Erectile dysfunction (ED), otherwise known as impotence, is a common problem for the aging man. ED is a term that refers to the inability to get or sustain an erection for intercourse. Being unable to sustain an erection once in a while is not a cause for concern and can happen for many reasons. However, when this is happening on a regular basis it can be very disconcerting for the man and his partner.
Studies suggest that 15% of men over 70 years of age are impotent all of the time while all men over 60 years occasionally have a problem. Indeed, approximately 5% of all males their 40’s have ED.1
A family doctor is a good place to start when you have erectile problems. See your doctor if:
You are experiencing other symptoms along with erectile dysfunction, such as decreased sexual desire
The penis is usually in a flaccid state due to the contraction of the corpus cavernosa muscles, which surround the penile artery. During sexual arousal, these muscles relax allowing blood flow into the corpus spongiosum causing the penis to be erect and firm to facilitate penetration. Any process that can damage the blood vessels can impede erection. As you can imagine, a man who has signs of blood vessel disease in other parts of his body, (i.e. angina, high blood pressure, diabetes), will often have ED.
Thus, the vast majority (85%) of ED is caused by arteriosclerosis (hardening of the arteries), which in turn is caused by, smoking2, elevated cholesterol3 high blood pressure, obesity, diabetes and advancing age. Certain other chronic diseases such as multiple sclerosis, spinal cord injury and stroke can also cause ED. Operations of the prostate, bladder and colon can result in some residual ED.
There are a number of prescription and OTC (over-the-counter) medications that list ED as a potential side effect. These include:
If you are taking any of these, discuss changing them with your physician. Do not abruptly stop them.
Other substances, stimulants and depressants, are also known to contribute to ED. These include recreational and frequently abused drugs:
These drugs not only affect and often suppress the central nervous system,
but can also cause serious damage to the blood vessels, leading to permanent ED.
Finally, ED may be attributed to psychological conditions such as depression, stress, martial discord or relationship problems.
Diagnostic workup for ED will include checking for diabetes, B12 and folic acid deficiency (which leads to nerve damage), and elevated cholesterol. If libido is abnormal (i.e. no desire) then a serum testosterone level will be done. A prolactin level may be added to check for a particular brain tumour. When all of these tests are found to be normal, your doctor can offer you treatment.
Treatment for an ED depends on the cause of the problem and may be multifactorial. Your physician will help to determine if the cause is mental, physical, or a combination.
Many doctors approach ED in a step-by-step approach that may include:
Current oral therapies for ED available in Canada include the following:
These medications are phosphodiesterase (PDE) inhibitors and all work in the same way. The first one to be marketed was sildenafil or Viagra. It’s discovery for use in ED was actually serendipitous. Viagra has been touted as the “little blue pill that changed the world”. Prior to sildenafil, the treatment of ED consisted of painful penile injections and suction devices. Happily, sildenafil has altered all of that and has been one of the most successful (albeit expensive) medications ever marketed.
Sildenafil functions to dilate the blood vessels of the penis by increasing nitric oxide (a potent vasodilator). Although it previously was touted as working specifically on the penis, we now know that it can cause dilation of other vessels leading to some unpleasant side effects including headache, stuffy nose, blurred vision and, rarely, blue/green halos around objects.
Because of these side effects, care must be exercised when using sildenafil if you are on antihypertensive medications (specifically beta blockers and nitrates). Further, sildenafil should not be used more than twice per week. It must not be taken if you are on certain medications. These include:
If medical treatment fails, there are some other treatment options that your urologist can discuss with you. One of these is penile implants. The two types of implants available are semi rigid rods or inflatable implants.
Basically a device is surgically inserted into the penis that can be manually inflated to achieve erection. Such devices do have some associated risks including: infection, erosion and failure of the device.
Other treatments for ED include injections, rectal suppositories, penile pumps and an external prosthesis. All of these have their pros and cons and some men may find them unpleasant to use.
In 2020, there are a number of promising trials for new treatment options in ED. Stem cell therapy, platelet rich plasma, vascular stents and shockwave therapy are all being researched and many of these modalities show great promise.
Erectile dysfunction is a common problem that is highly treatable. Your family doctor can guide you through the various causes and effects to arrive at a solution that works for you.
For a thorough review of this subject, I recommend the following on-line resource: UROLOGY HEALTH.
References:
© 2020 “Ask The Lady Doctor” by Dr Shannon Lee Dutchyn, MD, CCFP, FCFP
