Erectile dysfunction
Every man has an off night — after no sleep, one drink too many, a hard week, or for no obvious reason at all. That is not an illness and needs no treatment.
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Medicines commonly prescribed for Erectile dysfunction
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 25 mgActive substance: sildenafilManufacturer: Krka D.D. Novo MestoPrescription requiredDosage form: TABLET, 5 mgActive substance: tadalafilManufacturer: Industria Quimica Y Farmaceutica Vir S.A.Prescription requiredDosage form: TABLET, 100 mgActive substance: sildenafilManufacturer: Ratiopharm GmbhPrescription required
Every man has an off night — after no sleep, one drink too many, a hard week, or for no obvious reason at all. That is not an illness and needs no treatment. The conversation begins where the failures stop being occasional: they go on for months and get in the way of living. At that point there is almost always something specific behind them, and that is the main news, because erectile dysfunction is rarely a problem that travels alone. Far more often it is the first visible sign of another condition the man does not yet know he has. Which is why it is worth seeing a doctor about it for reasons well beyond the bedroom.
When it counts as a problem
We are talking about a disorder when the erection is consistently not firm enough for sex — either it does not come at all or it fades halfway — and this has been going on for at least several months. Isolated failures do not belong in that picture.
It becomes considerably more common with age: from forty onwards roughly half of men experience it to some degree. But common is not the same as normal and best left alone. Age by itself does not cancel an erection; it merely gives more time to the processes that spoil one — and those processes can be worked on.
It is also worth separating three things that get muddled constantly: low desire, premature ejaculation and difficulty with erections are different problems, with different causes and different treatments. They can travel together, but the doctor needs to understand which of them is actually troubling you.
What points to the cause
Before any talk of tests it helps to answer a few questions for yourself. The doctor will ask them anyway, and they already explain a good deal.
- Are there erections in the morning and during the night? If those are intact but things do not work with a partner, the machinery is fine and the trouble is most likely in the head: anxiety, expecting failure, the relationship, depression.
- Did it start abruptly or build up over years? A sudden onset tied to a particular event also points to a psychological origin — or to a new medicine. Slow decline over several years is typical of vascular causes.
- Is it always, or only in certain circumstances? If it fails with one partner while another situation is fine, the body is not the issue.
- Has a new tablet appeared in your life? Trouble starting within weeks of a new drug is a strong lead.
The simple rule: preserved morning erections and a sudden onset tilt towards a psychological cause; their disappearance and a gradual decline tilt towards a physical one. Pure cases are rare, though. Anxiety layers itself onto any physical cause within weeks, the circle closes, and both sides have to be untangled at once.
Why this is a conversation about blood vessels and the heart
An erection is first and foremost blood flow. Anything that disturbs the arteries therefore shows up here before anywhere else, and this is why it matters more than it seems: the arteries of the penis are appreciably narrower than the coronary ones. A plaque of the same thickness will narrow a narrow vessel long before it narrows a wide one. Put plainly, the arteries send their signal where the channel is smallest, and the heart's turn comes later.
On average, erectile dysfunction runs several years ahead of the first signs of coronary heart disease. That is not a reason to be frightened but an unusual opportunity: you have years of warning in which to check your blood pressure, cholesterol and glucose, stop smoking and start moving — that is, to intervene before a heart attack rather than after one.
This is why a proper appointment about erections always includes a conversation about blood pressure, weight, smoking, glucose and cholesterol. If instead a tablet is written out and you are sent home, the most important part of the job has been left undone.
What else lies behind a failing erection
- Diabetes is among the commonest causes. It damages both the vessels and the nerves, so the problem starts earlier and responds less well to treatment. Sometimes it is this very complaint that leads to the diabetes being found.
- Medicines. The list is long: some blood pressure drugs, certain water tablets, antidepressants, antipsychotics, and treatments used for an enlarged prostate and for prostate cancer. Do not stop anything on your own — abruptly dropping a blood pressure medicine is more dangerous than any trouble in bed. Tell your doctor and there is almost always a substitute.
- Hormones. Low testosterone usually shows itself not through erections alone but as a cluster: desire fades, tiredness grows, muscle is lost. Thyroid disease and a raised prolactin also play a part.
- Smoking, alcohol, excess weight and inactivity — the contribution of each is well studied and, more to the point, reversible.
- Surgery and injury in the pelvis, above all prostate operations, spinal cord injury and radiotherapy.
- Neurological illness: multiple sclerosis, Parkinson's disease, the aftermath of a stroke.
- Peyronie's disease — scar tissue inside the penis that bends it and makes the erection painful and incomplete. Here the plaque itself is dealt with first.
- Depression and anxiety disorders, along with exhaustion from chronic lack of sleep and from sleep apnoea: snoring with pauses in breathing is worth investigating separately.
What you can do yourself
This is one of the rare cases where a person's own effort genuinely changes the outcome: lifestyle changes improve erections about as much as some drugs do, and they work for the heart into the bargain.
