Erectile dysfunction can cause a high degree of emotional and social distress but depending on the cause, may be treatable and manageable
Erectile dysfunction (ED) is one of the most common presenting problems in men, particularly if they are in middle age. A 2019 study stated that in the US, regular and chronic ED increases with age from ~35% of men aged 60, to ~50% of men older than 70 being affected. Apart from the obvious relationship problems this can cause, it can have a knock-on effect on a man’s mental health and self-esteem.
According to the HSE, common causes of ED can include tiredness; stress; anxiety; and excessive alcohol consumption. However, in some cases it can be caused by an underlying condition that requires medical attention. The National Institutes of Health states that the conditions that can cause ED include:
- Type 2 diabetes.
- Heart and blood vessel disease.
- Atherosclerosis.
- High blood pressure.
- Chronic kidney disease.
- Multiple sclerosis.
- Peyronie’s disease (a condition in which plaque forms under the skin of the penis).
- Injury from treatments for prostate cancer, including radiation therapy and prostate surgery.
- Injury to the penis, spinal cord, prostate, bladder, or pelvis.
- Surgery for bladder cancer.
- Priapism (penile inflammation), relationship problems and depression have also been implicated as risk factors for ED. Whilst ED itself can be a simple diagnosis to make, the causes can be highly multifactorial and may also require psychological support.
A study published in 2012 that was specific to Ireland showed that ED has a particular impact on perceived quality of life and sometimes, it can be a sentinel marker of cardiovascular disease. The authors collected data from the Irish Study of Sexual Health and Relationships (ISSHR) and surveyed men aged 18-to-64, who were asked questions about sexual problems which lasted for at least one month in the past five years of their lives.
SEXUAL DYSFUNCTION
The authors wrote: “Male sexual dysfunction [MSD] has a high prevalence in the Irish population. Predictors of MSD, such as past STI infections, could help healthcare providers detect the patients most likely to experience MSD. More research is required on the epidemiology of, and risk factors associated with, anorgasmia and dyspareunia. Understanding the prevalence of and factors associated with sexual problems will improve the provision of care and support available.”
In the study, whilst marital status and fertility were found to have no significant association with sexual dysfunction, at least one MSD was detected in 49.6 per cent of men who participated. Erectile dysfunction was reported by 15.4 per cent of men, while premature ejaculation by reported by 24.4 per cent of men. Dyspareunia (painful intercourse) and anorgasmia (difficulty having an orgasm after plenty of sexual stimulation) both had a higher than expected prevalence of 16.1 per cent and 14.9 per cent, respectively. The most common sexual problem was low sexual desire, which had a prevalence of 30.2 per cent. Marital status and fertility were found to have no significant association with MSD; however, a previous STI and having had first sexual intercourse at a young age (especially 16 years or younger) were both associated with an increased prevalence of MSD.
TREATMENT OPTIONS
Sometimes, lifestyle changes can have an effect on the severity of ED. These include: Smoking cessation; losing weight (if overweight); an improved diet; daily exercise; and dealing with stress and anxiety. The HSE also recommends to avoid cycling for more than three hours per week, as cycling can damage nerves and compress arteries in the penis if done excessively. The Executive also recommends limiting alcohol intake to less than 17 standard drinks a week. Patients should be given counselling as to risk factors that can exacerbate their ED.
If the patient has no underlying medical conditions, oral medications are the most common and trusted treatment for ED and are the first line of treatment for ED refractory to lifestyle modifications.
In terms of physiology and how these medications work: An erection starts with nerve stimulation, which releases nitric oxide (NO) — this then stimulates guanylate cyclase (GC), which converts guanosine triphosphate (GTP) into cyclic guanosine monophosphate (cGMP). cGMP then induces smooth muscle relaxation — this allows for flow of blood into the penis and the subsequent erection. The molecule PDE5 breaks down cGMP and allows the penis to return to the flaccid state. These medications inhibit PDE5, which keeps the level of cGMP high and promotes erections. This is the mode of action of the most common way oral medications are used to treat ED. However, it should be explained to patients that these medications are not a ‘magic bullet’, and sexual stimulation is required to achieve an erection.
More invasive treatments are sometimes deemed necessary, such as intracavernosal injections, intraurethral suppositories, vacuum-assisted erectile devices, or penile prostheses. These interventions are beyond the scope of this article.
If a GP is treating the patient, they may also recommend a sex therapist, either on its own or in combination with other psychotherapy.
References on request
