Erectile Dysfunction (ED)?
ED is the inability to attain and maintain an erection sufficient for sexual activity.
Sexual activity is defined as cuddling, close physical contact, direct physical stimulation either alone or with a partner and NOT simply penetration.
How common is ED?
ED affects around 40% of men over 40 and increases with age. ED is more common in diabetes (75%), heart disease (60%), high blood pressure (65%), raised cholesterol (60%), prostate symptoms (70%) and depression (70%). It can often be aggravated by medications used to treat these conditions, especially anti-depressants, beta-blockers and diuretics such as bendrofluazide.
What causes ED?
ED is most commonly caused by conditions that block arteries such as smoking, diabetes, raised cholesterol and blood pressure. It can also be caused by conditions that affect the never supply to the penis, such as diabetes and multiple sclerosis. Prostate or urinary symptoms are commonly associated with ED. About 20% of men with ED have low levels of testosterone, suggested by reduced libido and loss of morning erections, and these men may require testosterone therapy. Most men worry about losing their erections and this “performance anxiety” can aggravate the problem. Rarely, this can be the major problem. Of course, men can have multiple causes at the same time. Recreational drug use and excessive internet pornography are important contributors to ED, especially in younger men.
Why is ED important?
Because the blood vessels supplying the penis are about 60% of the diameter of the coronary arteries in the heart, ED symptoms often occur 3-5 years before heart disease and represent an “early warning sign”. Rather than ignoring ED, as most men do, for up to 3 years, early medical assessment can diagnose important illness and prevent progression to serious cardiac events by addressing these factors in a timely manner. There is also evidence that frequent sexual activity, greater than twice per week, reduces the risk of heart disease. Although the medical profession is aware of the importance of ED, they are concerned that “asking the question” may be uncomfortable or embarrassing, but it is important for the man to tell the doctor or nurse that ED is important to them, rather than wait to be asked.
Symptoms of ED
In the early stages, men may be less able to maintain their erection and feel that they have to “rush” as they feel the erection going. In time symptoms may progress to inability to get an erection in the first place. The important message, is that the earlier the condition is treated, the better the results. Healthy men should have 2-3 episodes of erection on most mornings and these are important for the maintenance of healthy tissues in the penis. Loss of morning erections should be taken seriously and should prompt a medical consultation with a doctor or nurse.
ED and relationships?
Men do not like to fail, even occasionally, as they interpret it as a “loss of manhood”. The most common response is to withdraw from physical contact that might lead to sex. This usually takes the form of working longer hours or going to bed later. The partner interprets this response as meaning that “he no longer finds me desirable” or “he must be having another relationship”. The relationship can then deteriorate and either or both partners then wonder if “things might be better with somebody else”! Sexual problems in the partner will usually aggravate the problem. Having treated men with sexual problems for many years, I find myself usually trying to save a second marriage as the first one long since failed.
Lifestyle and ED
There is considerable evidence that stopping smoking, reducing (not stopping) alcohol, and taking moderate exercise 3 times per week improves erections, but benefits may take up to 2 years. Best results are seen in mild cases, not in men with established heart disease or type 2 diabetes, although improving lifestyle is still important. Medication for ED should always be combined with lifestyle change as this will enhance the effect and increase the chance of recovery. Pelvic floor exercises improve erections and enhance the control of ejaculation.
Should I be medically investigated if I have ED?
All men with ED should have diabetes excluded by a fasting glucose or HbA1c, plus cholesterol and lipids plus a morning testosterone level check. A simple questionnaire called a SHIM (Sexual Health Inventory for Men), takes 2 minutes to complete and assesses the severity of the problem and the possible changes with treatment.
Medical Treatment for ED
The availability of oral therapy termed Phosphodiesterase 5 inhibitors (PDE5i), initially as VIAGRA, has revolutionised the treatment of ED. These medications are taken 1-4 hours before sexual activity and require direct physical stimulation to work. Men may take 6-8 doses and, as with men in new relationships this might not be possible, so “testing” the first couple of doses with self-stimulation is highly recommended.
Do tablets work?
PDE5i works in around 70% of men and around 50% with type 2 diabetes. The more medical conditions, the higher the chance of failure. Trying a second or a 3rd “on-demand” tablet rarely solves the problem. A low daily dose of the long-acting PDE5i, tadalafil, can be effective in “saving” patients who have failed with “on-demand” medication and allow for spontaneous sexual activity and return of the morning erections that are very important for the health of the penis.
For some couples, and especially for men in new relationship, “orchestrated” sex is just not satisfactory, and low daily dosing is much more convenient, often meaning the difference between success and failure.
What does the NHS provide?
Only generic Sildenafil is available on NHS prescription and supplies are often illogically restricted to one tablet per week and 4 tablets maximum, based on a health and lifestyle survey created in the 1980s. GPs are currently banned from prescribing the low daily dose based on the historically high price, that no longer applies. The trend is for the NHS to be passing these so-called “lifestyle conditions” to pharmacists, which seems inappropriate given the association with important medical conditions. As these medications are now generic and inexpensive, many men would prefer assessment and prescribing from a route that avoids the difficulties of accessing treatment through the NHS.
What other treatments are available?
A range of other treatments are available through the Newson Health Men’s Clinic, including, injections, pellets, vacuum devices, testosterone therapy and even the latest shock wave treatments.