Erectile dysfunction

You are not alone

Erectile dysfunction is the inability to get or keep an erection firm enough for sexual activity. It is very common: studies suggest around 40% of men in their 40s, and up to 70% of men in their 70s, will have some degree of erectile dysfunction at some stage. Despite this, many men do not seek help, which is unfortunate because there are several good treatments.

It can be a useful warning sign

Erectile dysfunction can be a marker of other things going on in the body, particularly with the blood vessels and the heart. For this reason it is treated as a "sentinel" event - a sign to also look for things like high blood pressure, diabetes, high cholesterol, and hormone imbalance, all of which can be helped if they are picked up.

What is checked

Initial assessment usually involves:

• A general medical examination, including pulses, the testicles and the prostate.
• Blood tests - general bloods, blood sugar, cholesterol.
• Hormone tests - testosterone, SHBG, prolactin, FSH, LH, and thyroid.

Psychological factors are common too. Stress, relationship issues, and anxiety can all play a role - sometimes counselling alone, or in combination with medication, is enough.

Treatments, in order of how they are usually tried

1. Tablets (PDE5 inhibitors). These prescription medications have transformed the treatment of ED. They are usually taken half an hour to an hour before sexual activity, and you still need to be in the mood for them to work. Side effects are uncommon and usually mild (indigestion, nasal stuffiness, occasional headache). They must not be combined with nitrate heart medications. One of these tablets can also be taken at a low daily dose, which suits some men better than on-demand use.
2. Vacuum pump. A device is placed over the penis, a vacuum is created, blood is drawn into the penis, and a soft band is then slid onto the base. There is a one-off cost, the result is reproducible, and there are no medications. The trade-off is a slight "hinge" effect because only the outer part of the erection tissue is engaged.
3. Penile injection therapy. A small amount of medication (prostaglandin or a triple-mix) is injected with a tiny insulin-style needle into the side of the penis. It works in 5 to 10 minutes and lasts roughly half an hour to an hour. It feels daunting at first but most men find it surprisingly easy. Possible side effects are local scarring (reduced by rotating the injection site), and rarely a prolonged erection (priapism), which needs urgent attention if it does not settle - go to an emergency department.
4. Penile prosthesis (implant). If the steps above do not give a satisfactory result, a penile implant can be a very good option. See the short version: surgery for erectile dysfunction.