Erectile Dysfunction – The Basics

What is erectile dysfunction?

Erectile dysfunction (ED), sometimes called impotence, means having repeated difficulty getting or keeping an erection that is firm enough for satisfying sex.

Almost every man has the occasional "off night" – after too much alcohol, when tired, stressed or unwell. That is normal and is not ED. Doctors usually talk about ED when the problem happens on most occasions, or has been going on for several months.

ED is very common:

• Around half of men aged 40 to 70 have some degree of erection difficulty

• It becomes more common with age, but it is not an unavoidable part of getting older

• Younger men are affected too, often because of stress, anxiety or lifestyle

How does a normal erection work?

An erection is a team effort between the brain, nerves, blood vessels, hormones and the muscle inside the penis.

• Sexual thoughts or touch send signals from the brain along the nerves to the penis

• These signals release chemicals that relax the smooth muscle inside two spongy tubes running along the penis (the corpora cavernosa)

• The arteries widen and blood rushes in, filling the spongy tissue like a sponge filling with water

• As the tissue swells, it squeezes the small veins that normally drain blood away, trapping the blood so the penis stays firm

• After orgasm (or when arousal fades), the muscle tightens again, the veins open and the penis softens

If any part of this chain is not working properly, erections can be affected.

What causes erectile dysfunction?

In most men there is more than one cause. The main groups are:

Blood vessel (vascular) causes – the most common

• Narrowing and hardening of the arteries, the same process that causes heart attacks and strokes

• High blood pressure

• High cholesterol

• Smoking

• Being overweight and inactive

Diabetes

• Diabetes affects both the blood vessels and the nerves

• Men with diabetes are around three times more likely to develop ED, and often at a younger age

Hormonal causes

• Low testosterone

• Less commonly, thyroid problems or a raised prolactin hormone

Nerve causes

• Surgery for prostate, bladder or bowel cancer

• Pelvic radiotherapy

• Spinal cord injury, multiple sclerosis or Parkinson's disease

Medicines

Some medicines can affect erections, including some blood pressure tablets, antidepressants, prostate tablets (5-alpha reductase inhibitors such as finasteride), and hormone treatments. Never stop a prescribed medicine on your own – talk to your doctor, as there is often an alternative.

Lifestyle

• Heavy drinking

• Recreational drugs, including cannabis and anabolic steroids

• Long-distance cycling on a hard saddle in some men

Psychological causes

• Performance anxiety, stress, low mood and relationship difficulties

• These are particularly common in younger men

• Even when ED starts for a physical reason, worry about "failing" again often makes it worse – a cycle that treatment can break

Problems with the penis itself

• Peyronie's disease (a scar plaque causing a bend in the erect penis)

• Scarring after previous priapism (a prolonged erection) or injury

Physical or psychological – how can you tell?

Some clues point towards a psychological cause:

• The problem started suddenly, perhaps at a stressful time

• You still wake up with firm morning erections

• Erections are fine when alone but not with a partner

Some clues point towards a physical cause:

• The problem came on gradually over months or years

• Morning erections have become rare or weak

• You have diabetes, heart disease, high blood pressure or you smoke

In reality, many men have a mixture of both, and a proper assessment is the best way to find out.

Why ED matters for your general health

ED is not just a quality-of-life problem. Because the arteries in the penis are smaller than those in the heart, they often show signs of narrowing first. ED can appear several years before a heart attack or stroke.

For this reason, every man with ED should have his heart risk factors checked – blood pressure, cholesterol and blood sugar. Treating these, stopping smoking and becoming more active protects your heart and can also improve erections.

When should I seek help?

• Erection problems happening most of the time, or for more than a few weeks

• Tablets you have bought have not worked

• ED together with low sex drive, tiredness or reduced body hair

• A new bend, lump or pain in the penis

• An erection lasting more than 4 hours – this is an emergency (go to A&E)

ED is a medical condition, not a personal failing. It is one of the most treatable problems in urology.