Erectile dysfunction

What is erectile dysfunction?

Erectile dysfunction (ED) is a common male sexual disorder. It is the inability to get or keep an erection that allows for satisfying sexual activity. It can happen occasionally or regularly, with or without any clear reason. Some men with ED are not able to get an erection at all.

ED is not a life-threatening disorder, but it can have a negative impact on your quality of life and that of your partner.

How common is ED?

ED is a common condition in men of all ages and ethnicities. The risk of having ED increases with age.

What is an erection?

Getting an erection is a process that includes physical, hormonal, and psychological elements. The penis is made of soft, spongy, elastic tissue that fills with blood to make it grow in size and become rigid. Around the spongy tissue and the prostate, there are nerves that send signals so that the blood vessels supply the blood (Fig. 1). These signals are controlled by the male hormone testosterone.

Fig. 1: Anatomy of the penis.
Fig. 1: Anatomy of the penis.

What causes ED?

Risk factors for ED and cardiovascular disease (CVD) are similar. The most cases of ED result from a vascular disturbance of the endothelium. Risk factors are such as:

  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Low levels of testosterone
  • Neurologic diseases (e.g Parkinson’s disease, spinal cord injury)
  • Nerve damage to the penis or the pelvic area
  • Obesity
  • Pelvic surgery
  • Radiation therapy to the pelvic area
  • Smoking

Cardiovascular disease and ED

ED and cardiovascular disease share common risk factors, like obesity, smoking, high cholesterol, high blood pressure, and lack of exercise. ED can be an early sign of heart disease because problems with blood flow affect erectile function. This is why men who experience ED should go to the doctor to get checked for heart disease.

Urinary symptoms and ED

ED is often associated with urinary symptoms, such as urinary frequency, nocturia, and urgency. Often these symptoms are related to benign prostatic enlargement (BPE). It is unclear if the urinary symptoms cause ED, but generally, ED gets worse when urinary symptoms worsen.

Psychological risk factors for ED

Several psychological conditions have been associated with ED. These include:

  • Anxiety
  • Depression
  • Feelings of self-inadequacy
  • Low self-esteem
  • Inability to describe emotions
  • Stress

Social ideas of how men and women are supposed to interact can also contribute to ED. These can include unrealistic expectations about love and sexuality, and inappropriate male and female role models.

ED is sometimes the cause and sometimes the result of unsatisfying or dysfunctional relationships. It is often difficult to find out which started first.

Diagnosis

Erectile dysfunction (ED) is a problem that needs to be diagnosed correctly, to find what causes it so that you get the appropriate treatment.

Discussing ED with your family doctor or urologist may be uncomfortable, but it is important to do so. Together you can discuss which treatment is right for you.

This section lists the different tests your doctor may need to assess your situation. It offers general information about the diagnosis of ED. Keep in mind that situations can vary in different countries.

Medical history

Your doctor will take a medical history to understand your general state of health. As part of the medical history your doctor will ask about any other conditions you may have.

Your doctor may ask you:

  • If you take any medication
  • If you smoke
  • When and how much you drink
  • If you drink much coffee or alcohol
  • If you use recreational drugs on a regular basis
  • If you ever had pelvic surgery
  • If you have any heart and/or vascular problems
  • If you have hormonal disorders
  • If you have any psychological problems

Sexual history

Your doctor will also ask you questions about your sex life, which could be very personal but are necessary for proper diagnosis and treatment. Some of the questions could be:

  • The status of your previous sexual relationships
  • Your current sexual relationships
  • Your current emotional state
  • When the erectile problems started
  • How long have the erectile problems lasted
  • If you have seen another doctor specifically for ED
  • If you have received treatment for ED before

Your doctor will ask you to describe the firmness and duration of your morning erections, and sexually stimulated ones. The doctor will also ask if you have problems with arousal, ejaculation, and orgasm.

If you have a sexual partner, it may be useful to attend this consultation together.

Questionnaires

Your doctor may ask you to fill out questionnaires, which are used to assess different aspects of your sexual health. The most common are:

  • The International Index for Erectile Function (IIEF)
  • The Sexual Health Inventory for Men (SHIM)
  • The International Prostate Symptom Score (IPSS)
  • The Clinical Depression Questionnaire

Physical examination

The doctor will perform a complete physical examination, to check for abnormalities in the penis, scrotum, and testicles. To check for heart disease the doctor will take your blood pressure, measure your heart rate, and order a blood test to check your level of cholesterol. Your doctor will do a digital rectal examination to feel the size, shape, and consistency of the prostate, and if necessary check the level of prostate specific antigen (PSA) in your blood. To check for diabetes the doctor may order a test to measure the level of glucose in your blood. It could also be necessary to assess your testosterone levels in the morning. This is also done with a blood test.

Cardiac risk evaluation

Because of the relation between erectile dysfunction and heart disease the doctor generally does a cardiac risk evaluation as part of the diagnosis. Your doctor may refer you to a cardiologist for further evaluation and specific cardiac tests, such as a ‘stress test.’