- Stopping smoking is the most effective single move. The improvement does not arrive at once, but it arrives.
- Losing weight where there is excess: fatty tissue shifts the hormonal balance, and spare kilos almost always come packaged with high blood pressure and high glucose.
- Moving regularly. Walking, cycling or swimming several times a week is enough; endurance exercise helps most.
- Cutting down on alcohol. A small amount relaxes, a large one reliably gets in the way, and a habitual daily intake damages both vessels and hormones.
- Sorting out sleep and reducing the load as far as it is within your power.
- If you cycle a great deal, try an anatomical saddle and take breaks on long rides: pressure on the perineum disturbs both blood flow and sensation.
- Talking to your partner. Silence and avoiding intimacy wind the anxiety up more than the problem itself does.
How the appointment goes
There is nothing alarming about it and most of it is conversation. You will be asked how long this has been happening and in what circumstances, whether there are morning erections, what medicines you take, and how things stand with blood pressure, weight, smoking, sleep and mood.
After that, blood pressure and waist measurement are taken and the external genitals and testicles examined; if there are urinary symptoms, the doctor may suggest examining the prostate. Of the tests, the usual ones are blood glucose or glycated haemoglobin, a lipid profile and testosterone — taken in the morning while fasting and, if abnormal, always repeated, because a single result says very little. Thyroid hormones and prolactin are added where indicated. An ultrasound scan of the penile vessels is not for everyone but for particular cases: suspected injury, or when surgery is being considered.
How it is treated
Two things always start together: treating the cause that has been found and restoring the erection itself. Neither replaces the other.
The main drugs are PDE-5 inhibitors: they do not create an erection by themselves but amplify the natural response to arousal, so without desire and stimulation they do nothing. Within the group the drugs differ in how quickly and how long they act, and a suitable one can usually be found. Things worth knowing in advance:
- they must never be combined with nitrates — the medicines taken for angina, including glyceryl trinitrate under the tongue. The combination drops blood pressure sharply and is life-threatening. Tell your doctor about everything you take, and if you are already on one of these drugs and chest pain develops, say so to the ambulance crew;
- they call for caution in certain heart conditions and alongside some blood pressure and prostate treatments;
- common side effects are headache, facial flushing, a blocked nose and heartburn;
- "it didn't work" often means "it wasn't taken properly": with some of these drugs a heavy fatty meal blunts the effect, and the result should be judged after several attempts rather than one.
Buying these medicines online is a poor idea. Counterfeits make up an enormous share of that market: a packet may contain no active ingredient at all, or more than stated, or something else entirely. For a man with heart disease that is not a theoretical concern but a real risk. A prescription and a conversation with a doctor cost less than the consequences.
When tablets are unsuitable or ineffective, plenty of options remain: vacuum devices, injections of vasodilator drugs into the penis, and preparations placed into the urethra, all of which are taught at the appointment. Testosterone replacement makes sense only where a deficiency has been confirmed, not as a general tonic: without a deficiency it does not help, while it does suppress the body's own hormone production and sperm production. Where the psychological component is prominent, or the difficulty belongs to the couple, psychotherapy works well, including as a couple. In severe cases, once everything above has been exhausted, there is a surgical solution: an implanted prosthesis.
When not to wait for an appointment
There are a few situations in which the clock does not run in weeks.
- An erection that will not go down after four hours, particularly a painful one. This is called priapism and it is an emergency: without blood the tissue begins to die, and delay threatens permanent loss of function. What is needed is not a consultation but immediate care — an ambulance or the nearest emergency department. The single European number is 112.
- Sudden loss or sharp deterioration of vision in one eye, or sudden loss of hearing or ringing in the ears after taking a drug for erections. Stop it at once and see a doctor the same day.
- Chest pain or tightness and breathlessness on exertion in a man with erection problems: grounds for investigating the heart without delay rather than on a routine waiting list.
- A sudden painful bend in the penis, or an injury during intercourse with a cracking sensation and swelling, belong in the same category.
Online consultation
This is exactly the sort of subject where a remote appointment is often easier than a face-to-face one: what delays people here is embarrassment, and over video the conversation comes more readily. The doctor will work out what is happening and what it resembles, help separate the psychological part from the physical, go through your list of medicines and find the culprit if one is there, explain which tests are worth having and how to have them done properly, and consider whether treatment suits you given your heart and your other drugs. Results you already hold can be reviewed in the same appointment. A face-to-face examination will still be needed for curvature and pain, for suspected prostate problems, and where vascular studies are required. And for an erection that will not subside or a sudden loss of vision, what is needed is urgent care rather than a consultation.
This material is for information only and does not replace medical advice.
Consult with a doctor about Erectile dysfunction
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Online doctors for Erectile dysfunction
Discuss your symptoms and possible next steps for Erectile dysfunction with a doctor online.
