Erectile dysfunction: causes, treatment and what is proven to help

What erectile dysfunction is and how common it is

Erectile dysfunction means being unable, over at least three to six months, to achieve or maintain an erection sufficient for satisfying intercourse. Occasional failure when tired, after alcohol or under stress is normal and not a disease.

The Massachusetts Male Aging Study, the largest population study on the subject, found erectile dysfunction in 52 percent of men between 40 and 70: 17 percent mild, 25 percent moderate, 10 percent complete. Complete dysfunction rose from 5 percent at 40 to 15 percent at 70. Younger men are affected too; in them psychological causes predominate. The number of unreported cases is high because many men wait years before speaking about it. That is the most important reason to offer a discreet video consultation.

How an erection arises and what disrupts it

An erection is an interplay of nerves, vessels, hormones and psyche. On sexual arousal nerves release nitric oxide, the arteries of the erectile tissue widen, the tissue fills with blood and compresses the veins so that blood cannot drain. The messenger that maintains the vessel dilation is broken down by the enzyme phosphodiesterase-5; this is where PDE5 inhibitors act.

Nature Reviews Disease Primers summarises the causes as follows:

• Vessels. Atherosclerosis from high blood pressure, diabetes, raised lipids, smoking and overweight is the most common cause in men over 40. The penile arteries are narrower than the coronary arteries, so vascular disease shows there earlier, often three to five years before a heart attack or stroke.
• Nerves. Diabetic nerve damage, slipped discs, multiple sclerosis, surgery on the prostate or rectum.
• Hormones. Testosterone deficiency, thyroid disease, raised prolactin.
• Medicines. Beta blockers, thiazide diuretics, many antidepressants, antiandrogens, opioids; also alcohol, nicotine and drugs.
• Psyche. Performance anxiety, pressure, depression, stress, relationship conflict. They amplify every physical cause and are themselves amplified by every failure.

Indications of a mainly psychological cause are sudden onset, situational problems and preserved morning erections. A gradual onset and absent morning erections point to a physical cause.

Why the assessment is more than a prescription

The European urology guideline recommends for every case of erectile dysfunction a history with a validated questionnaire, an assessment of cardiovascular risk and, depending on findings, laboratory values: fasting glucose or HbA1c, lipids and, with symptoms of testosterone deficiency, morning total testosterone. Blood pressure and waist circumference are part of it. The reason is simple: anyone who takes erectile dysfunction seriously as an early warning sign can prevent heart attack and stroke years earlier.

This is exactly the assessment the video consultation at OpenClinic24 provides: the doctor discusses onset and course, pre-existing conditions, medicines, lifestyle and exercise tolerance, clarifies contraindications and decides on a prescription. You measure blood pressure at home or at the pharmacy; laboratory values can be added via your GP. With indications of heart disease, neurological causes or testosterone deficiency you receive a clear recommendation for further examination.

Treatment: what the evidence says

Lifestyle first, even if it sounds unspectacular

In the randomised trial by Esposito and colleagues in JAMA, overweight men with erectile dysfunction lost an average of 15 kilograms through dietary change and exercise; a third then achieved normal erectile function, hardly anyone in the control group. A systematic review in Sexual Medicine confirms: 40 minutes of moderate to vigorous endurance training four days a week measurably improve erections, particularly clearly in men with overweight, high blood pressure or vascular disease. Stopping smoking, less alcohol, a Mediterranean diet, enough sleep and pelvic floor training complement this. These measures work more slowly than a tablet, but they treat the cause.

PDE5 inhibitors: first choice of drug therapy

Sildenafil was the first substance of this class in 1998. In the approval trial by Goldstein and colleagues in the New England Journal of Medicine, 56, 77 and 84 percent of men on 25, 50 and 100 mg reported improved erections, compared with 25 percent on placebo. Today four substances are available:

Substance	Onset	Duration	Notes
Sildenafil	30 to 60 minutes	4 to 5 hours	A fatty meal delays the effect
Tadalafil	30 to 120 minutes	up to 36 hours	Also as a low daily dose, independent of meals
Vardenafil	30 to 60 minutes	4 to 5 hours	Also as an orodispersible tablet
Avanafil	15 to 30 minutes	about 6 hours	Fastest onset

All PDE5 inhibitors amplify the erection on sexual arousal; without stimulation nothing happens. Common side effects are headache, facial flushing, blocked nose, heartburn and, with sildenafil, transient visual changes. The combination with nitrates and the NO donor molsidomine is prohibited because blood pressure can fall to life-threatening levels. Caution applies with alpha blockers for prostate symptoms, severe liver or kidney disease and unstable heart disease; anyone who cannot climb two flights of stairs without symptoms needs a cardiological assessment first.

German statutory health insurers do not reimburse ED medicines (section 34 SGB V). The substances are available as generics and have become considerably cheaper. Buy them exclusively from pharmacies on prescription; a large proportion of the products offered online without prescription are counterfeit, wrongly dosed or contaminated.

If tablets are not enough

About one in four men does not respond sufficiently to PDE5 inhibitors, often with diabetes or after prostate surgery. Then intracavernosal injections with alprostadil, urethral pellets, vacuum pumps and low-intensity shockwave therapy, whose evidence the guideline rates as limited, come into consideration in the urology practice. The last step is a penile implant; satisfaction among patients and their partners is above 80 percent in studies.

Treating the psychological component

Performance anxiety keeps many cases of erectile dysfunction going, even if they began physically. Sex or couples therapy, often combined with temporary medication that restores confidence, is effective. With depression or marked anxiety the underlying condition is treated too; it is worth looking at medicines that themselves cause erectile dysfunction.

Testosterone and erection

Testosterone deficiency is the cause in only a small proportion of men but then plays an important role for desire and erection. With reduced libido, absent morning erections, tiredness and loss of muscle mass, a morning measurement of total testosterone on two different days is part of the assessment. Only with a proven deficiency and matching symptoms is testosterone therapy sensible; it can then also improve the effect of PDE5 inhibitors. With normal values it has no benefit and carries risks. More in the article on testosterone deficiency.

Erectile dysfunction in younger men

In men under 40 psychological and situational causes predominate: performance pressure, insecurity in a new relationship, stress, lack of sleep, alcohol or comparison with unrealistic images from pornography. Typically the erection is normal during masturbation and in the morning and fails only in the situation with a partner. Here a tablet helps in the short term because it restores confidence; in the long term conversation, less pressure and, if needed, sex therapy solve the problem. Nevertheless, even in young men it is worth checking blood pressure, weight, smoking and blood sugar, because early vascular disease is rare but not excluded, and medicines such as antidepressants or hair loss treatments that can promote erectile dysfunction.

Checking medicines as a cause

One of the most productive questions in the consultation is: what changed before the problems began? Often it is a new medicine. Beta blockers and thiazide diuretics for high blood pressure, many antidepressants from the SSRI group, antipsychotics, antiandrogens for prostate disease, finasteride for hair loss, opioids and some acid blockers can impair erections. Do not stop anything on your own; there is often an equivalent alternative without this side effect, for example an ACE inhibitor or sartan instead of the beta blocker. The doctor can coordinate this with the prescribing practice. Alcohol, cannabis and nicotine also belong on this list: nicotine constricts vessels immediately, and just two weeks without smoking measurably improve erections in many men.

Talking helps, also with your partner

Erectile dysfunction burdens relationships above all through silence. Partners often interpret withdrawal as lack of interest. An open conversation removes pressure, and pressure is the erection’s greatest enemy. Anyone who shies away from visiting a practice can start with the video consultation: it is confidential, takes a few minutes and provides a medical assessment that leads somewhere.