Problems with erection

Most men have had the occasional, embarrassing experience of badly timed erection failure – tiredness, alcohol and the pressure to impress a new partner are often to blame.

It is estimated, however, that up to five million men in the UK have persistent problems with erection. Other surveys have found that about seven per cent of all men will exper­ience serious problems with their erection at some point in their lives.

Unfortunately data also suggest that only ten per cent of those who have problems seek treatment, which can be successful in many cases.

Many men may choose instead to ignore or deny the situation, often at great cost to their own happiness and the stability of their relationship. A man who has erect­ile problems can feel deeply inad­equate and unmanly, and avoid sexual contact with his partner.

His partner may also suffer, feeling helpless and rejected, or wonder if he is having an affair.

‘Erectile dysfunction’ is the mo­dern term to describe persistent problems with erection. It replaces the older, still widely used term ‘impotence’, which is inaccurate be­cause of its connotations of weak­ness or unmanliness.

Erectile dysfunction can range from the ability to achieve erection and orgasm by masturbation but not intercourse, to the total inability to achieve erection, no matter how stimulated.

Experts now believe that in about 70 per cent of cases there is a physical cause, with psychological causes accounting for the remainder.

Successful treatment is available for both causes. If a man still has the occasional erection at any time, e.g. in sleep or first thing on wak­ing, his problem is almost certainly psychological.

CAUSES OF ERECTILE DYSFUNCTION

Physical causes

• Alcohol and drugs:

Alcohol consumption is thought to account for one in six cases of erectile dysfunction. Prescribed drugs can also cause problems, and these include some antihypertensive medications (methyldopa, guane­thidine, beta blockers and diur­etics), drugs containing the female hormone oestrogen, or drugs that counteract the male hormone tes­tosterone. Cocaine can also de­crease erection.

• Conditions that affect hormone levels:

Conditions that affect the organs that regulate hormone levels in the body can have an effect on erection. These include Addison’s disease, adrenal gland tumours, rare conditions affecting testosterone production, obesity, and overactive or underactive thyroid.

• Conditions affecting the cir­culation:

An erection requires blood to flow into the penis, and to remain there and not ‘leak’ out. If this mechanism is affected either way, i.e. too little blood in or too much blood out, erection can be affected. Blockage of the blood supply to the penis (similar to blockage of the heart vessels in heart disease) is a common cause. Heavy smokers are therefore at risk of both, and of poor circulation elsewhere in the body.

• Diabetes:

Diabetes can cause blood vessel disease, and can also affect the nerve supply to various parts of the body, including the penis.

• Neurological conditions:

These include conditions that affect the spinal cord or nerve supply to the penis, such as spinal injury, multiple sclerosis or tumours. Surgery to the prostate may rarely cause problems due to nerve or tissue damage.

• Conditions affecting the penis itself:

Conditions affecting the tis­sues of the penis lead to difficulties with erection. These include Pey­ronie’s disease (fibrous swelling of part of the penis), damage caused by untreated priapism or paraphim­osis (see page 32) or infection.

• Serious illness:

Severe, chronic disease of the liver or kidneys may lead to erectile failure. Any serious illness (heart attack, heart failure, chest problems, injury, ma­jor surgery) can result in erectile dysfunction for a variety of reasons.

Psychological causes

Any psychological stress or dis­turbance can interfere with erec­tion. People who are depressed, anxious or traumatised by a recent event can experience erectile failure. Relationship problems or marital discord can also manifest itself this way. Men who are con­fused about their sexual orientation may be unable to achieve erection with a female partner. The pressure to perform sexually can also lead to failure, and up to a quarter of men who seek help for erection dif­ficulties originally had problems with premature ejaculation.

TREATMENT

Treatment is very much tailored to the cause. A man with erectile problems may seek help through a variety of sources – general prac­titioners and sexual health clinics (genitourinary or special clinics) are good initial points of contact. Referral to a specialist in a variety of disciplines (hormones, diabetes, circulation, etc.) may then follow.

Age should not be a barrier to seeking help; although erectile problems are more common in older men, they should not be seen as a fact of ageing. The doctor will need to ask about the patient’s medical and sexual background. He or she may then ask more spe­cific questions about the pattern of erection difficulty, and about any other emotional or relationship difficulties that may be present.

Initial tests may include a full medical examination, a blood pressure check, and a series of blood and urine tests. Further in­vestigation will depend on what the doctor finds.

Treatment options for physical causes of erectile dysfunction

• Changing lifestyle or medication:

Cutting down or stopping alcohol intake and smoking can help a great deal. A change of med­ication, if options are available, may do the same.

