a problem. 

What's the risk?

• Most men will experience an erection problem at least once. This could be due to stress, exhaustion, too much alcohol or simply not feeling like sex.
• Persistent erectile dysfunction (ED) is estimated to affect about 10% of men at any one time.
• Although age itself isn't a cause of erectile dysfunction (ED), the risk nevertheless increases as you get older: 18% of 50—59 year olds have trouble with their erections compared with 7% of 18—29 year olds. 

What causes it?

There are two main causes of ED: physical and psychological. Most doctors agree that the majority of cases are physical but it's also clear that many men with ED also quickly start to feel anxious, stressed or depressed. These feelings can easily make the symptoms of ED worse.

The main physical causes are:

• Diabetes. Up to 25% of all diabetic men aged 30—34 are affected by ED, as are 75% of diabetic men aged 60—64.
• Inadequate blood flow to the penis because arteries have got furred-up (a condition called atherosclerosis) or damaged. This causes about 40% of ED cases in men aged over 50. Smoking cigarettes, which is implicated in up to 80% of ED cases, constricts the blood vessels and is a major cause of damage to the arteries leading to the penis. One little-known cause of damage to key blood vessels is cycling.
• Regular heavy drinking. Alcohol can damage the nerves leading to the penis, reduce testosterone levels and increase levels of the female hormone oestrogen.
• The side-effects of prescribed drugs, particularly those used to treat high blood pressure, heart disease, depression, peptic ulcers and cancer. As many as 25% of ED cases may be caused by drugs taken to treat other conditions.
• Spinal cord injury. Almost a quarter of men with spinal injury are affected by ED.
• Prostate gland surgery (or other surgery around the pelvis). The risk of ED depends on the type of surgery, but up to 30% of men who have a radical prostatectomy (the complete removal of the gland affected by cancer) will experience ED.

The main psychological causes of ED are:

• Relationship conflicts
• Stress and anxiety
• Depression (90% of men affected by depression also have complete or moderate ED)
• Unresolved sexual orientation
• Sexual boredom

One rough-and-ready way of working out whether your ED has a physical cause is to see whether there any circumstances in which you get an erection. If you can produce one when masturbating but not with a partner, wake up with an erection, or have erections during the night, then there's a good chance that your ED has psychological causes. 

How can I prevent it?

• Have a healthy lifestyle. Quitting smoking and drinking alcohol in moderation will help. Regular aerobic exercise and a low-fat diet will also reduce the risks of atherosclerosis.
• If you have diabetes, ensure it's properly controlled.

Should I see a doctor?

Yes. Get help and advice as soon as you notice a problem. This isn't only important in terms of getting treatment for your ED: it could also be a symptom of other potentially serious conditions (such as diabetes or heart disease - click here for more information.)

One study of 50 men with ED who had sought prescriptions for Viagra found that although none of them had any symptoms of heart disease, six were found to have blockages in all three major heart arteries, seven had two arteries that showed narrowing and one artery was blocked in another seven. Overall, 40% of the men were at significant risk of angina or a heart attack.

If you are on treatment for a medical or psychiatric problem and you think that this treatment is affecting your sex life tell your doctor. Alternative treatments that may have less likelihood of affecting sexual function are often available.

If your doctor doesn't take your problem seriously, ask to be referred to a specialist. Don't let yourself be fobbed off with comments like "What do you expect at your age?"

A wide variety of treatments for ED are now available. Remember, however, that not all men are entitled to treatment through the NHS. 

What are the main treatments?

• Oral drugs. These are by the far the most commonly used treatments. There are now a number of oral treatments available and most work by helping to relax the blood vessels in the penis, allowing blood to flow in. They don't work unless you're also sexually stimulated. The most common side-effects are headaches and facial flushing. These oral treatments must not be taken by men who are also using medicines containing nitrates (commonly prescribed for angina). There are a number of oral treatments available including Cialis, Levitra, Uprima and Viagra. There are pros and cons with each and it is important to discuss these with your doctor. More details can be found on this site.
• Injection therapy. This is an effective and reliable way of producing an erection with drugs but, understandably, many men don't like sticking a needle into their penis every time they have sex. When injected, the drug (most commonly alprostadil, commonly known as Caverject and Viridal), relaxes the blood vessels and muscles, allowing increased blood flow and producing an erection within 15 minutes.
• MUSE (medicated urethral system for erection). This method also uses alprostadil, but this time it's administered by means of a small pellet inserted into the urethram the opening to ther penis, via a single-dose, disposable plastic applicator. More details can be found on this site.
• Vacuum pumps. The penis is inserted into a clear plastic cylinder and the air is pumped out, creating a vacuum. The penis fills with blood and, when it's hard enough, a plastic constricting ring is placed around the base of the penis to trap the blood. There are few side-effects (apart from occasional slight bruising) and the devices work for more than 90% of men. Many men find the process too unnatural and intrusive, however, and prefer to try other methods of tackling ED.
• Hormonal supplements. Testosterone can be given to men in the relatively few cases where low levels are the cause of ED, especially if they also have low sexual desire. Before taking testosterone, always insist that your doctor measures your testosterone level to confirm that it really is low.
• Penile implants. Now that so many other effective treatments have become available, implants are only now used as a last resort. A mechanical device is surgically inserted into the penis. It can be either permanently rigid or have a hydraulic action, operated via a valve in the scrotum.
• Sex therapy. Whatever the cause or treatment of their ED, many men could benefit from counselling or therapy. In fact, the best treatment centres provide it as a matter of course. Sex therapy will be particularly necessary if the ED has psychological causes which can't actually be "cured" with physical treatments. If a man has ED as a result of emotional conflict with a partner, for example, providing him with a drug that produces an erection isn't going to resolve that conflict; in fact, it might even make it worse. Men whose ED has a physical cause may also have lost a great deal of self-esteem and sexual confidence which sex therapy could help restore. It usually makes sense to also involve any permanent partner in sex therapy since the loss, as well as the restoration, of a man's erectile functioning will almost inevitably profoundly affect their relationship. 

How can I help myself?

• Share your worries. No, you don't have to tell your work colleagues about your penis problems, but it will help enormously if you can talk to someone you trust. It's particularly important to communicate with your partner. Some men try to deal with their ED by hiding it from their partner and make all sorts of excuses not to attempt sex. This can cause feelings of confusion and rejection as well as suspicions that you're having an affair. You best bet is to be as open and honest as possible with your partner and ask for support.
• Place less emphasis on intercourse and more on developing other forms of sexual intimacy. Spending time cuddling, kissing, licking and massaging can still be pleasurable and will help keep you emotionally close to your partner.
• Don't try and treat yourself by seeking out pornography, or by asking a partner to wear erotic clothing or act out your fantasies. This almost certainly won't work and could leave you feeling even more upset.
• Don't be tempted to buy herbal supplements or so-called aphrodisiacs through the Internet or magazine advertisements. You can't be sure what you're getting and these remedies are very unlikely to work.
• Don't blame yourself for your ED. It's a health problem and not a reflection of your masculinity. Don't be tempted to blame your partner either.

What's the outlook?

There's an excellent chance that your erections can be restored through one of the increasingly wide range of treatments now available but the psychological scars may take longer, and be more difficult, to heal. 

Who else can help?

See Sexual problems - Further Information.