Laboratory testing

Your doctor may order laboratory tests to identify metabolic disorders underlying the ED.

Other tests

In some cases, it may be necessary to do specific diagnostic tests other tests. These may include:

  • A nocturnal penile tumescence and rigidity (NPTR) test
  • An intracavernous injection test
  • Penile Doppler Ultrasound
  • Neurological tests

These are not common tests for initial diagnosis of ED and are only necessary if your doctor needs additional information to assess your personal situation.

If necessary, your doctor may refer you to a neurologist, a psychiatrist, an andrologist, or an endocrinologist for further tests.

Treatment

Erectile dysfunction (ED) is a common condition. Although it is not life-threatening, it can negatively affect your quality of life. Because it can be related to other conditions, such as heart disease, it is important that you get the right treatment. There are various treatment options for ED, discuss with your doctor which option is best for your individual situation.

This section offers general information about treatment options and situations can vary in different countries.

Education and couple assessment

An important part of treatment is understanding the condition and the consequences it may have on your intimate relationships. Your doctor will often recommend a combination of physical and psychological approaches to treat ED. In the past doctors focused mainly on treating the physical aspect of ED. Nowadays, psychological and emotional aspects of the condition are also dealt with.

Treatment that includes psychological approaches has proved to be more effective than treating only the physical symptoms. This approach has also shown to be effective in single patients, or in cases when the partner is not involved.

If you are in a committed relationship, it benefits your treatment if your partner agrees to the type of treatment, is aware of how it works, and you are able to talk about it.

Keep in mind that treatment is based on your individual situation and what may be helpful for others is not always helpful for you.

If you have other conditions that may be related to ED, your doctor will discuss referring you to a specialist for assessment and further treatment.

Lifestyle advice

Improving your general health could help improve your symptoms. Your doctor will advise you to stop smoking, drink less alcohol, and exercise regularly.

Depending on your individual situation, your doctor may recommend that you adapt your diet. It is important to discuss this with the doctor first. As a general rule, try to have a varied diet which is low on sugar, salt, and fatty foods.

Phosphodiesterase 5 inhibitors

Phosphodiesterase 5 inhibitors (PDE5Is) are a group of drugs used for the treatment of ED. These drugs relax smooth muscle in the vessels in the penis to increase blood flow. They do not cause an erection without sexual stimulation.

There are 4 approved types of PDE5Is:

  • Sildenafil
  • Tadalafil
  • Vardenafil
  • Avanafil

PDE5Is are the most commonly prescribed treatment for ED. All types of PDE5Is can be equally effective. Which drug is best for you depends on how often you want to have sexual activity, and your personal experience.

Because of the success of PDE5Is in treating ED, there are many fake pills on the market. These drugs are not approved for sale, they may be toxic and may damage your health. Always talk to your doctor or healthcare provider before using or buying medication for ED.

Interesting Fact

Sildenafil, best known by its brand name Viagra®, is the oldest and best-known drug for ED. Although new drugs have been developed, it still accounts for more than 40% of all PDE5Is sales.

ED after treatment for localised prostate cancer

Prostate cancer is a malignant tumor in the prostate gland. It is the most common form of cancer in older men. There are various treatment options for localized prostate cancer. Two of the most common ones are radical prostatectomy and radiation therapy. These treatment options can affect sexual health, and men frequently experience erectile dysfunction (ED) after treatment.

Why is prostate cancer treatment associated with erection problems?

The prostate gland is located just below the bladder and is surrounded by nerves and blood vessels. These nerves and blood vessels are needed to achieve a normal erection. Much research has been done to understand where these nerves are located and how to prevent them from getting damaged during surgery or other treatments.

Radical prostatectomy

Radical prostatectomy is a surgical treatment option to remove the entire prostate and surrounding tissue. If the tumour is limited to the prostate gland, the surgeon will try to keep the nerves that lead to the penis intact during surgery. This is called nerve-sparing surgery. Even if nerve-sparing surgery is successful, temporary ED is common after radical prostatectomy.

This is because your nerves are so delicate that they are affected by the slightest injuries. If any injury happens during surgery, the nerves stop transporting signals to the blood vessels in the penis. It can take up to 2 years for the nerves to recover.
The blood vessel running to and from the penis can also be affected by the surgery. As a result, less blood will flow to the spongy tissue of the penis, and damage it. Because of the damage it can be more difficult to recover from ED.
In some cases nerve-sparing surgery is not possible because the tumour has spread outside of the prostate, or for other reasons. Recovery of erectile function after non-nerve sparing surgery is unlikely but not impossible. Discuss your concerns and possible treatment options with your doctor.

Radiation therapy

Radiation therapy is a type of cancer treatment that uses radiation to control or kill malignant cells. It can be done from outside the body, or by placing the radiation source into the prostate. Because the radiation can also kill healthy cells it may damage the nerves and blood vessels around the prostate which lead to the penis. Although there is still a risk of ED after radiation therapy, technical developments have increased the precision of the beam.

Will I be able to have normal erections after the treatment?