• Drugs:

A few years ago Viagra was hailed as a wonder drug offering a solution to erectile dysfunction that could previously only have been dreamt of. In recent years, several new drugs have become available and the choice includes the following:

• Viagra is a trade name for a drug called sildenafil. It works by blocking an enzyme, which in turn prevents the blood vessels in the penis from filling. The final effect is that, with sexual stimulation, the blood vessels are able to fill to a greater extent and so the erection is harder.

Taken an hour before inter­course, seven out of ten men achieve an erection when stim­ulated and aroused; in this way it has a far more natural effect than some therapies which give an erection no matter what the circumstances. Improvements have been seen in both physical and psychological causes of erectile dysfunction, although men with diabetes or those who have had prostate surgery report less success.

Side effects are uncom­mon but include headache, skin flushing, dizziness and diarrhoea; more importantly, the drug can be dangerous for men with certain heart conditions, so it is crucial that it is obtained through the proper channels and prescribed by a doctor.

• Cialis (tadalafil) and Levitra (vardenafil) are drugs that have a similar action to Viagra. Although there are many similarities between these drugs, they differ in dose and for how long they stay effective. For example, although Viagra and Levitra can aid erection for up to four hours, Cialis continues doing so for 24 hours or more.

• Apomorphine is a drug that works by stimulating certain receptors in the brain, especially in an area called the hypo­thalamus. This results in a relaxation of penile muscle, which increases blood flow into the penis, thus improving erection. It is given in a tablet dissolved under the tongue about 20 minutes before sex, and works for about three hours.

It does not work if the tablet is swallowed. Side effects include headache, yawning, nausea and dizziness.

All these drugs have potential side effects and may interact with existing medical conditions and therapies. They should be prescribed only by a doctor who has details of the patient’s overall health. The choice of drug depends on the medical advice and personal preference.

In rare cases hormone therapy may be suitable. Some men also find the drug yohimbine helps increase penile sensitivity and aids erection. The drug is, however, unlicensed for this use, and can only be prescribed if the patient pays for it. It should also not be taken by patients with heart conditions or high blood pressure.

• Injections:

In this method, the man learns to give himself a small injection into the penis before intercourse takes place. The erec­tion occurs within 10 minutes and lasts a sufficient length of time for sex (about 45 minutes) and will subside of its own accord. This method is popular among many men, because results are quick and the injection can be done discreetly. If needles are a problem, a treatment in which the drug is introduced into the urethra as a small pellet may be suitable. This is known as MUSE (medicated urethral system for erection). The rare side effect to watch out for is priapism – when the erection lasts for longer than four hours. This needs to be reduced in a hospital accident and emergency department urgently or permanent damage may result. The dosage then needs to be adjusted to avoid this again.

• Vacuum devices:

This involves the man putting his penis into a plastic cylinder, which is then pumped to create a vacuum. This results in an erection, which is maintained by a rubber band at the base of the penis. This is also a popular method and good if needles are unacceptable. The process can be seen as being rather mechanical and unromantic, but otherwise works very well. The rubber band can be used on its own in some men who are able to achieve an erection but not to maintain it for intercourse.

• Surgery:

This can help men whose specific problem is blood flow to the penis. Surgery may be able to remove any blockage that prevents an erection, or repair any leakage of blood from the penis during erection.

• Penile implants:

Inflatable or semi-rigid rods can be surgically placed along the shaft of the penis. With the semi-rigid rods, the erection is present all the time. The inflatable device is more sophisticated and is connected to a pumping device usually placed in the scrotum. Surgery is usually seen as a last resort, but many men who have had this operation are pleased with the results.

Psychological treatment

Psychosexual therapy or relation­ship counselling can address emotional issues which may have led to erection failure. This can be done alone or with the partner.

In general terms the man has to recognise that his unhappiness, fear or anxiety about a certain issue is responsible for his erection prob­lem, and that the therapist is not going to ‘teach’ him how to regain his erection. A man cannot will an erection any more than his female partner can will vaginal lubrication. He often also needs to recognise that his anxiety about his erection has led him to become a ‘spectator’ sexually, i.e. in lovemaking, he watches anxiously over his per­formance, rather than give himself over to pleasurable sensations.

Once the therapist has explored various issues, the couple may be set exercises to re-learn pleasuring each other in a completely non­threatening way. These usually include sensate focus (see page 36) with the emphasis in later stages on the man maintaining his erection.

The outlook for those who are well motivated is excellent, and most men benefit from treatment whether for physical or psycho­logical causes.

KEY POINTS

• Seventy per cent of cases of erectile dysfunction have a physical cause

• If erection can occur spontaneously at any time, the cause is likely to be psychological

• Age should not prevent anyone from seeking help

• A variety of treatment methods is available

• The outlook for many men is excellent