Erectile Dysfunction (ED)

Erectile dysfunction is also commonly referred to as impotence. ED is a disorder that is not sexually transmitted, and that increases with age. It is felt that ED affects less than 5% of sexually active men in their fourth decade and climbs to approximately 60% of men in their seventh decade of life. When ED occurs in young men, there is frequently a strong psychological component to its origin. Psychologically related ED may be more prevalent in young gay/homosexual men who are coming to terms with their sexuality.

What is erectile dysfunction? ED is the inability to achieve and/or maintain a quality erection for fulfilling sexual activity. An erection must be stiff or tumescent enough to be able to penetrate the mouth, vagina or anus. It is important to note that anal penetration requires a more turgid penis (stiffer erection) as the penis must penetrate the strong anal sphincter muscles. When impotence occurs solely in the face of anal penetration, this is a particular form of ED. In some forms of ED, the man is able to achieve erection and penetrate, yet loses his erection as coitus and climax are pursued.

How common is erectile dysfunction?

ED is estimated to affect anywhere from 2 to 3 million men in Canada.

What causes erectile dysfunction? Erectile dysfunction may be due to purely psychological causes; anxiety, stress, a new sexual partner, a new sexual situation, depression etc. This form of ED is much more prevalent in the sexually active 20 to 40 year old male population. At times one episode of erectile dysfunction leads to a certain "anticipatory anxiety" that the problem experienced once may become recurrent. The performance anxiety can be such that it becomes a self-fulfilling prophecy – no erection or a poor quality erection.

When the cause is physical, your physician will pursue tests and appropriate treatment.

Vascular (blood vessel) problems - most common physical cause

This is due to narrowing of the vessels – the pipes can’t fill properly with blood and so erections are less than impressive. The disorder is called atherosclerosis (narrowed blood vessels) and is commonly associated with smoking, diabetes, high blood pressure and elevated cholesterol (often lifestyle issues).

Nervous system problems - There is a crucial communication between your brain (desire and/or stimulation) via the spinal cord to the genitals. In the event of poor communication – erections are disabled. Nervous system damage may result from disease; diabetes, multiple sclerosis, stroke, etc. Damage may be traumatic as with spinal cord injury or pinching of nerves from slipped vertebral discs. Any procedure that may compromise the genital nerve may perturb erectile capacity (i.e. prostate cancer surgery).

Hormonal disorders – particularly low testosterone levels. The importance of anabolic steroid drug use must not be underestimated – the use of anabolics sends a message to your own brain-testes hormone production cycle to shut down. This dysfunction may be temporary or permanent. Thyroid disease (responsible for thyroid hormone – implicated in metabolism and energy levels) may also be responsible in some men. Low testosterone levels are much more prevalent in men with HIV/AIDS and even moreso in those taking anti-retrovirals (anti-HIV medications). This leads us to the section on chemical causes of ED;

Legal and illegal drugs – if your problems start subsequent to the initiation of a new medication or drug – talk with your physician. There are many classes of medications which are responsible for erectile dysfunction, go over them all with your physician. Erectile dysfunction may be secondary to recreational drug and/or alcohol consumption. Remember, alcohol is a stimulant in its early phase, leading to disinhibition. This phase is rapidly followed by its "depressant" phase, whereby alcohol impedes erectile function. Tobacco also has its own direct influence on erectile dysfunction – one of the first steps in addressing ED should be the cessation of smoking!!

What are the symptoms of erectile dysfunction?

• The inability to achieve erection
• The inability to maintain an erection up to and through climax
• The inability to penetrate your partner (loss of erection with penetration or decreased stiffness with penetration)

How is erectile dysfunction diagnosed?

In order that erectile dysfunction may be diagnosed, you have to "bring it up". Talk with your physician – your erectile dysfunction is not obvious to anyone outside of your sexual partner(s). Once addressed, your physician will likely conduct a detailed history and physical examination in an attempt to elucidate the potential causes of your ED.

