Erectile Dysfunction

What is Erectile Dysfunction?

Erectile dysfunction (ED), also known as impotence, is the inability to achieve or maintain an erection firm enough for satisfactory sexual activity. For a diagnosis of ED, this condition typically needs to persist for six months. ED is a common issue affecting millions of men, with its likelihood increasing with age. Certain health conditions also elevate the risk. In the U.S., an estimated 12 million men experience ED.

What causes Erectile Dysfunction?

There are several types of ED. Each type depends on different causes. These include physical and psychological factors.

Vascular ED

Vascular ED is the most common type. It occurs due to poor blood flow to the penis. This can happen due to:

• Arterial insufficiency: Narrow or blocked arteries reduce blood flow. Risk factors include high blood pressure, diabetes, and smoking.
• Venous leakage: Blood leaks from the penis too quickly, preventing a sustained erection.

Neurogenic ED

Neurogenic ED occurs when nerves involved in erections are damaged. This can result from:

• Spinal cord injuries
• Neurological conditions like Parkinson’s disease or multiple sclerosis
• Surgery in the pelvic area
• Diabetes, which can damage nerve function

Neurogenic ED reduces nitric oxide in the penis. This affects smooth muscle function and can lead to structural changes.

Hormonal ED

Hormonal ED arises from hormonal imbalances. Low testosterone is the most common cause. Other issues include:

• Ageing, which reduces testosterone levels
• Testicular dysfunction
• Pituitary gland problems

Other hormones, like thyroid and growth hormones, may also play a minor role.

Psychogenic ED

Psychogenic ED stems from psychological issues. It is often linked to:

• Performance anxiety
• Stress or depression
• Relationship problems

This type often involves high levels of noradrenaline, which can prevent erections. Treating psychological factors is crucial for recovery.

Additionally, this sexual dysfunction can also stem from

• Medications

Blood pressure drugs, antidepressants, and certain painkillers can cause ED.

• Lifestyle Factors

• Smoking damages blood vessels, reducing blood flow.
• Excessive alcohol can lower testosterone and harm erectile function.
• Obesity and poor diet increase the risk of ED. Lack of exercise can also contribute.

What Is The Relationship Between Erectile Dysfunction And Age?

The prevalence of ED varies by age and overall health. Studies show that approximately 9% of men aged 40–44 and up to 56% of men over 65 report moderate or complete ED. 

Research such as the Massachusetts Male Aging Study (MMAS) found that 52% of men aged 40–70 experience mild to moderate ED, influenced by age, physical health, and emotional well-being. 

Similarly, the European Male Aging Study (EMAS) reported ED rates ranging from 6% to 64% in men aged 40–79, with an average prevalence of 30%.

Interestingly, ED is not limited to older men. One in four men seeking medical help for ED is under 40, and 22.1% of men in this age group scored low on the Sexual Health Inventory for Men (SHIM), indicating significant ED prevalence. 

For younger men, psychological factors such as stress, anxiety, or performance pressure often play a major role. However, in men under 55, ED may also indicate underlying health issues like diabetes or heart disease.

In addition to its impact on sexual function, ED is often linked to systemic endothelial dysfunction. This connection makes it a potential early warning sign for cardiovascular diseases, underscoring the importance of medical evaluation and timely treatment.

What Are The Symptoms of ED?

Symptoms vary based on the cause.

• Psychogenic ED Symptoms: Sudden onset, inconsistent erectile function, and normal nocturnal erections. Response to ED medication is usually positive.
• Organic ED Symptoms: Gradual onset, persistent poor function, and better erections when standing (in cases of venous leakage).

A medical evaluation can identify the underlying cause of symptoms.

How Is Erectile Dysfunction Diagnosed?

Diagnosing ED requires a full medical history and physical examination. Doctors may conduct tests to find the cause.

Specialists Who Diagnose ED

1. General Practitioners (GPs): They conduct initial assessments and order basic tests.
2. Urologists: They specialise in male reproductive health and urinary issues.
3. Endocrinologists: They diagnose hormonal problems.
4. Cardiologists: They check for heart-related causes.
5. Neurologists: They assess nerve-related conditions.
6. Psychologists: They address stress, anxiety, or other mental health factors.

ED often signals broader health issues. Early diagnosis can improve sexual health and overall well-being.

