What is Erectile Dysfunction or ED?

Erectile dysfunction (impotence) is the inability to develop or keep an erection sufficient for sexual intercourse. 10% of men suffer from impotence and it is seen in almost one third of diabetic men. The ability to develop an erection is an important part of a man’s overall health, regardless of age.

What are the Symptoms of ED?

Symptoms for ED may include:

  • getting an erection, but it not lasting long enough for sex
  • getting an erection, but not when you want to have sex
  • not being able to get an erection at all

ED may be a major warning sign of cardiovascular disease. It can signal blockages in a man’s vascular system. Some studies have shown men with ED

How do normal erections occur?

If a man has to achieve an erection, he needs an adequate circulating level of hormones, an adequate blood flow to the penis, intact nerves supplying the penis and an appropriate sexual desire. If there is a problem with one or more of these mechanisms, erection may fail.

During arousal, nerve impulses travel from the brain to the penis and trigger smooth muscle relaxation in the penis. This encourages blood to flow into the erectile tissues. As the penis fills with blood, it enlarges and becomes erect. During enlargement, the veins in the penis become compressed, blocking the flow of blood out of the penis so that erection occurs. The penis remains erect until orgasm and/or ejaculation is completed or sexual arousal ceases.

What are the causes for erectile dysfunction?

Psychological: ED can be caused by stress, depression, anxiety, relationship problems, embarrassment, guilt and other psychological issues.

Psychological component, often called performance anxiety, is common in men with impotence.

Of the 90% of men who have an underlying physical cause, the main abnormalities found are:

  • Cardiovascular disease in 40%;
  • Diabetes in 33%;
  • Hormone problems (e.g. high prolactin or low testosterone levels) & drugs (e.g. antihypertensives, antipsychotics, antidepressants, antihistamines, heroin, cocaine, methadone) in 11%;
  • Neurological disorders in 10%;
  • Pelvic surgery or trauma in 3-5%; and
  • Anatomical abnormalities in 1-3% (e.g. tight foreskin, short penile frenulum, Peyronie's disease, inflammation, penile curvature).

What happens during initial consultation?

The doctor or nurse will ask about duration and severity of ED, your lifestyle and relationships and any problems you might be having. Basic health checks such as taking your blood pressure, examine your genitals to rule out any obvious physical cause and if you need to pee more often, you may also need to have an examination of your prostate.

Performance Anxiety:

When a man has difficulty getting an erection, whatever the cause, he will often experience pressure to perform especially around the time of ovulation. Reducing the anxiety, having sex every 2-3 days without know the fertile days can help to reduce erectile dysfunction.

What tests are done for erectile dysfunction?

There are some simple blood tests to measure your lipids (cholesterol), blood sugar (diabetes), earlymorning fasting testosterone levels (male hormone), and measuring your blood pressure. In selected cases, penile Doppler scan is done to check blood flow, girth of the penis before and after injection of the medication.

What are the things you can do to help with erectile dysfunction?

Healthy lifestyle changes can sometimes help erectile dysfunction.

Do’s:  lose weight if you're overweight, eat a healthy diet, daily exercise and try to reduce stress and anxiety. Also reducing blood pressure, blood sugar, cholesterol will also help.

Do not: do not cycle for a while and do not drink more than 2units of alcohol a day, Smoking and drug abuse.

Emotional (psychological) problems:

It's more likely to be an emotional problem if you only have erection problems sometime, but not always. For example, you get an erection when waking up in the morning, but not during sexual activity. Anxiety and depression can be treated with counselling and cognitive behavioural therapy.

What treatments are available?

It is up to you and your sexual partner to decide what treatment you choose. Treatments for erectile dysfunction are usually effective and the problem often goes away. There are also specific treatments for some of the causes of erectile dysfunction.

Before medical treatment, improvements in your lifestyle, such as a eating healthy diet, reducing alcohol intake, losing weight and increasing your exercise can dramatically improve erectile dysfunction. More specific treatment usually involves:

  • Weight loss and increased exercise (this may reduce the risk of erectile dysfunction by up to 70%)
  • Treatment of any hormone abnormality (testosterone treatment is only indicated if your testosterone levels are low and may be harmful if your hormone levels are normal);
  • Lifestyle modification (e.g. Reduce stress, stop smoking, reduce alcohol consumption & stop illicit drugs);
  • Treatment of any anatomical abnormality if present (e.g.  Circumcision, frenuloplasty, penile straightening);
  • Psychological support if necessary.

