Erectile Dysfunction: Solutions and How to Get Help

Consultant Urological Surgeon and Andrologist

Dr Asif Muneer

IVI London

When it comes to discussing male fertility issues, the focus is normally on whether there is enough sperm, and the reasons as to why the sperm are unable to fertilise the egg. Now take a step back in the journey: in order to deposit semen at the cervix, couples must engage in regular sexual intercourse whereby ejaculation will result in semen being released into the vagina. In order to have penetrative intercourse, men need to have good erectile function. However, erectile dysfunction (often also termed impotence, or ED) is a common problem. The good news is that the vast majority of cases can be helped with medication and simple lifestyle changes. 

How common is erectile dysfunction?

If you are experiencing erectile dysfunction, you are certainly not alone. Erectile dysfunction affects more than 150 million men worldwide, and 50% of men between the ages of 40 and 70 will suffer from ED at some stage. In the UK, 1 in 5 men are affected by erectile dysfunction. Despite being common, it is often a taboo subject. For a long time men have been reluctant to discuss sexuality or sexual dysfunction with partners – or medical practitioners. When we add in the stress associated with subfertility as well as performance anxiety, it’s not surprising that we often meet young male patients, with no additional risk factors, who will only acknowledge that they’re suffering from erectile dysfunction when asked directly. 

Often through embarrassment, many individuals do not want to talk about the issue but it is extremely important to assess erectile function in men.  Not only is erectile function important for sexual function, but it can be a barometer for overall cardiac health. There are studies which indicate that men with ED are at higher risk for a cardiac event within 10 years. Therefore, it’s not a symptom to ignore. Increased accessibility to medication and readily available online resources have allowed more men to do their own research and seek help. Only when erectile dysfunction is addressed can a treatment be prescribed to meet your needs: it’s simply a case of acknowledging the problem and seeking advice. 

What causes erectile dysfunction?

There are lots of reasons why men may suffer from erectile dysfunction at some stage in life. Although it can develop more frequently with age, aging is not a direct cause of ED. The underlying issue may be physiological (‘organic’) or psychological (‘psychogenic’). However, there is considerable overlap between these two and vary rarely is it purely organic or purely psychogenic. 

Psychological issues

You may have a higher risk of suffering from erectile dysfunction if you are experiencing:

• Anxiety
• Depression
• High levels of stress
• Low self-esteem
• Fear or feelings of guilt about intimacy or sex
• Fear of sexual failure

If you are struggling with a psychological issue, there is no shame in asking for help. There are a number of therapies and prescribed medications that can offer some relief from the symptoms and prevent them from controlling your day-to-day life, which in turn can aid erectile function. Some medications, including certain anti-anxiety medication and antidepressants, can worsen sexual dysfunction. In order to prescribe the most appropriate treatment, it is important that your doctor is aware of any sexual issues you are facing.

Physiological issues

There are also a number of physiological or physical risk factors for erectile dysfunction including:

• Diabetes
• Smoking tobacco
• High blood pressure
• High cholesterol
• Obesity

The mechanism of penile erection involves dilatation of the blood vessels and smooth muscle in the penis to allow more blood to enter the penis. This results in an increase in the length and girth of the penis and therefore allows penetrative intercourse. Although this is a brief overview, the whole process is a complex neurovascular event: any damage to the nerves supplying the smooth muscle either due to neurological damage or diabetes, or conditions which cause damage to the smooth muscle, will impair the muscle relaxation.

Erectile dysfunction can often be a symptom of an underlying physical health problem. A number of studies have now shown that ED can be an early warning sign of heart disease, because it indicates small vessel disease which is then mimicked in the heart. Erectile dysfunction can also be caused by underlying hormonal issues. In this case, blood tests can normally identify any hormonal abnormalities, as well as any problems with cholesterol or other lipid disorders. If no underlying issues are found that could be contributing to erectile dysfunction, more invasive diagnostic tests can be performed including specialist ultrasonography to check the arterial inflow to the penis.

How is erectile dysfunction treated?

The good news is that the majority of ED cases can be helped with medication and lifestyle changes. Weight loss, pelvic floor exercises, stopping smoking and regular exercise can all improve erectile function. If medical treatment is required, there are a number of options for erectile dysfunction.

PDE-5 inhibitors

If medication and lifestyle changes do not solve the issue, an oral treatment using PDE-5 inhibitors can help. Over 80% of patients will have a response to medication such as sildenafil (Viagra) or tadalafil (Cialis). As one of the first PDE-5 inhibitors launched worldwide, Viagra is known universally. This was a landmark for the treatment of erectile dysfunction, but it also started to change sexual behaviour in society. Viagra helped men become more open to talking about the issue and seeking treatment. We have now moved forward to over-the-counter sildenafil being available in regular pharmacies, making it accessible to individuals who may not have sought treatment otherwise.

There isn’t much difference between PDE-5 inhibitors on the market, except the half-life of the drug. For more spontaneity, tadalafil is better as it has a longer half-life and stays in the system longer. That’s not to say the erection lasts longer, it just avoids having to plan ahead. Sildenafil must be taken an hour before sex on an empty stomach whereas tadalafil has no restriction.

Intracavernosal injections

In more severe cases, alternative treatment options include intracavernosal injections. This is medication injected directly into the side of the penis. Often men with diabetes or those who have had major pelvic surgery require this type of treatment. Of this group, men with prostate cancer requiring surgical removal of the gland or radiotherapy will often need intracavernosal injections. Despite it appearing painful, the needle used to inject the drug is of a very small calibre. One of the risks that patients should always be aware of is the development of a prolonged erection (priapism) where the erection remains for more than 4 hours. Your doctor will be able to provide instructions on what to do if this occurs.

Penile prosthesis

In cases where medication fails, there is a surgical option. A penile prosthesis is an hydraulic device inserted into the penis, controlled by a pump in the scrotum. This inflates and deflates the device. Although the tissues in the penis are replaced by the cylinders, orgasm and ejaculation should be maintained post-operatively. This is an excellent surgical solution for end stage erectile dysfunction. The main risk is infection of the device but the risk is very low in high volume centres.

Help is always available

If couples are not engaging in sexual intercourse regularly due to erectile dysfunction, then this can be a reversible cause for subfertility. Seeking advice from your general practitioner or a specialist can often detect underlying risk factors and offers an opportunity to change your lifestyle to reduce long term risks. Men don’t have to live with erectile dysfunction – there’s always a solution. At IVI, we have male fertility specialists who can help you achieve your goal if you wish to build your family and become a parent. If you would like to request more information or book an appointment, please contact us.