Erectile difficulty, and what it is telling you

Erectile difficulty is one of the few conditions where the embarrassment is inversely proportional to the difficulty of treatment.

How common it is

Prevalence rises steadily with age, and population studies find substantial rates from the forties onward, with occasional difficulty being close to universal across a lifetime.

Occasional failure after alcohol, exhaustion, stress or in a new situation is a normal event and not a condition.

The clinical definition involves persistent difficulty achieving or maintaining an erection sufficient for satisfactory sexual activity, over a period of months.

Why it matters beyond sex

The point that turns this from an embarrassing subject into an important one.

An erection is a vascular event, dependent on healthy blood vessels and endothelial function.

The penile arteries are smaller than the coronary arteries, which means that endothelial dysfunction shows there first.

Cohort studies have consistently found erectile dysfunction preceding cardiovascular events by a period of years, and current guidance treats new erectile dysfunction in a middle-aged man as an indication to assess cardiovascular risk — blood pressure, lipids, glucose, weight, smoking.

Which is why the appointment is worth attending even for someone who is not troubled by the symptom itself.

The causes

Usually more than one at a time.

Vascular: atherosclerosis, hypertension, diabetes, metabolic syndrome, smoking.

Diabetes is particularly strongly associated, through both vascular and nerve mechanisms.

Neurological: spinal injury, multiple sclerosis, pelvic surgery including prostate surgery.

Hormonal: low testosterone, thyroid disease, raised prolactin — a minority of cases but worth excluding.

Medication: some antihypertensives, several antidepressants, antipsychotics, finasteride and others.

This is a common and reversible cause and is worth reviewing before anything else is assumed.

Psychological: anxiety, depression, relationship difficulty, and performance anxiety, which is self-sustaining — one failure produces anticipation, and anticipation produces sympathetic arousal, which is physiologically the opposite of what an erection requires.

Lifestyle: alcohol, recreational drugs, sedentary behaviour, obesity, poor sleep, and sleep apnoea specifically.

Distinguishing the type

A useful rough guide.

Gradual onset, absent morning erections, difficulty in all situations, and other vascular risk factors point towards a physical cause.

Sudden onset, preserved morning and solo erections, difficulty only with a partner or only in certain situations, and a clear precipitating event point towards a predominantly psychological component.

Both frequently coexist, since a physical cause reliably produces performance anxiety on top.

Treatment

Effective, and stepwise.

Address the modifiable causes: smoking, weight, exercise, alcohol, sleep, glycaemic control, and review of medications with the prescriber rather than unilaterally.

Exercise in particular has good trial evidence for improving erectile function, with aerobic activity showing meaningful effects.

Oral medications of the PDE5 inhibitor class are first-line, work in a large majority, and require sexual stimulation to work — a fact frequently not explained, which leads people to conclude the tablet has failed.

They are contraindicated with nitrates, which is the critical safety point.

Where oral treatment is unsuitable or insufficient, options include vacuum devices, intracavernosal injections, urethral preparations and, ultimately, surgical implants, all of which are effective.

Psychosexual therapy is effective, particularly where anxiety maintains the problem, and combining it with medication outperforms either alone in several trials.

Testosterone

Worth a specific note because of how it is marketed.

Testosterone treatment helps where there is genuine, confirmed deficiency diagnosed on repeated morning samples alongside symptoms.

It is not an effective treatment for erectile dysfunction in men with normal levels, and the online market selling it as a general vitality product is operating well outside the evidence.

It also suppresses fertility, which is frequently not disclosed.

Buying medication online

A serious safety issue rather than a moral one.

Analyses of counterfeit erectile dysfunction medication have repeatedly found wrong doses, wrong ingredients and contaminants.

Legitimate online pharmacy services exist in many countries with a proper consultation, and these are a reasonable route for anyone who will not attend in person.

What is not reasonable is buying an unregulated product to avoid a conversation that also happens to be a cardiovascular assessment.

General information only, not medical advice. Consult a qualified clinician — do not take PDE5 inhibitors with nitrates, and do not buy prescription medication from unregulated sources.