Erectile dysfunction


Erectile dysfunction can cause considerable distress, but fortunately more men are seeking help, and treatment has advanced rapidly.

Erectile dysfunction (ED) is the inability to get or maintain an erection sufficient to ensure satisfactory sex for both partners.

ED is distinguished from other sexual functioning difficulties such as premature ejaculation, male orgasmic disorder (delay or absence of orgasm) and hypoactive sexual desire disorder (diminished sexual interest). Men with ED may or may not have these other problems.

Roughly 10% of men are affected. Incidence rises with age: 5% of men at age 40, and 25-40% at 65 have ED. With age, men typically report some loss of sexual desire also.

Temporary or occasional erectile failure is probably not serious; all men sometimes have erectile problems.

What causes ED?

For an erection to occur, mental impulses from the brain and sensory nerves in the penis relax the smooth muscles in two spongy cylinders running the length of the penis. Blood flows into spaces in the spongy tissue, making the penis swell. A membrane surrounding the cylinders traps the blood and maintains the erection. The penis becomes flaccid when the muscles contract, stopping inflow of blood and opening outflow channels.

Erection problemsoccur if any events in this sequence are disrupted. Most ED is due to a combination of factors, but 85-90% of cases have a physical cause.

Physical causes can be vascular (48%), neurological (14%), or involve problems withpenis structure or surrounding tissues (3%).

These are in turn caused by:

  • Illnesses e.g. diabetes, kidneay disease, multiple sclerosis, cardiovascular problems.
  • Injury to the penis, spinal cord, prostate, bladder or pelvis: the result of e.g. sports or car accidents, or bicycle seats (usually temporary).
  • Complications of surgery or radiation (e.g. for prostate cancer).
  • Medication side-effects e.g. drugs for high blood pressure, anti-depressants, antihistamines, tranquilisers, appetite suppressants, cimetidine (an ulcer drug), diuretics.
  • Drug or alcohol abuse, smoking.
  • Hormonal factors e.g. low testosterone, thyroid problems.

Psychological causes

Psychological problems interfere with the erection process by distracting the man from triggers thatnormally arouse him. Even where the underlying problem is physical, psychological factors can play a secondary role.

Psychological factors include:

  • Depression
  • Relationship problems
  • Anxiety and stress
  • Low self-esteem
  • Guilt because of extramarital affairs
  • Major life changes e.g. retirement, loss of a partner.
  • “Performance anxiety” can worsen ED. A man who can’t have satisfactory intercourse may still have a strong sex drive, causing frustration. In some cases, for example where the problem is because of transient factors such as a life change, erection problems may resolve spontaneously. But where there are multiple causes and the problem is causingacute distress, spontaneous recovery is less likely.

When to see a doctor

Watch and wait if you’ve had a singleerection problem episode: it could be temporary and easily reversible. But consult your doctor about persistent, bothersome erection problems.

Your doctor will take a medical history, including questions about your sex life, and perform a physical exam. If the penis doesn’t respond normally to certain touch stimuli, there may be a nervous system problem. Abnormal secondary sex characteristics, such as loss of body hair, may suggest a hormonal problem.

Lab tests may be done, including of testosterone levels if sexual desire is low.

Tests to evaluate penile arteries and veins include medication to assess erections, ultrasound and angiography.

Psychological evaluation may be recommended when a major psychological cause is suspected. Nocturnal penile tumescence testing (rigiscan) monitors if you have involuntary erections while asleep, which is normal in healthy men.


Treatment depends on whether the problem is predominantly psychological or physical, or both.

Non-surgical treatments work for 60-70% of men:


  • Oral medications e.g.Sildenafil (Viagra) increaseblood flow into the penis to allow for an erection.
  • Medication for other conditions may be adjusted, if side-effectsare negatively affecting erections.
  • Correction of abnormal hormone levels through testosterone replacement therapy.
  • Vacuum erection apparatus: A vacuum pump sucks blood into the penis, and a constriction band is placed around the base to prevent blood outflow and maintain the erection. This process takes getting used to, but suits some men well. It may be the only effective treatment after radical prostatectomy.
  • Injection therapy: Intracavernosaldrug injections (into the body of the penis) sound painful, but are actually not. This produces an erection for 20-30 minutes.
  • Surgical approachesinclude penile implants, repairs to the penile vascular system, and penile curvature correction. (Peyronie’s disease is a painful condition which causespenile deformity or curvature.)

Natural Supplements:

Natural supplementation may help to address erectile dysfunction

  • Consider taking a men’s multivitamin designed to support men’s health.
  • Also consider zinc, which supports male reproductive health, and Magnesium and B Vitamins for energy and to help deal with stress.
  • Gingko biloba can promote better circulation and blood flow, which is critical for getting and maintaining an erection.
  • ‘Horny Goat Weed’ is a supplement with a history in ancient Chinese medicine that has traditionally been used for treating ED and libido problems.

Implants include:

  • A bendable implanted rod, making the penis sufficiently rigid for sex, yet flexible enough to be tucked away unobtrusively.
  • A cylinder that extends when fluid from a reservoir implanted under the abdominal muscle is pumped into it, by manually squeezing a small pump in the scrotum.
  • While implants avoid using drugs, they carry the usual risks related to surgery. About 2% of implants are removed because of infection. In 5-10% of cases there is mechanical failure of the device, necessitating another operation.

Surgery to repair or remove penile blood vessels (revascularisation) may be appropriate for a young man as a result of injury. In older men, blood vessel repair tends to be more difficult. Reduction of venous outflow (venous occlusion) can sometimes improve erections.


Many erection problems can be prevented by a more relaxed approach to sex and rediscovering sensuality. Sexual intimacy is a form of communication. Discussing lovemaking with your partner helps reduce anxiety, and will likely make sex more relaxed.  It may gradually become more difficult to have an erection as you get older. However, foreplay and the right environment can increase your ability to have erections, regardless of age. Add to this a healthy lifestyle: maintain correct weight, exercise, don’t smoke and treat underlying diseases.

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