‘Oh, just one more thing doctor’: The latest on dealing with erectile dysfunction
Whether you need a little bit of help or a lot, there’s likely a solution out there for those with erectile dysfunction. We give you the latest.
“Oh and there’s just one more thing, doctor …”
This offhand comment at the end of a visit to the GP is often the start of the journey for men dealing with erectile dysfunction.
The topic of ED can be discomfiting, or downright embarrassing, but it’s vital for men to know that it is not only a common condition, but also a treatable one in most cases.
So what is ED exactly? What causes it? How common is it? Who should you talk to about your concerns? And what can you do about it?
Answering these questions can be more than informative, they can be transformative for men worried their days of having sex are over forever.
What is erectile dysfunction?
Writing about this topic will require some bluntness, but in the interests of clarity it is preferable to be straightforward than to deal in euphemisms.
ED is the inability of a man to have an erection firm enough, or for a long enough period of time, to engage in penetrative sexual intercourse. The penis won’t get hard, or it won’t stay hard.
For those wondering if this is the same as impotence, the answer is yes. But impotence is a word no longer in common medical use due to the stigma of inadequacy with which it became associated.
The biomechanics of an erection are complex. It starts in the brain, where the desire to have sex manifests. That message is transported along the spinal cord into the pelvis, opening arteries in the penis and allowing blood to fill two sponge-like chambers that run along its shaft.
By enlarging the penis, the veins are closed off, so the blood is trapped.
This process of filling, or trapping, the blood may fail for a number of reasons, either physical or psychological.
The impact can be acute. It means not having sex in the way you want to, if at all. It can be devastating for men, who may feel a loss of masculinity, with all the flow-on emotions that entails.
It can put a huge strain on couples, the loss of physical intimacy sometimes spelling the end of a relationship. And for men looking for a new partner, it can feel like a huge hurdle at the starting gate.
What causes it?
Melbourne urological surgeon Christopher Love says the days of thinking that ED is primarily a psychological issue are long gone, though for some, around one in 10 cases, it is still the primary cause.
“We now know that about 90 per cent of chronic ED cases are related to physical or medical factors. We’re talking about smoking, being overweight, having high cholesterol or high blood pressure,” Dr Love says.
“There is one factor you can’t change, which is ageing. ED is more common the older you get. Your arteries tend to harden, restricting blood flow.”
Dr Love also notes that surgery or cancer treatment that affect the pelvic area, such as prostate cancer treatment, can be a common cause of ED.
How common is it?
There are conflicting statistics on ED prevalence in Australia. The federal Department of Health and Aged Care in its examination of the link between smoking and ED notes that “one in five men over the age of 40 have some problem with erections and one in 10 men over 40 are unable to get an erection”.
Yet that page links to a government-sponsored health advice page, healthdirect, which reports that erectile dysfunction affects up to two in three males aged over 45.
Another research paper, published in the Medical Journal of Australia in 2013, examined ED across a cohort of more than 108,000 men in the 45 and Up Study.
It found the overall prevalence of ED was 61 per cent for over-45s. This figure was broken down into 25 per cent who reported mild erectile dysfunction (experienced ED “sometimes”), 19 per cent with moderate ED (“usually”) and 17 per cent had complete erectile dysfunction.
“Overall, the risk of moderate/complete ED was higher among men with low socio-economic status, high body mass index, those who were sedentary, current smokers, and those with diseases including diabetes, heart disease, and depression/anxiety, compared with men without these risk factors,” the study says.
“Almost all men aged 75 or older reported moderate/severe ED; however, increased physical activity was associated with lower odds of ED in this group.”
That finding was closer to a US study cited by the Cleveland Clinic that finds ED affected around 40 per cent of men at age 40 and nearly 70 per cent at age 70. Complete ED increased from 5 per cent at age 40 to 15 per cent at age 70.