Typical investigations in the work-up of ED:

• Blood sugar
• Cholesterol
• Blood pressure
• Hormonal levels (particularly testosterone)
• Genital examination
• Inguinal pulses (blood vessels in the groin)
• Neurological evaluation
• Medication history
• Recreational drug history
• Alcohol use and/or abuse
• Tobacco history

At times the baseline work-up may be entirely negative or normal. It is at this point that your physician may refer you to a specialist or urologist. The use of nocturnal penile tumescence testing helps to differentiate physical causes of ED from psychological causes. There are low and high tech methods that document the presence and frequency of erections while you sleep. One method is a penile strap attached to the flaccid (limp) penis at bedtime. If the band is broken upon rising, then an erection is recorded. The typical number of nocturnal erections is three to four per night. A simple evaluation is the presence or absence of morning erections (piss hard-on). When present in the face of sexual difficulties, the problem is likely psychological.

How can I prevent the onset of erectile dysfunction?

As in many aspects of good health, lifestyle issues need to be addressed early on. A well balanced diet helps to prevent high cholesterol, high blood pressure and obesity. Regular exercise helps to prevent the physical risk factors for ED, as does smoking cessation and moderation in the face of alcohol consumption. In the face of disease, consult your physician and pursue control of lifestyle related problems.

Did we already mention that you should quit smoking? Oh yeah, and chill out! Stress is not conducive to a healthy erection – try to manage your stress in a constructive manner.

How is erectile dysfunction treated?

There are several options available to the man suffering from ED. Speak with your physician as to the medication/approach best suited to you.

Drugs called PDE5 inhibitors (available in Canada under the trade names Viagra-sildenafil, Cialis-tadalafil and Levitra-vardenafil hydrochloride) help a man achieve and maintain an erection. With sexual stimulation, these drugs increase blood flow to the penis, allowing an erection to occur naturally. These drugs will not work if the nerves that control erection are removed or damaged due to injury or subsequent to surgery (radical prostate surgery). If nerves are damaged, penile implants can be used. They can be used safely in most men with diabetes, including select elderly men. However, they are not safe for men with certain heart conditions or men who take nitrates (which are often used to treat angina). Use of PDE5 inhibitors should be discussed with your physician.

It is important for sexual partners to be involved in any discussion about treatment choices.

For men who can't take PDE5 inhibitors or find that they don't work, other options include other drugs, injections, hormone replacements, mechanical devices such as vacuum constriction devices, implants and surgery.

It also makes sense (for many health reasons other than ED) to keep your blood glucose, blood pressure and cholesterol in the target range, to quit smoking and start exercising. These will all lead to better overall health and, in turn, better sexual health.

Did we mention QUIT SMOKING?!

How do PDE5 inhibitors work? 

The use of PDE5 inhibitors prior to sexual activity permits the vascular caverns of the penis to relax – the vessels widen and dilate with blood. This hardening compresses the veins at the base of the penis and thereby prevents efflux of blood from the penis – an erection! (Nerves and vessels must be intact). Successful erection with PDE5 inhibitors requires sexual stimulation, it is not magic! The effect of the medication varies from one man to the next but typically lasts for up to 4 hours. The effects of the medication may be slowed if taken with a large meal and/or alcohol. Side effects may occur but are rarely troubling – discuss these with your doc. The evaluation by your physician prior to starting a PDE5 inhibitor is important to ensure that your heart is able to handle the extra stress imposed by sexual relations.

It is important to avoid the combination of PDE5 inhibitors and medications that contain nitrates. Amyl nitrate also known as "poppers" should not be used in combination with PDE5 inhibitors, as pronounced and even dangerously low blood pressure levels have been reported.

Other erectogenic medications (erection provoking) – other oral medications include;

• Yohimbine (better than placebo)
• Trazodone (not much better than placebo + lots of side effects)
• Phentolamine (better than placebo)

Direct agents:

Alprostadil as an injection into the penis or as a suppository (intra-urethral). This latter approach is called "medicated urethral system for erection" or MUSE. These direct approaches cause direct relaxation of the vessels and may provoke erection in the absence of sexual stimulation.