Let’s talk about erectile dysfunction (ED), the inability to achieve or sustain an erection during sexual performance. It can be an awkward subject that many men fear or have difficulty discussing. Due to personal and/or societal expectations, many men feel that their penises should work on cue. However, they may face tremendous pressure if/when things don't go as planned, which can have a significant impact on their self-esteem.

We at Yoxly want to assure you that ED is very common. In the UK alone, 4.3 million men struggle with ED each year. So why don’t we take a closer look at some of the common causes of ED, and what you can do to restore your sexual performance?

How Erections Work

An erection occurs as a result of increased blood flow to the penis when an individual is stimulated sexually.

When a man is sexually aroused, the muscles in the penis relax. The arteries in the penis then expand and blood flow increases into two chambers (corpus cavernosum). The penis is composed of three cylinders: the corpus spongiosum, and two corpora cavernosa. There is an artery going through the middle of each corpora cavernosum. When these chambers are full, the penis expands and becomes rigid, compressing the veins that drain the blood out of the penis, resulting in an erection.

An erection ends when the muscles in the penis contract and allow for the accumulated blood to flow out, allowing the penis to become flaccid.

The same physiology applies when the size of a soft penis varies with cold and hot weather, whereby shrinkage caused by cold weather induces a state of contraction, reflecting the balance of blood leaving and coming into the penis.

Symptoms Of Erectile Dysfunction

Erectile dysfunction is often characterised by the following symptoms:

• Trouble getting an erection
• Trouble maintaining an erection throughout sexual activity
• Decreased libido: the drive to have sexual activity

Causes Of Erectile Dysfunction

ED can result from a variety of health issues, both physical and psychological.

Physical

Physical issues contributing to ED are often associated with underlying conditions or medications. ED can happen when:

• There is a lack of blood flow: Various cardiovascular issues, such as hardened arteries (atherosclerosis), high blood pressure, and heart disease, can all reduce blood flow to the penis.
• Blood cannot be held in the penis to maintain an erection: This can occur at any age, despite misconceptions that it only happens in older men.
• Nerve signals from the brain are not sent to the penis: Injury or trauma to the pelvic regions can affect nerve signalling from the brain to the penis and result in ED. Examples of this include multiple sclerosis, spinal cord injuries, and chronic alcoholism.
• Diabetes: Studies have shown the link between diabetes and ED to be multifactorial - in other words, diabetes can result in many factors which contribute to ED. For example, diabetes can lead to peripheral neuropathy, hypogonadism, and vasculopathy, all of which can lead to ED.
• Cancer: Penile and pelvic cancers can cause ED. Additionally, cancer treatments--both surgical and radiological, in the lower abdomen or pelvis--can cause ED.
• Medication side effects: Various medications can cause ED. If you believe that you are experiencing ED as a result of medication, you should consult with your GP or pharmacist at your earliest convenience.

Psychological

Psychological issues contributing to ED aren’t always as obvious. That being said, some of the most common psychological causes for ED are:

• Stress: Sometimes stress can serve as a powerful motivator. However, even the simplest stress can hinder your sexual function.
• Anxiety: Psychological conditions CAN manifest with physical symptoms. Anxiety is known to cause an increased heart rate, sweaty palms, and fatigue. However, anxiety can also result in erectile dysfunction.
• Depression: The correlation between depression and erectile dysfunction has been firmly established. Studies show that men with depression are almost twice as likely to develop ED. Depression is associated with a loss of interest in pleasurable activities, one which may very well be sex.
• Relationship problems: Arguments, poor communication, and a general unhealthy relationship can lead to ED.

Treatment of ED

The treatment of erectile dysfunction may differ depending upon the suspected cause. Your doctor may want to start by taking a look at your cardiovascular health and suggesting a few lifestyle and diet improvements.

Your doctor may also suggest talking therapies to help with ED which may stem from physiological factors. Alternatively, ED can be treated using oral medications, known as phosphodiesterase-5 inhibitors (PDE5 inhibitors).

Medication

PDE5 inhibitors are sometimes used in the treatment of erectile dysfunction. These are vasodilating drugs that work by dilating the corpora cavernosa in the penis, relaxing the penis’s smooth muscle, allowing the penis to fill with blood and resulting in an erection.

The most common PDE5 inhibitors used to treat ED are:

• Sildenafil (Viagra)
• Tadalafil (Cialis)
• Vardenafil (Levitra)
• Avanafil (Spedra)

Owing to changes in regulations regarding sildenafil’s classification from a prescription-only medicine (POM) to pharmacy medicine (P), you can now buy sildenafil as Viagra Connect in most UK pharmacies, though you must have a confidential consultation (even online) with your pharmacist to ensure it is safe for you to take the medication before you purchase it.