The risk of having ED after prostate cancer treatment depends on the surgical technique or type of radiation used by your doctor, but also on your:

  • Age
  • Build
  • Disease characteristics
  • Sexual health before the treatment

Living with ED

Nearly every man can experience brief problems with erectile function. In almost all cases it is related to certain and specific life circumstances, problems, or stressful situations. Usually, these erectile problems disappear once the situation is resolved or changed. You generally don’t need to go to the doctor.

If you experience erectile dysfunction (ED) for more than 6 months you should seek professional help. Your doctor can help you find the causes by performing physical and psychological tests. Read more about them in the section Diagnosis of ED.

ED can have a negative effect on quality of life. Quality of life involves both physical and psychological health. It is important not only to feel healthy but also to feel free of the psychological discomfort of living with ED. Another important issue is that different people can experience the same symptoms differently. Therefore both your personal experience and your quality of life should not be underestimated: they are as important as diagnostic tests and treatment results.

Personal relationships and sex

An intimate relationship between two people is complex and involves many aspects. ED may affect or change your relationship with yourself and your partner. You may be embarrassed and feel guilty, making it difficult to talk to your partner about this issue. ED could have a direct impact on a committed relationship.

ED can have a negative effect on your sex life. It is difficult to feel attractive and confident or be intimate with your partner when you do not feel able to give him or her pleasure. This can have an effect on trust, intimacy, and closeness. Your intimacy as well as your daily interaction may be affected.

You can become more emotionally and physically reserved because you fear you will not be able to have satisfying sexual activity. Even though this behaviour may be a sign of frustration and humiliation, your partner may think that you are losing interest in him or her. This can have a negative impact on their self-esteem and feelings of attractiveness.

These changes can be very difficult to deal with because for most men sexuality and erection remains important throughout their whole life. You may even go into denial or suffer from depression. That is why the effect of ED on your quality of life should not be underestimated.

Many men think it is inappropriate to admit they need affection or just a hug. It is important to address the issue by discussing it with your partner. This may prevent emotional and physical distance, and can provide the comfort and emotional support you need.

Your partner may relate his or her own attractiveness and sexual attraction with the ability to get you sexually aroused. He or she can feel vulnerable, rejected, and fear infidelity or abandonment. These feelings may get worse the more often ED prevents you from having fulfilling sexual activity. While treatment to cure ED may solve the physical aspect, the psychological consequences for you and your partner may also need to be dealt with. It could help if you see a therapist.

Your partner may suffer without saying much, so it is very important that you openly discuss the best way to cope with this condition.

ED not only affects the sex life of men in a committed relationship. Single men with ED often avoid dating because of the condition.

It may be uncomfortable for you to discuss your sex life with a urologist or a sexologist, but it is the most effective way to deal with your concerns. Together with your doctor, you can identify what is important in your sex life and choose the best treatment option to have a satisfactory sex life. If you have a partner, it is important to include them in these consultations.

Seeking help

ED is a very intimate and private condition. Most patients consult multiple sources of information for erectile problems: friends, the Internet, media, a sexual health shop, a pharmacist, a psychologist, or a medical doctor.

Some men choose not to discuss it with anybody or not to go to their doctor because they:

  • Think they have normal erection, so it is unnecessary to take any treatment
  • Assume they can stop their sexual life, so it is unnecessary to take any treatment
  • Are afraid they may have an incurable disease
  • Are worried about a wrong diagnosis
  • Do not have easy access to a doctor
  • Have had a negative experience in the hospital
  • Have friends or relatives who had a negative experience when treated for a similar condition
  • Do not know about possible treatment options
  • Have financial issues
  • Feel isolated because of their age or condition

While these reasons may seem convincing they should not prevent you from seeking help and improving your quality of life.

Questions to ask your doctor

You may have a lot of questions regarding your condition. EAU Patient Information on ED covers many of these questions but it does not deal with your personal situation. The urologist and the sexologist are the best people to discuss this with and you should not feel embarrassed about addressing any of your concerns.

Here are some of the questions you could ask your doctor:

  • Why have I developed this problem?
  • Why is this happening to me?
  • What will happen in the next months and years if I do not get treatment?
  • What will happen in the next months and years if I choose to have treatment?
  • Which are the available treatment options?
  • Which treatment option do you recommend for me?
  • Why do you recommend this treatment option for me?
  • What can I expect from that treatment?
  • What are the possible side effects or risks of this treatment?
  • Will it cure my condition?
  • How long will I need to be treated for?

This information was produced by the European Association of Urology.

  • Dr. Maarten Albersen, Leuven (BE)
  • Dr. Eduardo García-Cruz, Barcelona (ES)
  • Prof. Dr. Kostas Hatzimouratidis, Thessaloniki (GR)
  • Prof. Dr. Markus Margreiter, Vienna (CH)
  • Dr. Ege Can Serefoglu, Istanbul (TR)
  • Dr. Chaira Simonelli, Rome (IT)
  • Prof. Dr. Wolfgang Weidner, Giessen (DE)

Updated March 2018 by the EAU Patient Information Working Group

  • Dr. Mazhar Ortac, Istanbul (TR)