Erectile Dysfunction

Erectile dysfunction is diagnosed when a man has difficulty achieving and/or maintaining an erection when experiencing sexual arousal. This means he becomes unable to engage in satisfactory sexual intercourse. Caused by a lack of blood flow to the penis, it can eventually lead to other problems and mental health issues such as anxiety, relationship difficulties and loss of self-esteem.^[1]

How does an erection work?

In simple terms, an erection is the process of the increased blood flow into the corpora cavernosum causing the penis to become enlarged, elongated and firm.

For this to occur, there is a series of complex processes that need to happen, beginning in the brain. The erection process starts with mental or sensory stimulation caused by arousal.

When this happens, impulses are sent from the brain to local nerves to instruct the muscles around the corpora cavernosum to relax. This allows blood to flow in through the penile artery and the penis expands. The blood flow to the penis at this point can be eight times that of the normal blood flow.

At the same time, the tunica albuginea membrane around the corpora cavernosum stretches and blocks off the veins that drain the blood. The blood is now trapped in the penis, and the pressure increases allowing the penis to become, and remain, erect. At this point, the blood pressure in the penis can be as much as twice as high as in the rest of the body's circulation system.

An erection is stopped when the muscles in the penis contract. The tunica contracts and opens up the channels for draining blood. The deoxygenated blood is then carried away via the deep dorsal veins and the penis becomes flaccid.

Is it the same as premature ejaculation?

No. Whilst both fall under male sexual dysfunction, they are separate conditions. Impotence is the inability to achieve or sustain an erection after arousal, whilst premature ejaculation occurs when a man can achieve/sustain an erection but reaches orgasm before a satisfactory duration.

Penile anatomy

The penis consists of three main sections or parts:

1. The Root: This refers to where the penis attaches to the pelvic wall and the abdomen.
2. The Shaft (or Body): This is the longest part of the penis and is the visible part that extends from the root to the head of the penis.
3. The Glans (or Head): This is the cone-shaped head at the top of the penis. The ridge that separates the shaft from the glans is called the corona. A loose fold of skin called the prepuce, or foreskin, covers the Glans of the penis in uncircumcised men.

The shaft of the penis is made up of three columns of erectile tissue, which can be seen in the diagram below.

• Corpora Cavernosum: These are the two columns of erectile tissue that run along the sides of the penis and fill up with blood during an erection. They contain supporting fibres called Trabeculae and Cavemosal spaces. They are partially separated by the Septum, a fibrous partition.
• Corpus Spongiosum: This is the third column of erectile tissue that runs along the front of the penis. The Urethra runs through the Corpus spongiosum, carrying urine out of the body.
• Tunica Albuginea: This is the membrane that surrounds the corpora providing a tough outer sheath.
• Deep Dorsal Vein: This vein runs the length of the penis shaft. It drains the deoxygenated blood from the glans.
• Cavemosal Artery: These are deep-paired arteries than run near the centre of each of the corpus cavernosum. They allow blood to flow to and fill the corpora.

Erectile dysfunction (ED) can be caused either by psychological or physical issues, or sometimes a combination of the two. A great way for a man to identify the underlying cause is usually to see whether an erection occurs naturally in the morning or if there is a general struggle to achieve an erection when aroused. If this is the case, then there are various physical or psychological causes that can be looked at. The primary cause of erectile dysfunction is linked to old age with the following chart detailing just how significant this is. However, it is important to note that, as you can see, a large percentage of men affected are below the age of 40.

Some of the most common causes of impotence can also include:

Physical vs psychological causes of impotence

When erectile dysfunction is observed in young males, it is often assumed that it is psychological, however, a physiological issue cannot always be ruled out. This is why it is important to speak with a medical professional such as a urologist when first being diagnosed with erectile dysfunction.

Stress, testosterone levels, depression and relationship problems can all contribute to erectile problems. Older men experience erectile dysfunction at a higher rate than younger men, so if you are in the 60+ age bracket then it really is nothing to be alarmed about, as it affects around 40% of men in that demographic.^[2]

Stress & Depression

ED can be exacerbated through stress at work or at home, as well as bouts of depression. This is mainly because the science behind the erection process is reliant on a delicate balance of hormones and nerve impulses, which can sometimes be disrupted by depression. Like anxiety, depression can also be brought on by sexual dysfunction itself, due to a loss of confidence and feelings of inadequacy.

Low testosterone levels

The level of testosterone in the male body gradually decreases with increasing age, for some men more than others. If you think you have low testosterone, it is always wise to get this checked by a doctor as you may benefit from male hormone replacement therapy.

Pornography

Recent studies have suggested that overconsumption of pornography among young males has led to the rise in porn-induced erectile dysfunction, a psychological phenomenon which can only be cured by ceasing pornography consumption and seeking the necessary professional assistance.

Binge drinking and smoking

Lastly, heavy nights out can lead to temporary erection problems. Alcohol and nicotine both affect the blood flow to the penis, and both drinking and smoking can have long-term effects on a man's sexual function.

