The inability to obtain or maintain an erection sufficient for penetration and for the satisfaction of both sexual partners
- Impotence becomes commoner with increasing age and is seen in 50-55% of men between 40 and 70 years old
- It is often associated with obesity, high blood pressure, high cholesterol & diabetes which are all significant risks to health
- Most treatable causes can be identified by a clinical history, physical examination and routine blood tests
- If there is no treatable cause, treatment with tablets is the first option for most men
- Other methods of treatment are only indicated if tablets prove ineffective, cause side-effects or cannot be used because of specific medical conditions
Causes of erectile dysfunction
90% of men with impotence (erectile dysfunction) have at least one underlying physical cause for their problem. Although a psychological component, often called "performance anxiety", is common in men with impotence, a purely psychological problem is seen in only 10%.
Of the 90% of men who have an underlying physical cause, the main abnormalities found are:
- Vascular disease in 40%
- Diabetes in 33%
- Hormone problems (e.g. high prolactin or low testosterone levels)
- Drugs (e.g. antihypertensives, antipsychotics, antidepressants, antihistamines, heroin, cocaine, methadone) in 11%
- Neurological disorders in 10%
- Pelvic surgery or trauma in 3-5%%
- Anatomical abnormalities in 1-3% (e.g. tight foreskin, short penile frenulum, Peyronie's disease, inflammation, penile curvature)
Other specific tests normally arranged by an andrologist include: -
- A full history enquiring about lifestyle factors (e.g. job, work pressures, smoking habits, alcohol intake and drug consumption).
- Detailed sexual history to determine why erections are failing and under what circumstances the patient is having sexual difficulties. It is also normal to ask about sex drive (libido), whether the patient still gest nighttime or early-morning erections and whether their partner is also concerned about the patient’s difficulties. It is important the patient notifies their doctor if they also have premature ejaculation (uncontrolled ejaculation before or immediately after penetration) or symptoms of prostatic obstruction because they are often associated with impotence (erectile dysfunction).
- IIEF Symptom questionnaire (International Index of Erectile Function) as an aid to further assessment and discussion of treatment options.
- A physical examination to assess the development of male sexual characteristics and to detect any abnormality of the penis or genitals. Leg pulses will normally be assessed and the nerve reflexes involving the legs and penis or anus are also tested. Rectal examination is normally performed to assess the prostate gland.
- General blood tests to measure kidney function, liver function, cholesterol & prostate-specific antigen (PSA and blood sugar to exclude diabetes
- Urine stick testing for sugar which might indicate diabetes
- Hormone measurements. Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinizing hormone) and thyroid hormones will normally be measured.
- Measurement of penile blood flow by ultrasound
- Formal nerve conduction tests
- Trial injection of the drug prostaglandin E1 (Caverject®) into the
penis; a good erection after the injection means that the arterial blood
flow to the penis is likely to be normal
Treatments options for erectile dysfunction
Treatment is only indicated if both partners are troubled by the erectile dysfunction and they have realistic expectations of what can be achieved by any treatment
Initial treatment usually involves:
- treatment of any anatomical abnormality (e.g. circumcision, frenuloplasty, penile straightening)
- treatment of any hormone abnormality (testosterone treatment is only indicated if testosterone levels are low and may be harmful if your the levels are normal)
- lifestyle modification (e.g. reduce stress, stop smoking & drinking, stop all drugs)
- weight loss & increased exercise (which may reduce the risk of erectile dysfunction by up to 70%)
- specific support for psychological problems
- PDE5 inhibitors - Viagra®, Cialis® or Levitra® - These drugs require sexual stimulation to be effective and will not produce an erection without it; they will have no effect on male sex drive. Your doctor will arrange a reassessment after an initial period of drug usage. If drugs prove ineffective, if there are significant side-effects (seen in 15%) or if they cannot be used, other measures may need to be considered.
- Penile injections to produce erections. Self-administered injections of prostaglandin E1 (Caverject®) provide a simple means of obtaining a natural erection. The patient will be taught how to administer the injections and told what to do in the event of problems such as a persistent erection, which will not go down.
- Medicated urethral system for erection (MUSE) Insertion of a prostaglandin pellet in the urethra (water pipe) is now rarely used because of its poor success rates and significant side-effects
- Vacuum erection assistance devices (VEDs) provide a simple way of obtaining an erection for 30-45 minutes by sucking blood into the penis and holding it in place with a constriction ring. Ejaculation may be restricted by the ring but this technique is simple, safe and has no known side-effects.
- Vascular surgery/angioplasty - If the patient has a blockage of the large blood vessels to the legs and the pelvis, it may be possible to undergo reconstruction of the arteries or angioplasty to re-establish erections. Re-vascularization for small artery blockage is rarely successful
- Penile prostheses - Insertion of artificial penile implants is highly effective but is reserved as a last resort when all other forms of treatment have failed. It involves major surgery with a significant risk of complications and you will need to undergo long-term follow-up with an andrologist.