Erectile dysfunction (ED) is a common concern that affects millions of men worldwide, impacting not just their physical health but also emotional wellbeing and relationships. But more than just a blow to a man's confidence – it can also be a critical warning sign of underlying health issues, particularly cardiovascular disease. Miss Eleni Anastasiadis, Consultant Urological Surgeon and Andrologist at New Victoria Hospital, delves into the causes, diagnosis, and treatment options for erectile dysfunction.

What is Erectile Dysfunction, and how common is it?

Erectile dysfunction (ED) is more common than you might think. Defined as the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance, ED affects about half of all men by the age of 50, with its likelihood increasing as men get older. However, ED is not just a concern for older men. Studies have revealed that nearly 30% of men under 40 also experience some form of ED, dispelling the myth that it is solely age-related. While occasional difficulty in getting or keeping an erection is normal, persistent issues lasting at least three months and occurring more than half the time should be taken seriously and addressed by a healthcare professional.

Erectile dysfunction: tugging on your heartstrings

ED is not just a standalone condition – it can be an early indicator of cardiovascular disease (CVD), arterial damage and poor vascular health. The blood vessels in the penis are smaller than those in other parts of the body, meaning that symptoms of vascular problems often appear there first. Research has shown that men with ED are at a significantly higher risk of developing heart diseases such as coronary artery disease and stroke.

This is why ED is often considered a "sentinel marker" for cardiovascular disease. ED often precedes cardiac events by several years, meaning seeking medical advice could be a life-saving move. Addressing ED can provide an opportunity for early intervention and potentially prevent more serious heart-related events.

Other causes of erectile dysfunction

While cardiovascular disease is a major factor, ED can be caused by a range of physical and psychological factors. Diagnosing and understanding these can be key to finding the right treatment. Based on the underlying causes, ED can be classified into three main categories:

1. Organic ED (Medical causes):

Physical health plays a significant role in erectile function. Here are some of the common medical causes:

• Diabetes mellitus: Long-term uncontrolled diabetes can damage blood vessels and nerves and impair erectile function.
• Neurological conditions: Disorders like stroke or Parkinson’s disease can affect nerve signals to the penis.
• Post-prostate surgery: Treatments for prostate cancer, including surgery and radiotherapy, can lead to ED.
• Low testosterone levels: Also known as hypogonadism, low testosterone is linked to reduced libido and can exacerbate ED. As men age, testosterone levels naturally decrease, which can exacerbate problems in the bedroom.
• Obesity: Carrying excess weight is more than a strain on your heart; it is also linked to lower testosterone levels and reduced blood flow, both of which can contribute to ED.
• Medications: Some medications, including antidepressants, antihistamines, diuretics, and those for high blood pressure medicines, can interfere with your sexual function.

2. Psychogenic ED (Psychological causes):

Erections are not just about physical health – your mental state is equally important. Psychological factors such as anxiety, stress, or depression can be major contributors to ED. Performance anxiety, especially in younger men, is a common issue that can create a vicious cycle, where fear of failure leads to repeated difficulties.

3. Mixed ED:

For many men, ED is not just black or white – it is a combination of both organic and psychogenic factors. This is known as mixed ED and requires a holistic approach addressing both the body and the mind. Improving overall health, reducing stress, and seeking medical advice can all be part of an effective treatment plan.

Why should you see a Specialist for Erectile Dysfunction?

If ED follows a traumatic injury to the penis, perineum, or pelvis, it is especially important to seek medical advice to rule out any underlying damage. However, ED is more than just a bedroom issue – it can be an early warning sign of serious health problems, particularly cardiovascular disease. If ED becomes a persistent issue, it is crucial not to delay consulting a Urologist. A Specialist can help uncover underlying health concerns, such as high blood pressure, atherosclerosis, or diabetes, all of which are linked to ED and may drastically impact your overall well-being. Additionally, ED can be worsened by factors such as obesity and declining testosterone levels, both increasingly common issues affecting men worldwide.

Addressing ED early not only safeguards your long-term health but also improves your sexual health, confidence, and overall quality of life.

What to expect at your first consultation for ED?

During your initial consultation, your Specialist will begin by taking a detailed history of your symptoms, when and how often they occur, whether you experience early morning erections, and any relevant medical history. They will also explore other potential contributors, such as heart disease, your level of exercise tolerance, and any urinary symptoms.

A thorough physical examination typically follows. Your Specialist may check your Body Mass Index (BMI) and blood pressure, assess the external genitalia, and if needed, perform a digital rectal exam of the prostate to check for any signs of cancer. A neurovascular examination of the lower limbs may also be done to assess nerve and blood vessel function. This comprehensive approach helps ensure that nothing is overlooked, allowing you to tackle the issue head-on and improve both your sexual and overall health.

What tests are available for ED?

Testing for ED primarily focuses on identifying any underlying conditions. Common tests include:

• Blood tests to check for diabetes, testosterone levels (+/- prolactin), thyroid hormones, cholesterol/lipid levels, and Prostate-Specific Antigen (PSA).
• Specialised tests like penile Doppler ultrasound (USS) with a pharmacologically induced erection to evaluate blood flow abnormalities in the penis.

Are drugs and counselling the only treatment options for ED?

When it comes to treating erectile dysfunction, there is more on the table than just medication and counselling. Here is a breakdown of the treatment options available:

Lifestyle changes

Improving cardiovascular health with a heart-healthy diet, regular exercise, and weight management is a great place to start. Managing cholesterol, diabetes, and blood pressure is also key.

Oral medications

The most common and accessible treatment to boost blood flow to the penis is oral medications, known as PDE5 inhibitors, like Viagra (Sildenafil). Cialis (Tadalafil) can also offer daily low-dose options for spontaneity. Effectiveness of these medications will depend on severity of ED and underlying conditions.

Testosterone replacement therapy (TRT)

Boosts libido and enhances PDE5 inhibitors' effectiveness for those with low testosterone and symptoms like fatigue or brain fog. Available as injections or topical gel, but requires careful monitoring due to potential side effects.

Alprostadil (intra-urethral or injection)

Applied as a cream or injected directly into the penis when oral medications fail. Penile injections are more effective but may cause discomfort or rare complications like prolonged erections.

Vacuum erection device (VED)

Creates an erection by drawing blood into the penis. Useful post-prostate cancer surgery but can cause bruising or numbness. Not suitable for those with bleeding disorders or on blood thinners.

Penile prosthesis

For sever cases unresponsive to other treatments, a penile implant offers a permanent solution with semi-rigid or inflatable options but is irreversible.

Emerging and alternative treatments

Include Low-Intensity Shockwave Therapy (Li-SWT), Platelet-Rich Plasma (PRP), and stem cell therapy. Psychosexual counselling remains crucial when mental health factors are involved.

Taking control of your health

Erectile dysfunction is a complex condition that can significantly impact your quality of life. However, with the range of treatments available and ongoing research, there are numerous options for managing ED effectively. It is crucial to have a thorough evaluation by a Specialist, Urologist or Andrologist, to determine the underlying cause and develop a personalized treatment plan. While finding the right treatment can require a degree of trial and error, optimism, and perseverance from the patient, satisfactory results can be achieved with specialist advice to optimise your treatment.

Remember, seeking help for erectile dysfunction is not just about improving sexual function – it is about taking care of your overall health and wellbeing.

If you have any concerns or would like to discuss treatment options, book an appointment with one of our expert Urologists by calling our Outpatient Department on 020 8949 9020 or filling in our online form.