Smoking is a significant risk factor. The Health Department’s information says that for every 100 non-smokers aged over 40 with ED there are between 130 and 150 smokers.
Melbourne urologist Gideon Blecher describes his typical ED patient. “They’re average guys, some are a little overweight but not drastically so. They’ll have busy lives and jobs. They’ll say that in the last few years their erection is not as strong or they’re not lasting as long.
“They’ll have been burying their heads in the sand for years, so it is often huge for them to seek treatment. It can be really emotional,” Dr Blecher says.
Who should you talk to?
The first port of call can be your GP, or you may seek more anonymous advice from an online health service.
“Some men take a deep breath and just come out with it,” Melbourne GP David Fox says.
“But I’d say most spend a lot of time talking about other things, then right at the end of the appointment it will come as a ‘By the way’, or ‘There’s just one other thing,” he says.
“I understand that for men this is very uncomfortable and difficult to talk about, especially the first time. I’m likely to be the first person apart from their intimate partner who they’ve spoken to about it.
“So it’s important to give that more time, even though it might delay the timely start of the next patient’s appointment.
“I ask how long it has been an issue, what is the impact on him and on his partner, what level of ED we are talking about, and has he tried anything in terms of treatment,” Dr Fox says.
For those who don’t want to face their GP, or another doctor face-to-face, the other option is to seek advice online, not from Dr Google, but from a health practitioner operating remotely.
Dr Love, a penile implant surgeon, is also a medical adviser to men’s online health service MOSH, which offers consultation with health practitioners and treatment options without a face-to-face consultation.
“These online platforms do address issues such as a patient being too embarrassed to talk face-to-face, and GPs being time poor,” he says.
Dr Fox is concerned that online clinics may be too focused on the one issue without looking at broader health factors that may be relevant.
“This is important because ED can be an indicator of other issues such as cardiovascular disease.”
But Dr Love says the online consultations, done correctly, will cover this off.
“It’s not like you get a prescription without being asked broader questions about your general health,” he says.
Tests to examine the cause of ED range from simple blood tests to a full psychological examination, to a penile duplex ultrasound that checks blood flow into and out of the penis.
But most of the time ED and its causes can be established without invasive testing.
What are the treatment options?
The experts will all tell you that in the majority of cases there is a successful treatment option available for ED.
Oral medications
The first and most obvious, and most successful, option is an oral medication. Sildenafil, known by its commercial name Viagra, boosts chemicals in the body that open up the blood vessels to get more blood to the penis.
Similar drugs are available, with different strengths, including Vardenafil, Tadalafil and Avanafil. Tadalafil is unique in that it can be taken in a very low dose daily to provide for more spontaneous sexual activity.
Because it is no longer under patent, Viagra costs around $2.50 per tablet. It does require planning, as it needs to be taken an hour before sex.
Dr Fox says these drugs work for around 70-80 per cent of the patients he prescribes them to without any further concerns. But some have side effects like headache or facial flushing.
“And other patients will say it doesn’t work fully or at all, so we can try different oral medications for those for whom the first-line drug is not working or is giving them side effects.
“If they still aren’t working, at that point I’d refer them to a urologist,” Dr Fox says.
It can’t be forgotten that over the past few decades these tablets have been a game changer for many men.
“The tablets are great,” Dr Blecher says. “The vast majority of guys will respond to most forms of tablet, which successfully open up their blood vessels. The men will have penises that are harder, and last longer.”
If oral medications aren’t working, this is not the end of the road. Men have other options, including new ones coming onto the market. But some aren’t for the squeamish.
Self-injection therapy
“It sounds awful at first. I see guys wince when I suggest it in our appointments,” Dr Blecher says.
“But it’s only a small needle, and is really the next option for those not responding to tablets.”
The patient, or his partner, injects medication directly into the side of the penis in order to generate an erection about five to 15 minutes later. The small needle distributes a small amount of the drug, and according to the urologists the patients quickly get used to doing the injections.
