Patients can discuss some symptoms with their GP in remarkable detail – bowel movements, rashes and suspicious toenails among them. But other problems can make eye contact suddenly feel like an Olympic event. Erectile dysfunction (ED) is often one of those subjects.
Men may spend several minutes circling around the issue in the consulting room before finally saying what they mean. “Everything’s fine, really. It’s just… things aren’t working quite as well as they used to.”
In most cases, “things” means their penis.
Erectile dysfunction is the repeated difficulty of getting or keeping an erection firm enough for sex. Although discussing it can feel embarrassing, ED is extremely common. It can affect men at any age, but the likelihood increases with age.
Most men experience occasional problems getting an erection at some point.
Stress, tiredness and drinking too much alcohol can all play a part. Sometimes, the mind simply chooses the least helpful moment to focus on tomorrow’s work meeting, rather than the situation at hand.
A single unsuccessful sexual experience does not necessarily signal a serious medical problem. However, if difficulties become a recurring pattern, it is important to seek advice.
Although an erection may seem simple, it depends on a complex chain of events. The brain, nerves, hormones and blood vessels must all function together effectively.
Sexual stimulation sends signals that prompt the blood vessels supplying the penis to relax and widen. This allows increased blood flow, resulting in an erection.
If any part of this process is disrupted, achieving or maintaining an erection can become more difficult.
Dr Raj Arora says the most important thing she wants men to know, however, is that ED isn’t a verdict on your masculinity
That is why erectile dysfunction is not always solely a sexual health issue. In some cases, it may offer an early indication of a problem elsewhere in the body.
Health conditions that affect the blood vessels and nerves – including high blood pressure, high cholesterol, diabetes and cardiovascular disease – can all contribute to erectile problems.
Narrowed or damaged blood vessels may limit the circulation needed for an erection. Diabetes can be particularly damaging because it may affect the nerves involved in sexual function. Smoking, obesity and drinking excessive amounts of alcohol can raise the risk further.
The blood vessels supplying the penis are relatively small. As a result, erection problems can sometimes develop before more familiar signs of cardiovascular disease become apparent.
It may be tempting to order Viagra online, delete the browsing history and hope the problem disappears. But persistent ED should be discussed with a GP, as it can be an early warning sign of an underlying health condition.
Erectile dysfunction can also have other physical causes.
Low testosterone may sometimes be involved, particularly when erection problems occur alongside symptoms such as a reduced sex drive.
Some medicines can contribute to ED, including certain antidepressants and blood pressure treatments. Neurological conditions, prostate treatment and pelvic surgery may affect erectile function as well.
Yet one of the biggest misunderstandings about ED is the belief that its causes are always physical.
Your brain is very much involved in sex, sometimes rather inconveniently. And a number of psychological factors – stress, anxiety, depression – can interfere with the brain signals involved in sexual arousal.
When you are anxious, for instance, your body shifts into its ‘fight or flight’ response, releasing stress hormones such as adrenaline. That is useful if you need to run away from danger, but rather less helpful when you are trying to have sex.
Relationship difficulties can have a similar effect by reducing arousal or increasing anxiety.
And once ED happens once or twice, it can create a particularly unhelpful vicious circle: you worry it will happen again, that anxiety makes it harder to become aroused, and so you struggle with your erection. Next time, you worry even more.
Essentially, the moment you start desperately thinking, ‘Please work, please work, please work’, your brain can become spectacularly unhelpful.
One useful clue that there may be a psychological component to ED – ie performance anxiety – is whether you still experience erections at other times, such as when waking in the morning or during masturbation.
Morning erections occur naturally during certain stages of sleep and do not necessarily require sexual thoughts or stimulation.
If erections are happening normally in some situations but not others, it suggests the physical mechanisms are capable of working and that psychological or situational factors may be playing a part. It isn’t a perfect test, but it can be a useful clue.
So when should you see your GP?
If it happened once after a stressful week and several glasses of wine, you probably don’t need to panic.
Dr Raj says when you are anxious, for instance, your body shifts into its ‘fight or flight’ response, releasing stress hormones such as adrenaline
If it is happening repeatedly, has persisted for several weeks, is affecting your relationship or confidence – or you have other symptoms – book an appointment.
And please don’t be embarrassed. GPs talk about erections. We talk about vaginas, discharge, testicles, piles, sex and bowel habits. Nothing you say will be the most unusual thing we have heard that week and, quite possibly, not even that morning.
Depending on your history, we might check your blood pressure and arrange blood tests looking at things such as blood sugar, cholesterol and sometimes testosterone.
Treatment then depends on what we find.
Lifestyle changes aren’t particularly glamorous, but they matter.
Stopping smoking, reducing excessive alcohol intake, exercising regularly, maintaining a healthy weight and managing conditions such as diabetes and high blood pressure can improve erectile function as well as your overall health.
Medication can also be extremely effective.
Drugs such as sildenafil (better known by the brand name Viagra) and tadalafil (Cialis) work by relaxing the smooth muscle in blood vessel walls, allowing more blood to flow into the penis when you are sexually aroused.
They don’t automatically produce an erection the moment you swallow a tablet, despite what decades of comedy might have led you to believe. Sexual stimulation is still required.
They are also not suitable for everybody. In particular, they can interact dangerously with nitrate medicines used to treat angina, which is another reason to seek proper medical advice rather than buying medication online.
If anxiety or relationship difficulties are contributing then psychological therapy or psychosexual counselling can be valuable.
And if first-line treatments don’t work, that isn’t the end of the road. Other options and specialist services are available.
Perhaps the most important thing I want men to know, however, is that ED isn’t a verdict on your masculinity.
And if things aren’t quite working as they used to, resist the very male temptation to ignore the problem for six months in the hope that it will magically sort itself out.
More often than not, it won’t. And if it doesn’t, it can tell us rather more about your health than you might expect.