Medical treatment

Commonly used PDE-5 inhibitors are Sildenafil, Tadalafil, Vardenafil and   Avanafil.

These should be taken after consultation with the doctor.

In 90% of ED cases, medications will work as most of them is due to psychological and anxiety issues. This will boost the confidence of the man and improve couples relationship.

The drugs work by dilating (opening) the blood vessels supplying the penis; this causes a greater blood flow into the penis and improves your erection. 

Side-effects occur in approximately 1 in 10 patients (10%) but only 3% stop treatment because of them.  

You should not use PDE-5 inhibitors if you are taking nitrate medications for angina or heart disease.  

They will have no effect on your libido (sexual desire), ejaculation or fertility.

They do require sexual stimulation to be effective.

They may not work in severe erectile dysfunction or where the natural erectile mechanism has been irreversibly damaged. 

Tablet should be taken between 30 minutes and 1 hour before anticipated sexual activity.

Most of the drugs are affected by drinking alcohol or eating a heavy or fatty meal before taking the drug.

We normally advise you to take them on an empty stomach, or 2 – 3 hours

after a meal.


You should not to take more than one dose per day. Treatment is usually


Because of its long half-life, Tadafil may be taken at a lower, daily dose so that the drug is always in your system to provide a background boost to erections. This can help with night-time and morning erections.

We normally advise you to try treatment for four to six weeks (at least 12 tablets) to see whether it works.

You must not use PDE-5 inhibitors if you take nitrate medications (GTN spray, isosorbide or amyl nitrate) for angina, heart disease or other reasons, PDE-5 inhibitors interact with nitrates and can cause a dangerous drop in bloodpressure. This may result in cardiac arrest or even death.

You should probably avoid taking these drugs with alcohol.

The most common side-effects include headache (12%), flushing (10%), backache and indigestion (7%). Some patients develop altered (blue-tinged) vision and dizziness (3%).

Smoking can seriously impair your erectile function, and we would advise you to stop smoking completely if you have problems with erections

Hormone treatment: This is only offered to patients who are deficient in male hormones (testosterone). Medication can restore hormone imbalance and but does not always restore potency. Hormone treatment will not improve erections in men who do not have hormone deficiency (and may even be harmful in this situation).

Vacuum erection assistance devices

Vacuum erection assistance devices are a non-invasive method of obtaining and sustaining an erection in men with impotence (erectile dysfunction). To use the device, you insert your penis into a cylinder (right) with plenty of lubrication to provide a seal at its base. You get an erection by creating a negative pressure inside the cylinder, using a hand-operated or battery-powered pump. A ring is often placed around the base of your penis to help maintain the erection.

Self-injection therapy:

This treatment involves injecting a drug into the side of your penis each time you want an erection. The injection causes the muscles in your penis to relax which encourages blood to flow into your penis. If medications do not work, Injection therapy is very effective but some men find the idea difficult to accept, particularly as a long-term treatment option. Injections can be used up to twice a week but you should never inject yourself more than once in any 24-hour period. As with all drugs, there are some side-effects. Rarely your erection may not go down and you then need to come to hospital to have it reversed.

Intra-urethral pellets or cream:

This involves insertion of a pellet of prostaglandin into the urethra. Only 35 to 40% of patients get good quality erections, and the pellet can cause pain or facial flushing.

Penile implants:

This is an invasive surgical procedure which involves putting prostheses (implants) into your penis to allow you to achieve erections for sexual intercourse. These implants are available either as inflatable or malleable (bendy) prostheses.

Penile implants are reserved for patients who have either tried or failed, or are unable to tolerate other medical treatments such as tablets, injections, vacuum devices or pellets. They may also be used in patients with other conditions in which erections have been affected, such as following priapism (prolonged painful erections) or in men with Peyronie’s disease (curvature of the penis). The entire device is implanted into the body. It can be felt through the skin but is not visible on the outside.