Erectile dysfunction: Breaking the taboo

Why is it important we speak about erectile dysfunction?

I think it is time that we talked about this often-taboo topic. In my experience, so many of my male patients will present with a different medical problem first and then disclose at the end of the consultation that, actually, their main worry is erectile dysfunction (ED). I want people to know that there is no need for fear or stigma and just talking about it is likely to help.

Do you see a lot of patients with ED?

Yes, it’s a common problem we encounter in primary care. It can occur at any age but becomes more common with increasing age. Approximately 50% of men between the ages of 40-70 and 70% of men aged 70+ have ED.

An important new pattern I am seeing is that more younger men are presenting with ED concerns due to social media targeted selling of ED/testosterone medications and health anxiety from Googling afterwards.

What causes it?

Broadly speaking, ED can have medical and/or psychological causes. For example:

1) Medical causes

• Reduced blood flow to the penis – this can be caused by high cholesterol levels narrowing the blood vessels or high blood pressure damaging the blood vessels
• Diabetes – persistent high blood sugar causes damage to the small blood vessels and nerves in the penis
• Low testosterone – this is a critical sex hormone in men. Low levels can be due to problems with signalling from a gland in the brain or due to production in the testicles
• Medication side effects – regular use of many drugs such as antidepressants, opiates and some blood pressure tablets
• Lifestyle – smoking and abuse of alcohol/recreational drugs

2) Psychological causes

• Performance anxiety – anticipation due to pressure
• Conscious/subconscious stress – anxiety and depression from work/family can manifest as ED
• Relationship problems – having frequent conflict with your partner can result in less arousal and affection
• Sexuality uncertainty – accepting you may have a different sexual orientation rather than forcing sexual feelings
• Hardcore or overuse of pornography – this can cause normal physical sexual encounters to seem under stimulating, as the threshold for arousal has been modified

What questions will a doctor usually ask during a consultation about ED?

Your doctor will usually ask a number of different questions, some more general, others more specific. Commonly asked questions include:

• How long has it been going on for?
• Does it happen every time you want an erection?
• Do you have difficulty initiating an erection and/or sustaining an erection?
• Can you still get an erection from masturbation?
• Are you able to ejaculate?
• How often do you get spontaneous morning erections?
• Do you have any testicular asymmetry?
• Do you still have a libido for sex or pornography?
• Are you sexually attracted to your partner?
• Are you stressed/anxious/depressed?
• Are you using any medications/drugs?

How is a doctor likely to investigate it?

Your doctor will usually do the following:

• Blood pressure
• Testicular examination if indicated
• Blood tests: early morning testosterone level, diabetes and cholesterol screen

If the investigations are normal, we usually accept that the cause is likely to be psychological rather than medical.

What is the best medicine for ED?

It’s so easy to succumb to the advertising and easy internet delivery offers for private prescriptions of the “little blue pill for erections” known as Sildenafil (Viagra). Viagra is very useful in certain cases and not so useful in others. For some, turning to medication first can lead to performance dependency and a delay in identifying a possible underlying cause, such as high cholesterol or low testosterone.

In my opinion, the best medicine is talking - ‘the truth shall set you free’! It may be a cliché but talking helps whatever the underlying cause. So many of my patients report feeling relieved to have just vocalised the problem to another person. Learning about what causes ED can empower many men to address psychological and lifestyle factors. As openness is key, I also often encourage patients to speak to their partner and bring them to follow up if they wish.

Due to the fact that it’s considered a sensitive problem, so many men avoid talking to their friends or family about this due to embarrassment. Smash the stigma and speak to your doctor!