Erectile dysfunction (or impotence) is a man’s inability to get or keep an erection that allows sexual activity with penetration. Erectile dysfunction is not a disease, but a symptom of some other problem – physical, psychological or a mixture of both.
Don’t worry about occasional failure to get or keep an erection. This is normal. Some of the causes include drinking too much alcohol, anxiety and tiredness. Unless it continues, there is no reason to be concerned. However, ongoing erectile dysfunction should be investigated by a doctor.
Treatments for erectile dysfunction include medications given orally (usually tablets), counselling, vacuum penile pump devices, injections directly into the penis, and penile prosthetic implants.
Causes of erectile dysfunction
Doctors used to think that erectile dysfunction was mainly caused by psychological factors, such as anxiety or depression. In fact, most cases of erectile dysfunction are caused by physical illness. Psychological problems cause only one in ten cases of persistent erectile dysfunction.
Physical erectile dysfunction happens over a period of months or years, and is often a gradual loss of function. If erections still occur spontaneously overnight or in the morning, the problem may be psychological.
Erectile dysfunction can be due to:
- physical illness – erectile dysfunction is frequently associated with conditions affecting the blood flow in the penis. Diabetes, high cholesterol, hypertension (high blood pressure), cigarette smoking and obesity are often involved, and there is a strong association between erectile dysfunction and cardiac (heart) disease. Men who have multiple sclerosis may also experience erectile dysfunction
- psychological factors – a man’s sexual drive or performance can be affected by stress such as problems at work, relationship difficulties or financial worries. Psychiatric conditions, and feeling depressed or anxious about poor sexual performance can also result in a failed erection
- a combination of physical illness and psychological factors – physical problems with maintaining an erection may cause the man to feel anxious about sexual performance, which makes the problem worse
- unknown – in a few cases, neither physical nor psychological causes are obvious. Vascular disease is likely to be the underlying cause in these cases.
Diagnosis of the cause of ongoing erectile dysfunction
Ongoing erectile dysfunction should be investigated by a doctor. While occasional erectile dysfunction is normal, ongoing erectile dysfunction can be a symptom of a serious physical illness. It is important that your doctor fully investigates any ongoing problems to check for any underlying medical cause that may also need treatment. This may include heart and blood vessel diseases, diabetes, high blood pressure or high cholesterol.
Tests can determine if the blood flow to the penis is affected. Blood tests can also help to determine if hormone problems, such as low testosterone, are causing the erectile dysfunction.
Once you find out whether your erectile dysfunction has a physical or psychological cause, you can get the proper course of treatment.
Treatment for erectile dysfunction
There are many treatments for erectile dysfunction. These include:
- changing your prescription medication if it is the cause
- psychotherapy and counselling
- oral medication (tablets) such as Viagra®, Cialis® and Levitra®
- external vacuum penile pump devices to create blood flow
- injections directly into the penis (such as Caverject Impulse®)
- penile prosthetic implants
- hormone therapy (rarely given)
- vascular surgery (rarely undertaken).
The first approach is to treat the underlying cause if one has been identified, or if not, to use treatments to promote a better erection.
Doctors usually start with the least invasive treatment, such as tablets. If that fails, they may suggest more complicated injection treatments or surgery.
Sometimes, treatment of the cause may restore erectile function, for example, testosterone replacement, resolving substance abuse problems or withdrawing medication that may be causing the erectile dysfunction. Mostly, treatment aimed at directly restoring erectile function is necessary.
There are many treatments aimed at restoring erectile function. These can be grouped according to their level of invasiveness, being:
- non-invasive treatments
- minimally invasive treatments
- surgical treatments.
Non-invasive treatments for erectile dysfunction
Non-invasive treatments include reducing risk factors by treating disease or depression, oral medication (tablets), counselling and external devices such as vacuum penile pumps.
Medication (usually tablets) is effective in about 70 per cent of men with erectile dysfunction. Brand names include Viagra®, Cialis® and Levitra®. These are known as PDE5 inhibitors – they inhibit a particular enzyme in the penis, improving the erectile response to normal sexual stimulation.