“It’s like a superstrong version of Viagra going directly into the penis,” Dr Love says, with an erection usually lasting anywhere between 30 and 90 minutes.
He says about three in four men who try it are satisfied with the therapy as an option for them, though again this treatment involves pre-planning for sex.
But like any injection-based treatment, there is the risk of bruising and bleeding. And for this particular treatment there is also the risk of a prolonged erection, up to four hours, which may require medical intervention.
Vacuum devices
These devices basically do what you’d expect, how you’d expect.
A small vacuum tube is placed over the penis and pressed against the abdomen to create a seal. Then the air is sucked out of the device with a handheld pump, drawing blood into the penis. It is trapped there by placing a rubber ring at the base of the penis.
“The penis is basically sucked up into an erection,” Dr Love says.
He says this is a useful option for those who can achieve a partial erection through foreplay, and has the advantage of being non-invasive.
“But while it can be quite effective for patients who get used to using it, it doesn’t really create a rock-hard erection, so it’s not ideal for young to middle-aged patients,” he says.
Dr Blecher says about 10 to 15 per cent of his patients are using the vacuum technique.
“It can be cumbersome to use and is not very sexy. But some guys are in long-term, great relationships wanting to enjoy their sex lives, and they’re very happy with this as an option for them,” he says.
Shockwave therapy
This treatment for ED, which has been in use for about a decade, sounds shocking but is completely painless.
The doctor will run a low intensity shockwave machine, which looks like a large pencil, along the side of the penis, the idea being that it will promote blood flow in the area and improve erections. It requires weekly treatments for about six weeks.
“This is for a guy who’s erections aren’t quite there, but who wants to move off the tablets or achieve a better response to them,” Dr Blecher said. “They like it because there is no side-effect profile, but the improvement is mild to moderate at best.”
Dr Love said a newer treatment along similar lines is gaining momentum, which involves a machine delivering radiofrequency energy to the penis. But he says that as yet there is not strong evidence of its effectiveness.
“The idea is that it makes the tissue heat up and that makes the body produce more collagen, which is important for the structural requirements of an erection. It may play more of a role in future treatments.”
Inflatable penile implants
This is the most complex and invasive of the treatments, but is also the most reliable in terms of guaranteeing an erection.
The surgical procedure has been around for 50 years, and has been taken up by hundreds of thousands of men worldwide, with high satisfaction rates.
Dr Love says they offer the most reliable, spontaneous answer to ED, and with a low risk of any side effects.
There are a number of different types, and the mechanics are intricate. The simplest description is that they are inflatable tubes replacing the natural tubes inside the penis, implanted through surgery.
When the man wants an erection, he can fill the tubes with a salt water solution from a reservoir that has been permanently inserted into his abdomen. The pumping mechanism is inside the scrotum.
The result is immediate, and the penis can be inflated to the desired firmness, within 30 seconds. After sex, the man can reverse the process, pumping the solution back into the reservoir.
“We see men who have been struggling for years, they’ve tried everything else, and are embarrassed and frustrated that nothing works. By the time we see them their relationship has taken a hit,” Dr Blecher says.
“But this procedure is low risk, and they get a reliable erection and enjoy it.”
Dr Love agrees. “It’s a great treatment because it will work no matter how bad the erectile problem is. All other aspects of sex are the same, touch, feel, ejaculation, it’s all the same.”
There are downsides though, including that once an implant has been inserted the man will no longer be able to have a natural erection. This is why it is for the most difficult cases.
A final word
Dr Love says having an enjoyable sex life is an important part of life, and men should be willing to explore their options.
“Oral medication works for most, but if they don’t there are other good treatments, so don’t stop just because the tablets aren’t doing the trick,” he says.
Dr Blecher says men of all ages who continue to be interested in having sex should check what’s available.
“In our practice we see quite a lot of men in their mid to late 80s who still enjoy a healthy sex life and want to maintain it.”
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