Erectile dysfunction and psoriasis

Psoriasis is an autoimmune disease that attacks healthy skin cells causing the body to overproduce T-cells (every 3-7 days instead of 3-4 weeks). This results in flaky, silvery patches of skin which generally appear on the elbows, knees, scalp, and back. They can be itchy and lead to an infection if scratched.

In relation to erectile dysfunction, psoriasis has been linked to the sexual condition for the following reasons:

• Psoriasis can appear all over the body, including the penis.
• The condition can affect your self-esteem if you feel embarrassed about the patches.
• Men with psoriasis have an increased chance of experiencing cardiovascular health issues.

There is no cure for psoriasis but you can use creams to sooth the skin and help improve sexual confidence. For extreme cases of psoriasis, phototherapy can be shone onto the affected areas.

Is impotence related to other conditions?

Absolutely. Current medication, lifestyle habits and also mental health can contribute to symptoms of erectile dysfunction.^[3] Take a look at the illustration below to get a better understanding of the wide-ranging reasons why you may be experiencing difficulty achieving and maintaining an erection.

Medications – Beta-blockers used to treat conditions such as high blood pressure for example are known to contribute towards erectile dysfunction.

Being overweight – Being overweight can lead to other health conditions like diabetes and high blood pressure, which are also known risk factors for erectile dysfunction.

Diabetes – Conditions such as type 2 diabetes can damage the nerve and blood vessels in the penis, making it difficult to achieve an erection.

Prostate cancer/surgery – Prostate medications and surgery can lead to erectile dysfunction.

Heart disease – Chronic heart problems can cause the arteries to harden. This can affect the blood supply to the penis, causing erection problems to occur.

Because impotence can sometimes point towards other conditions such as high cholesterol, diabetes and high blood pressure, it is always best to book an appointment with your GP and get advice tailored to your personal situation should you have any reason for concern.

High blood pressure and erectile dysfunction

High blood pressure can have a very negative impact on an individual's sex life, by lowering their libido and making it difficult to achieve and maintain erections.

Over time, high blood pressure which is left untreated can damage the arteries, making it difficult for blood to flow effectively through the body without increased strain on the heart which in turn makes it harder for a man to achieve and maintain an erection. If the heart is overworked, damage can occur to the lining of blood vessels and lead to atherosclerosis - a narrowing and hardening of the arteries.

If the arteries to the penis and pelvic organs are affected by atherosclerosis, the narrowed arteries may not be allowing enough blood to be delivered to the penile tissue to develop and maintain an erection. It has also been suggested that the more advanced your atherosclerosis is, the more severe your erectile dysfunction will be.

Erectile dysfunction as a side effect of medication

Certain medications used to treat high blood pressure can cause erectile dysfunction as a side effect. This situation can be a frustrating 'catch 22' for many men. If left untreated their high blood pressure can cause erectile dysfunction, but the treatment to control their blood pressure can in itself cause it.

This concerns beta blockers, which affect the same nerves that allow erections, and diuretics that can interfere with the intensity of blood flow to the penis. If you are finding your medication is negatively affecting your sex life, it is important to speak to your doctor. There are alternative medications that may avoid these side effects.

What does research show?

The British Heart Foundation conducted a survey of nearly 2,000 people in 2014. They found that 70% of men with heart problems had issues with erectile dysfunction. Of those with issues, 46% felt their medication was responsible, 36% felt it was a combination of their condition and their medication and 18% blamed their condition alone.

This finding is consistent with research published in the International Journal of Impotence Research, which found, across multiple studies, that 67-68% of men with hypertension reported difficulties with erectile dysfunction. In fact, this rose as high as 77% when they looked at those suffering from hypertension and diabetes.

It also found, that in addition to being more prevalent, hypertension also influenced the severity of erectile dysfunction issues. For general sufferers of erectile dysfunction, only 10% describe their issues as severe. However, in the case of men with hypertension, a staggering 45% describe their issues as severe.

Getting the help you need to restore your erectile health doesn't only extend to your sexual activity, it can have wide-reaching positive consequences for your entire life. Due to the way it can increase your confidence, you may feel more motivated to make the changes you were previously putting on hold. Confidence is a significantly important factor in men's wellbeing and self-esteem, so it makes perfect sense to ensure it is at the highest it can be.

• Ability to achieve a stronger erection
• Possible increase in self-esteem and sexual confidence
• Ability to sustain a stronger erection
• Improved blood circulation

Furthermore, restoring your sex life to how it was before you started experiencing problems could spur you on to make active changes in other areas of your life. Reducing stress, giving up smoking, cutting back on alcohol and losing weight by having a healthy diet and exercising regularly can not only improve your erectile problems but also your quality of living in general.

Although some cases of erectile dysfunction can be resolved through simple lifestyle changes or psychological help, most cases are longer term and therefore require an effective treatment method. From herbal supplements and natural methods, to prescription medication such as Viagra and Cialis, there are various options available and touted to be effective in treating this condition.