Tablets should usually be taken at least one hour before sexual contact. With Cialis® tablets, taking a lower dose on a daily basis can allow more spontaneous sexual activity. Fatty meals and large amounts of alcohol can interfere with the body’s absorption of some of these medications.
Side effects may include facial flushing, nasal congestion, headaches and indigestion. Although these medications act in a similar way, there are important differences between them, such as the period of time for which they are active.
Your doctor will help you decide the best treatment for you. Oral medication may not be suitable for all men. Men taking nitrate-containing heart medication should always consult their doctor, as erectile dysfunction medication may interact with these medications.
Psychotherapy and counselling can help if one of the underlying causes of erectile dysfunction is psychological. Counselling can also benefit a man who has lost sexual confidence, even though his erectile dysfunction is caused by physical factors. It may be provided by your doctor, a psychologist or a psychiatrist. Your partner may also be involved.
A vacuum device is a pump placed over the penis to create blood flow. It draws blood into specific tissues of the penis (the two corpora cavernosa), mimicking a normal erection.
Placing a rubber ring around the base of the penis can help make it rigid enough for intercourse. This can be useful when a man is able to get an erection, but has difficulty maintaining it.
Devices such as vacuums and rings are not always successful. Side effects may include penile pain, numbness, coldness and difficulty ejaculating. These devices need to be properly explained and fitted, and are best used after consultation with a doctor.
Minimally invasive treatments for erectile dysfunction
Minimally invasive treatments include:
- injections – some medication can increase blood flow when it is injected into the penis. A penile injection can create an erection within five to 10 minutes and last for up to one hour. Men must be shown how to use the penile injections properly and should have several supervised injections in a doctor’s surgery. One possible side effect is a painful erection lasting for hours, known as priapism. This occurs if the medication dose is too high. If an erection lasts for four hours or longer, the penis may be permanently damaged. In this situation, you should seek immediate medical attention
- testosterone replacement therapy (TRT) – only suitable for men whose levels of testosterone are low. Before treatment, a doctor needs to investigate the cause of low testosterone.
Surgical treatments for erectile dysfunction
Surgical treatments include:
- penile prosthetic implant – a device that is surgically implanted into the penis. It can enable erections through a mechanism of squeezing on a specific part of the device. Penile prosthetic implants are expensive and generally used only as a last resort, if other treatments have not worked
- vascular surgery – targets the veins and arteries that supply blood to the penis. This is a major operation and is rarely used. Surgery may help men who have vascular damage due to trauma in the area around the penis – for example, after a car accident or fall.
Men with diabetes and erectile dysfunction
Men with diabetes have a higher risk of erectile dysfunction, especially if their diabetes is not well controlled. We do not fully understand the reasons for this. Over the long term, poor control of a man’s diabetes may result in increased damage to the nerves and circulation that control blood flow to the penis. If blood glucose levels are kept in the normal range, these problems are less likely to occur.
Women with diabetes and sexual dysfunction
Some women with diabetes have impaired vaginal lubrication with arousal. Doctors think this is caused by damage to the nerves and circulation that control blood flow.
Unproven claims for treating erectile dysfunction
Many over-the-counter products claim to treat or even cure erectile dysfunction. These products are often expensive and usually have not been adequately tested for either their side effects or results. Treat such products with caution and use only under the supervision of a doctor.
Where to get help
- Your doctor
- Community health centre
- MensLine Australia Tel. 1300 78 99 78
- Melbourne Sexual Health Centre Tel. (03) 9341 6200 or 1800 032 017 or TTY (for the hearing impaired) (03) 9347 8619
- Diabetes educator
- Diabetes Australia Vic. Tel. 1300 136 588
- Life! Helping you prevent diabetes, heart disease and stroke Tel. 13 RISK (13 7475)
Things to remember
- Most cases of erectile dysfunction have a physical cause.
- It is normal for a man to experience occasional erectile dysfunction, perhaps from tiredness or drinking too much alcohol.
- Ongoing erectile dysfunction should be investigated by a doctor.
- Men with diabetes are at a higher risk of erectile dysfunction especially if their diabetes is not well controlled.
- Treatments include counselling, oral medications, vacuum devices, penile injections and implants.