NOTE: Some of the information provided contains graphic, medical images which individuals may find upsetting
What is erectile dysfunction?
Erectile dysfunction (impotence) is defined as an inability to obtain or maintain an erection sufficient for penetration and for the satisfaction of both sexual partners.
What should I do if I have problems with impotence?
Erectile dysfunction can be caused by many factors and may have a gradual or sudden onset. It can be very upsetting and result in a lot of stress and worry. It can feel embarassing to discuss this with your doctor but it is important that you do, so that you can receive the appropriate help. Erectile dysfunction can also be a sign of other illnesses such as heart disease or diabetes, so it is important that you seek medical advice.
What are the facts about impotence?
- Erectile dysfunction 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;
- Investigation is only indicated if both partners wish to pursue treatment;
- 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 medication proves ineffective, causes side-effects or cannot be used because of specific medical conditions.
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for men with erectile dysfunction (impotence). This will normally include some or all of the following:
A full history
Your GP will take a detailed sexual history to determine why your erections are failing and under what circumstances you are having sexual difficulties. You will also be asked about lifestyle factors (e.g. your job, work pressures, smoking habits, exercise, diet, alcohol intake and drug consumption). It is also normal to ask about your sex drive (libido), whether you still get night-time or early-morning erections and whether your partner is also concerned about your difficulties and whether or not your relationship is being affected.
You will also be asked a detailed past medical and surgical history as you may have other medical conditions which may be contributing to your erectile dysfunction. It is important to tell your GP about other symptoms such as pain, premature ejaculation (uncontrolled ejaculation before or immediately after penetration) or symptoms of prostatic obstruction because they are often associated with erectile dsyfunction.
Your GP may help you to complete a symptom questionnaire. The most commonly used are the International Index of Erectile Function and the Sexual Health Inventory for Men. They are generally used as aids to further assessment and to find a focus for the discussion of treatment options.
Using these questionnaires will help your GP to:
- understand your needs & expectations;
- identify the most suitable treatments;
- help you & your partner share in decision-making; and
- decide whether psychosexual counselling might be helpful.
A physical examination
A general physical examination will be performed to assess the development of your male sexual characteristics and to detect any abnormality of your penis or testicles. Your blood pressure, height and weight will normally be measured as part of this examination.
The pulses in your legs will normally be assessed and the nerve reflexes involving your legs, and your penis or anus (back passage). Rectal examination (pictured) may be performed to assess the tone of your anal muscles and to feel your prostate gland.
The usual tests performed are:
a. General blood tests
The tests performed will be left to your doctor's discretion. It is common to measure kidney function, liver function, cholesterol, as well as checking your blood cells for anaemia or other problems. A fasting blood sugar measurement will be performed to exclude diabetes. A PSA (prostate specific antigen) blood test may also be carried out if necessary.
b. Routine urine tests
Your urine will normally be tested to see whether it contains sugar (which might indicate diabetes), or blood (which may be a sign of infection or require further investigation).
c. Hormone measurements
Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones will normally be measured.
d. Other specific tests
Other tests, if indicated, are normally arranged by the urology specialist clinic and will be discussed with you.
What could have caused my impotence?
90% of men with impotence (erectile dysfunction) have at least one underlying physical cause for their problem
A psychological component, often called "performance anxiety", is common in men with impotence. However, 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:
- Cardiovascular 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%; and
- Anatomical abnormalities in 1-3% (e.g. tight foreskin, short penile frenulum, Peyronie's disease, inflammation, penile curvature).
What treatments are available for this problem?
Treatment is only indicated if both partners are troubled by the impotence and they have realistic expectations of what can be achieved by any treatment
Improvements in your lifestyle, such as a eating healthy diet, reducing alcohol intake, losing weight and increasing your exercise can dramatically improve erectile dysfunction. More specific treatment usually involves:
- weight loss and increased exercise (this may reduced the risk of erectile dysfunction by up to 70%)
- treatment of any hormone abnormality (testosterone treatment is only indicated if your testosterone levels are low and may be harmful if your the levels are normal);
- lifestyle modification (e.g. reduce stress, stop smoking, reduce alcohol consumption & stop illicit drugs);
- treatment of any anatomical abnormality if present (e.g. circumcision, frenuloplasty, penile straightening);
- psychological support if necessary.
First line treatment will be medication with a phosphodiesterase inhibitor such as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) or avanafil (Spedra). These drugs only work when used together with sexual stimulation and will have no effect on your sex drive. There is no evidence that these drugs are dangerous if you have underlying heart disease. However, they should not be used if you are taking nitrates (e.g. GTN, isosorbide) for angina
Download an information leaflet about Viagra, Cialis or Levitra.
Your GP will arrange a re-assessment after an initial period of drug usage. If the drugs prove ineffective, there are significant side-effects (seen in 15%) or they cannot be used, other measures may need to be considered. This will entail referral to your local Erectile Dysfunction Clinic where the available treatments include:
Penile injections to produce erections
Self-administered injections of prostaglandin E1 (Caverject® or Invicorp®) provide a simple means of obtaining a natural erection. You will be taught how to administer the injections (pictured) and told what to do in the event of problems such as an erection which will not go down.
Download an information leaflet about self-injection.
Medicated urethral system for erection (MUSE)
MUSE offers an alternative route for administration of prostaglandin using a small pellet inserted using an applicator into the tip of the urethra (water pipe opening). Once massaged the prostaglandin is released and helps the blood to flow into the penis to gain an erection. Some men experience a mild burning sensation afterwards in the water pipe but this is a good alternative option for men who do not like the idea of using injection therapy.
Vacuum erection assistance devices (VEDs)
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 (pictured). Ejaculation may be restricted by the ring but this technique is simple, safe and has no known side-effects. Unfortunately, most patients have to purchase VEDs themselves.
Download an information sheet about vacuum erection assistance devices.
If you have a blockage of one of the larger arteries supplying the area of the pelvis or penis then microsurgical reconstruction of the arteries or anangioplasty to re-establish erections may be indicated. The blockage in these situations normally follows traumatic injuries to the pelvis.
Insertion of a penile prosthesis (implant) (pictured) is an end stage solution when all other treatment options have failed. It involves a surgical procedure through a small incision in the junction between the penis and scrotum. Patients go home the following day if the procedure is uncomplicated, and the prosthesis can be used for sexual intercourse at 6 weeks following the operation. Complication rates are low in centres that conduct the surgery in large numbers. The risk of infection is <2% and over 85% of the devices are still functioning at 10 years.
Download an information leaflet about penile prostheses.