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What is ED? 1,2,3,4,5

Erectile dysfunction (ED) is the inability to get or keep an erection firm enough for sexual performance. ED can be a total inability to achieve an erection, an inconsistent ability to do so, or a tendency to sustain brief erections only. 1, 2, 3, 4

The word “impotence” is sometimes incorrectly used to describe ED. While the two are sometimes related, impotence is a non-specific, non-medical term. 1

Erectile dysfunction can be either primary or secondary. Primary ED means, that you have experienced this condition since you started your sexual life. Secondary ED means you have had no problems with erectile functioning during sexual activities until now, and ED is a new concern. 5

While ED impacts your physical and psychosocial wellbeing, and may alter intimate relationships and quality of life, you are not alone. In the USA, it is estimated that 30 million men are affected by it, but ED is more likely to occur, as you get older. Statistics show that 4% of men in their 50s, 17% of men in their 60s, and nearly half of men over 75 experience a total inability to achieve an erection. However, ED is not an inevitable part of ageing and it is treatable at any age. 1, 3, 5

An erection begins with sensory or mental stimulation, or both. 1, 6 Essentially, an erection is an event to do with blood. It is the balance  between blood flowing into your penis through arteries and blood flowing out of your penis through your veins.

The structure of the penis

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How is ED caused 1,4 and what are the risk factors?

ED usually has a physical cause, such as disease, injury, or as a side effect from drugs. Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED. 1

In order for an erection to occur it requires a precise sequence of events. ED can occur when any of these events are disrupted. This sequence of events includes nerve impulses in the brain, spinal column, and the area around the penis. It also includes response in muscles, fibrous tissues, and veins and arteries in and near the corpora cavernosa in the penis (see diagram above). 1

Damage to nerves, arteries, smooth muscles and fibrous tissue, often as a result of disease, is the most common cause of ED. In fact, disease accounts for the majority of ED cases. Prior to starting any form of ED treatment it is important to be thoroughly evaluated by your doctor for any other health issues. This is particularly significant when it comes to the medical risk conditions listed below. 1, 4

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Medical conditions which increase risk of ED

Psychological disorders 1, 4
Depression, performance anxiety, or stress

Vascular disorders 1, 4, 5
Hardening of the arteries, heart disease and disease of the blood vessels.

Neurological 1, 4, 5
Hardening of the arteries, heart disease and disease of the blood vessels.

Endocrine 1, 4
Hardening of the arteries, heart disease and disease of the blood vessels.

Chronic illness 3, 3, 4, 5
Hardening of the arteries, heart disease and disease of the blood vessels.

Metabolic syndrome
Hardening of the arteries, heart disease and disease of the blood vessels.

Psychological factors involved in ED 1,6

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Psychological factors can negatively effect nerves in the brain that send signals down through nerves in the spinal column and to the penis. The abnormal nerve signals prevent the muscles along the penis from relaxing. In so doing, blood flowing through the arteries that fill and expand the penis is blocked and the penis remains flacid. 1, 6

What can you do to reduce risk?1,3,4,5

Lifestyle choices that contribute to heart disease and vascular problems increase the risk of ED. Smoking, drinking alcohol excessively, being overweight, and a lack of physical activity are also possible causes of ED.

Regular exercise and maintaining a healthy weight can help to reduce the chances of a recurrence of ED. They can also help to reduce your risk of getting a heart attack or stroke. 1, 3, 4, 5

Most doctors suggest less invasive treatments and will only consider more invasive treatments such as surgery if there are no other options. Moreover, making healthy lifestyle changes may solve the problem without any need for more serious treatments. 1

How is ED diagnosed? 1,3

Your doctor will ask you questions about your medical and sexual history diseases can lead to ED. 1

Also, a simple discussion about sexual activity might identify treatable sexual problems. Bear in mind that drug effects are a frequent cause of ED so you must tell your doctor which prescription drugs or other medications e.g homeopathic or over the counter remedies you have used or are still using.

In consultation with your doctor you might need to consider cutting back on or replacing medicines that could be causing ED. 1

Your doctor might also give you a physical examination, which can identify any general nervous system, hormonal or blood problems which may be causing the ED. 1 Usually, this is enough for your doctor to recommend a treatment. However, if your doctor suspects that other underlying problems are involved they will do more tests or refer you to a specialist.1, 3

Treatment options

There are various effective treatment options available, oral and otherwise, and each comes with its own set of advantages and disadvantages. 1

Oral medications take the form of PDE-5 inhibitors, which improve blood flow to the penis. This allows a man to more easily achieve an erection naturally through sexual stimulation. 1, 3 Occasionally, men suffering from low testosterone may experience improved sexual function if they take testosterone. 3, 8, 9 Men who are on nitrate medications, commonly used to treat angina, should not take PDE-5 inhibitors. 3

Prior to starting a treatment programme consider how it will fit in with the lifestyle and how it will impact on your relationship with your sexual partner. You doctor can help you to decide the best treatment option for you.

1. National Institute of Diabetes and Digestive and Kidney Disease. Erectile Dysfunction. National Kidney and Urologic Diseases Information Clearinghouse. NIH Publication No. 09-3923 June 2009. Cited 10 Sept 2013. Available from: http://kidney.niddk.nih.gov/kudiseases/pubs/ed/

2. Jackson G, Boon N, Eardley I, et al. Erectile dysfunction and coronary artery disease prediction: evidence-based guidance and consensus. Int J Clin Pract 2010;64(7):848-857.

3. Wespes E, Eardely I, Giuliano F, et al. Guidelines on Male Sexual Dysfunction: Erectile dysfunction and premature ejaculation. European Association of Urology c2013. Cited 10 Sept 2013. Available from: http://www.uroweb.org

4. Whittaker C. Phosphodiesterase type 5 inhibitors and erectile dysfunction. SA Fam Pract 2010;52(3):207-211.

5. Porst H, Burnett A, Brock G, et al. SOP Conservative (Medical and Mechanical) Treatment of Erectile Dysfunction. J Sex Med 2013;10:130-171.

6. T. Lue, F. Giuliano, S. Khoury, et al. Clinical Manual of Sexual Medicine: Sexual Dysfunctions in Men. Publisher Health Publications Ltd. 2004. ISBN: 0954695615, 9780954695613

7. National Heart, Lung and Blood Institute. NIH. What is Metabolic Syndrome? Cited 10 Sept 2013. Available from: http://www.nhlbi.nih.gov/health/health-topics/topics/ms/.

8. Carnegie C. Diagnosis of Hypogonadism : Clinical Assessments and Laboratory Tests. Rev Urol 2004;6(suppl 6):S3-S8.

9. Syndromes. J Clin Endocrinol Metab 2010; 95:0. Cited 3rd March 2014. Available from: www.hormone.org

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