Erectile Dysfunction (impotence)

What should I do if I have problems with impotence?

Your GP will normally wish to review both you & your partner together and several visits may be needed before a full picture of the problem can be obtained. Following initial discussions, it is not unusual for some couples to decide not to pursue any further investigations or treatment for impotence (erectile dysfunction).

What are the facts about impotence?

  • Impotence becomes commoner with increasing age and is seen in 50-55% of men between 40 and 70 years old
  • It is often associated with the so-called “deadly quartet” of obesity, high blood pressure, high cholesterol & diabetes which are all significant risks to health
  • Investigation is only indicated if both partners wish to pursue treatment
  • Most treatable causes can be identified by a clinical history, physical examination and routine blood tests
  • If there is no treatable cause, treatment with tablets is the first option for most men
  • Other methods of treatment are only indicated if tablets prove ineffective, cause side-effects or cannot be used because of specific medical conditions

What should I expect when I visit my GP?

1. A full history

Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption). He/she will take a detailed sexual history to determine why your erections are failing and under what circumstances you are having sexual difficulties. It is also normal to ask about your sex drive (libido), whether you still get night-time or early-morning erections and whether your partner is also concerned about your difficulties.

It is important to tell your GP if you have premature ejaculation (uncontrolled ejaculation before or immediately after penetration) or symptoms of prostatic obstruction because they are often associated with impotence (erectile dsyfunction).

Your GP may help you to complete a symptom questionnaire (the International Index of Erectile Function) as an aid to further assessment and discussion of treatment options. This will allow your GP to:

  • identify your needs & expectations
  • help you & your partner share in decision-making
  • decide whether psychosexual counselling might be helpful.

2. A physical examination

A general physical examination will be performed to assess the development of your male sexual characteristics and to detect any abnormality of your penis or genitals. Your blood pressure will normally be measured as part of this examination. The pulses in your legs will normally be assessed and the nerve reflexes involving your legs and your penis or anus (back passage). Rectal examination (pictured) is normally performed to assess the tone of your anal muscles and to feel your prostate gland.

3. Additional tests

The usual tests performed are:

a. General blood tests

The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function, liver function, cholesterol & prostate-specific antigen (PSA) as well as checking your blood cells for anaemia or other problems. A blood sugar measurement will be performed to exclude diabetes.

b. Routine urine tests

Your urine will normally be assessed by stick-testing to see whether it contains sugar which might indicate diabetes.

c. Hormone measurements

Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones will normally be measured.

d. Other specific tests

Other tests, if indicated, are normally arranged by the urology clinic. Your GP may be able to arrange measurement of blood flow in your penis by ultrasound, formal nerve conduction tests and even a trial injection of a drug called prostglandin E1 (Caverject®) into your penis. A good erection after the injection means that the arterial blood flow to your penis is likely to be normal.

What could have caused my impotence?

Although a psychological component, often called “performance anxiety”, is common in men with impotence, a purely psychological problem is seen in only 10%.

Of the 90% of men who have an underlying physical cause, the main abnormalities found are:

  • Vascular disease in 40%
  • Diabetes in 33%
  • Hormone problems (e.g. high prolactin or low testosterone levels) & drugs (e.g. antihypertensives, antipsychotics, antidepressants, antihistamines, heroin, cocaine, methadone) in 11%
  • Neurological disorders in 10%
  • Pelvic surgery or trauma in 3-5%
  • Anatomical abnormalities in 1-3% (e.g. tight foreskin, short penile frenulum, Peyronie’s disease, inflammation, penile curvature)

What treatments are available for this problem?

Initial treatment will usually involve:

  • treatment of any anatomical abnormality (e.g. circumcision, frenuloplasty, penile straightening)
  • treatment of any hormone abnormality (testosterone treatment is only indicated if your testosterone levels are low and may be harmful if your the levels are normal)
  • lifestyle modification (e.g. reduce stress, stop smoking & drinking, stop all drugs)
  • weight loss & increased exercise (which may reduce the risk of impotence by up to 70%)
  • specific support for psychological problems

If these fail to help, your GP will issue a prescription for Viagra®, Cialis® or Levitra®. These drugs require sexual stimulation to be effective and will not produce an erection without it. They will have no effect on your sex drive. There is no evidence that these drugs are dangerous if you have underlying heart disease. However, they should not be taken if you are taking nitrates (e.g. GTN, isosorbide for angina).

You should only take Viagra, Cialis or Levitra by getting a prescription from your GP & you should have a detailed discussion about the risks & benefits before starting treatment.

1. Penile injections to produce erections

Self-administered injections of prostaglandin E1 (Caverject®) provide a simple means of obtaining a natural erection. You will be taught how to administer the injections (pictured) and told what to do in the event of problems such as an erection which will not go down.

2. Medicated urethral system for erection (MUSE)

Insertion of a prostaglandin pellet in the urethra (water pipe) is no longer widely used because of its poor success rates and significant side-effects.

3. Vacuum erection assistance devices (VEDs)

VEDs provide a simple way of obtaining an erection for 30-45 minutes by sucking blood into the penis and holding it in place with a constriction (pictured). Ejaculation may be restricted by the ring but this technique is simple, safe and has no known side-effects. Unfortunately, most patients have to purchase VEDs themselves.

4. Vascular surgery/angioplasty

If you have blockage of the large blood vessels to the legs and the pelvis, it may be possible to undergo reconstruction of the arteries or angioplasty to re-establish erections. Re-vascularisation for small artery blockage is rarely successful.

5. Penile prostheses

Insertion of artificial penile implants (pictured) is highly effective. It is reserved as a last resort when all other forms of treatment have failed. It involves major surgery with a significant risk of complications. You will need to undergo long-term follow-up in a specialist andrology unit for many years after the surgery.