Diagnostic Process

• Medical and Sexual History: A detailed history helps the doctor understand the nature of ED, its onset, severity, and potential contributing factors. Key aspects include:

1. 1. • Erectile function: Frequency, quality, and duration of erections.

      • Sexual activity: Types of sexual activities, presence of desire and arousal.

      • Medical history: Chronic diseases (e.g., diabetes, hypertension, heart disease), surgeries, medications.

      • Lifestyle: Smoking, alcohol consumption, exercise habits, diet.

      • Psychological health: Stress, anxiety, depression, relationship issues.

• Physical Examination:

1. 1. • Assessment of overall health and vital signs.

      • Examination of the genitals for abnormalities.

      • Evaluation of secondary sexual characteristics (e.g., body hair distribution, testicular size).

• Laboratory Tests:

1. 1. • Blood glucose: To check for diabetes.

      • Lipid profile: To assess cholesterol levels and cardiovascular risk.

      • Hormonal tests: Testosterone levels (especially in older men).

      • Other tests include prolactin and thyroid hormones, depending on the case.

• Specialised Tests (if needed):

1. • Penile Doppler Ultrasound (PDDU): Assesses blood flow in the penis.

   • Nocturnal Penile Tumescence and Rigidity Testing (RigiScan): Monitors erections during sleep to distinguish between physical and psychological causes.

   • Neurological Tests: Evaluate nerve function in the pelvic area.

   • Psychological Evaluation: Identifies psychological contributors to ED.

What Treatments Are Available For Erectile Dysfunction?

The choice of treatment depends on the underlying cause, severity of ED, and patient preferences. Treatment typically includes lifestyle changes, medical interventions, and addressing psychological factors.

Lifestyle Modifications

• Weight Management: Losing even a small amount of weight can improve erectile function.

• Regular Exercise: Enhances blood flow and cardiovascular health.

• Healthy Diet: A balanced diet rich in fruits, vegetables, and whole grains promotes vascular health.

• Smoking Cessation: Quitting smoking can improve erectile function.

• Moderate Alcohol Consumption: Reducing excessive alcohol intake benefits erectile function.

Medical Interventions

• Oral Phosphodiesterase Type 5 Inhibitors (PDE5i):

1. 1. • Sildenafil (Viagra): Effective within 1-2 hours; lasts 3-5 hours; best taken on an empty stomach.

      • Tadalafil (Cialis): Onset in 2-4 hours; lasts up to 36 hours; unaffected by food; available for daily use.

      • Vardenafil (Levitra): Similar to sildenafil; peak effect in 1-2 hours; lasts 3-5 hours.

      • Avanafil (Stendra): Onset within 30-45 minutes; lasts about 6 hours; food does not affect absorption.

• Alprostadil:

1. 1. • Administered via injection or intraurethral suppository.

      • Promotes blood flow and erection by relaxing penile blood vessels.

• Vacuum Erection Devices (VEDs):

1. 1. • Create a vacuum around the penis to draw blood into the erectile tissues.

      • Use a constriction ring to maintain the erection.

• Penile Implants:

1. • Surgical option for severe ED unresponsive to other treatments.

   • Types: Inflatable or semi-rigid prostheses.

Addressing Psychological Causes

• Psychotherapy or Sex Therapy:

  • Cognitive-behavioural therapy (CBT) and counselling for performance anxiety, relationship issues, or stress.

  • Sensate focus exercises to improve intimacy.

• Addressing Underlying Psychological Issues:

  • Managing depression, anxiety, or stress through therapy and relaxation techniques.

  • Enhancing self-confidence and communication with partners.

Comparison of ED Treatments

What Are The Methods For The Prevention Of Erectile Dysfunction?

• Maintain Cardiovascular Health: Control blood pressure, cholesterol, and diabetes.

• Adopt a Healthy Diet: Focus on fruits, vegetables, whole grains, and lean protein.

• Exercise Regularly: Engage in moderate-intensity activities.

• Quit Smoking: Improves vascular health and reduces ED risk.

• Manage Stress: Practice mindfulness, meditation, or therapy.

• Routine Checkups: Early detection of underlying conditions like hypertension or diabetes.

• Sleep Quality: Ensure adequate and quality sleep.