Natural treatments for impotence

According to studies, improving your diet and exercise can help better your erectile dysfunction. As high blood pressure and high cholesterol can damage the arteries, they are less capable of delivering sufficient blood to the penis when aroused. Taking active measures to lower blood pressure and cholesterol has been found to have a positive effect on a man achieving a successful erection. It is documented that certain lifestyle changes can benefit erectile problems in the long run. Whilst eating healthily, reducing your high readings, and lowering your cholesterol are always good things, they are still not guaranteed to be sufficient to treat your erectile problems.

Diet - A healthy diet is linked to low numbers of men reporting erectile dysfunction. So, loading up on fish and low-fat meats, vegetables, whole-grain foods and fruits is certainly a step in the right direction.^[5]

Communication – This could be in the form of counselling, group therapy sessions, or most importantly, discussing your erectile problems with your partner. This isn't to be underestimated. In fact, some of the psychological causes surrounding ED can sometimes be resolved with simple communication.

Alcohol – Studies have shown that alcohol doesn't just create a short-term problem, but symptoms of impotence can often persist for months after stopping heavy drinking.

Smoking – Smoking can clog the arteries and lessen blood flow. Not to forget, nicotine also restricts your blood vessels. So stopping smoking can have a significantly positive effect on ED.

Stress – Some men have found cutting their stress levels (i.e. via meditation) has had a positive effect on both their erection problems and sex drive in general.

Herbal treatments

The use of herbal treatments is very subjective depending on the individual; some react better to these compounds than others. As ED herbal remedies don't have the same success rate as prescription treatments and in nearly all cases are not subject to clinical studies, it is highly advised for you to consult your GP and research the options fully before making your decision.

Counselling

As mentioned under prevention, counselling is a good solution for those with psychologically induced impotence. This is also a promising option when teamed with prescription medication to help really get to the root of the problem.
This can include psychosexual therapy as well as Cognitive Behavioural Therapy (CBT).^[6]

Vacuum Constriction Devices

Vacuum constriction devices (penis pumps) create a vacuum that draws blood into the penis which causes it to swell and become erect. Although there is no proven evidence in the efficiency of vacuum pumps, studies suggest that between 50%-80% of men are satisfied with the results. As the effect is temporary and the usage of respective products doesn't come without risk, it is strictly advised to seek medical assistance before using a VCD.

Surgery

Surgery is usually a 'last resort' method when all other options have proven unsuccessful. Surgery is however usually the first go-to procedure for men who have been in serious accidents, or for men who have damage, disfigurement or anatomical issues with their penis.

Alongside these NHS surgical procedures there are penile implants (semi-rigid and inflatable), which are considered a cosmetic operation, and thus not available on the National Health Service. However, 75% of men report satisfaction with this treatment.

Testosterone replacement therapy (TRT)

Once a man reaches his thirties, his testosterone levels begin to decrease. Things like exercise, a healthy diet and genetics can help prevent large drops until later in life, as can TRT. Get your testosterone levels checked by your doctor if you feel like you have no libido. There is no harm in getting tested, even if just to rule out a deficiency.

Prescription medicines

Oral tablets are the most popular form of erectile dysfunction treatment as they are clinically proven to treat the symptoms of physiologiocally caused impotence through extensive research and strict supervision through governing bodies. They can provide either a long or short-term solution. There are quite a few prescription treatments available with varying dosages and strengths including:

• Viagra
• Sildenafil
• Cialis
• Cialis daily
• Levitra
• Levitra Orodispersible
• Spedra

All of the above work by increasing blood to flow to your penis and are grouped together under a drug class called PDE5 inhibitors. This enables you to achieve a firmer and longer lasting erection. As these medicines are ineffective without sexual stimulation, it is important to address any psychological factors as well as the physiological ones.

Ways to prevent erectile dysfunction will depend on pinpointing the relevant causes for you. This may include physical and psychological causes and therefore a range of treatment options. Often altering lifestyle choices can significantly help, but you may require some additional help in the form of counselling or medication.

Here at HealthExpress we only offer medically proven, prescription medication for this condition. Whilst Viagra is the most popular, there are various other active treatments manufactured with the intent of enabling a man to gain and sustain a stronger erection when previously unable to. Each treatment has its individual benefits although they all work in the same way. For example, Cialis Daily is the lowest dosage and can be taken once-a-day, which can be handy for those requiring spontaneity, whilst Levitra is suitable and effective for those with diabetes or high blood pressure.

We understand that this condition may be embarrassing for some men to discuss with others, which is why we offer this premium service geared towards ensuring that you get the most suitable treatment, discreetly and by the next day (same day if in London). If you're not sure which medication is right for you, you can take our free and quick online consultation and one of our doctors can help to recommend a treatment most suited to your individual circumstances.

What do I do if my ED symptoms persist?

If you are experiencing persistent symptoms of ED, the worst thing you can do is experience this condition in silence. The first thing to do is to discuss your condition with your partner and a doctor for emotional and professional support. Talking to someone can also help you to find out the underlying cause for your erection problems.

If you feel too uncomfortable speaking to your doctor, our discreet and confidential consultation service can help. Our service means you can avoid a face-to-face consultation with the doctor and get your treatment delivered to your door. Just complete our short, no-obligation online consultation, where our doctors can help to find the most effective impotence treatment for you.