Other PDE5 inhibitors (i.e. Spedra, Cialis, and Levitra) are prescription-only medications and therefore must be prescribed by a doctor.

Lifestyle Changes

Lifestyle modifications, especially for younger patients, can be of exceptional benefit when managing erectile dysfunction. Depending on your lifestyle, your doctor can recommend which areas to work on, such as:

1. Physical activity: Studies have shown that those who exercise more frequently have a lower risk of developing ED. Increasing physical activity helps improve your cardiovascular fitness and enhance blood flow to many parts of the body - including the penis! Additionally, exercising regularly helps boost self-esteem and has a positive impact on the psychological stresses associated with sexual dysfunction.
2. Weight loss: Evidence has found a direct link between obesity and erectile dysfunction. It is thought that obesity is associated with a metabolic syndrome causing reduced testosterone levels which result in erectile dysfunction. Therefore, for those who are overweight, losing weight will raise testosterone levels and help achieve and/or maintain an erection.
3. Smoking: Research shows that smoking, either directly or passively, contributes to erectile dysfunction. The good news? Studies also confirm that stopping smoking significantly enhances sexual function. If you are wanting to quit, we suggest going to your GP or local pharmacy and asking for advice. It’s never too late!
4. Alcohol: Chronic alcohol abuse (or diagnosed alcohol dependence) has been shown to impede one’s ability to sustain an erection. Although, oddly enough, consuming small amounts of alcohol may be related to reduced anxiety and heightened confidence--thereby improving sexual function. So if you do drink alcohol, it is recommended only to drink in moderation and stick to the national guide for men and women.
5. Dietary changes: Following a diet rich in fruit, vegetables, and legumes whilst limiting your intake of red meats, full-fat dairy, and large amounts of sugar has been directly associated with a reduced risk of ED. It is thought that this diet helps protect the cardiovascular system and allows for better blood flow to the penis.

Behavioural Therapies

Talking therapies such as cognitive behavioural therapy (CBT) can take place with a therapist who specialises in erectile dysfunction. The aim of CBT is to talk through any feelings or experiences which may contribute to ED.

CBT teaches methods of replacing negative thoughts with more positive ones, focuses on improvement techniques, and helps individuals to feel better about themselves. For victims of sexual trauma, CBT can also help address the issues linked to the negative connotations experienced during sexual intercourse. If you or someone you know has been the victim of sexual abuse, violence, or assault, please see this Yoxly page for more support and advice.

Surgical Treatment

In cases where medication, lifestyle changes, or behavioural therapies have been unsuccessful in managing erectile dysfunction, your doctor may refer you to a urologist for further consultation and/or treatment options.

Surgical treatment can include:

• Penile implant: A prosthesis, or penile implant, usually made out of silicone, can be placed in the penis. The implant can be inflatable (mechanical erection via a pump) or malleable (can be shaped), allowing you to adjust your erection to a suitable sexual position.
• Vascular surgery: This procedure involves the repair of the arteries in the penis to help restore blood flow.

Vacuum Pumps

A penis pump works by using suction to draw blood into the penis. The pump creates a vacuum to help the blood fill your arteries, causing your penis to become erect. A constriction ring is then placed around the base of the penis to prevent blood from flowing out of the penis and maintain the erection during sexual activity. It is important to not wear the constriction ring for over 20 minutes due to restricted blood flow.

The Bottom Line - Breaking The Silence

Denial delays the inevitable. Some make excuses, saying that they’ve drunk too much or that they’re too tired. And so, instead of doing what they’d normally do when they have a bodily concern--i.e. see a doctor--they suffer in silence.

Many may notice an impact on their relationship(s). They may stop initiating sex because of fear that they’ll be unable to perform. Their partner(s) may be too nervous to bring it up in conversation, and so it can cause disruption in their sex life and/or relationships.

So it’s time we start openly discussing ED amongst our peers, partners and loved ones. We need to reassure one another that like most other organs in our body, change in or loss of function can happen naturally. But we need to be honest about what our bodies are going through in order to correctly identify the cause and find the most appropriate treatment to allow ourselves to continue to live healthy, happy, and fulfilling lives.

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Hassan Thwaini is a qualified Clinical Pharmacist who has completed his Master's degree at the University of Sunderland. Since then he has not only pursued community and clinical pharmacy, but has expanded to aid in humanitarian work across the less fortunate areas of the globe. Hassan is currently working as a medical writer and has successfully been published within various nutritional websites, produced unique content for his university board, and carried out research for renowned surgeons.