There are certain symptoms patients will happily discuss with their GP in extraordinary detail – bowel movements, rashes, suspicious toenails – and then there are the problems that suddenly make maintaining eye contact feel like an Olympic sport. Erectile dysfunction (ED) is one of them.
Men will often sit in my GP room and talk around the problem for several minutes, before finally getting to the point. ‘Everything’s fine, really. It’s just… things aren’t quite working as they used to.’
By ‘things’, they usually mean their penis.
Erectile dysfunction, or ED, is when you regularly struggle to get or maintain an erection firm enough for sex. And while it can feel mortifying to talk about, it is incredibly common. It can also affect men at any age, though it becomes increasingly common as they get older.
Most men will experience difficulty getting an erection occasionally.
A stressful week, exhaustion, too much alcohol – or simply having your brain decide that now is the perfect time to think about tomorrow’s work meeting instead – can all interfere.
But one unsuccessful evening does not mean something is seriously wrong. It is when it starts happening repeatedly that it deserves attention.
An erection might appear relatively straightforward, but physiologically there is quite a lot going on behind the scenes. Your brain, nerves, hormones and blood vessels all need to work together.
Sexual stimulation triggers signals that cause blood vessels supplying the penis to relax and widen, increasing blood flow and producing an erection.
If something interferes with any part of that process, erections 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
And this is why ED isn’t always just about sex. Sometimes, it can be a clue to what is happening elsewhere in the body.
Conditions affecting our blood vessels and nerves, including high blood pressure, high cholesterol, diabetes and cardiovascular disease, can all contribute to erectile problems.
Damage or narrowing of blood vessels can reduce the blood flow needed to achieve an erection, while diabetes in particular can damage the nerves involved in sexual function. Smoking, obesity and excessive alcohol consumption can increase the risk too.
What’s more, because the blood vessels supplying the penis are relatively small, problems with erections can sometimes appear before more obvious symptoms of cardiovascular disease, for instance.
So while it may be tempting to order some Viagra online, clear your browsing history and pretend the whole thing never happened, persistent ED is worth discussing with your GP as it can be an early warning of other underlying health problems.
There can also be other physical causes of ED, too.
Low testosterone can sometimes play a role, particularly if erectile difficulties are accompanied by symptoms such as reduced libido.
Certain medications can contribute, including some antidepressants and blood pressure medicines. Neurological conditions, prostate treatments and pelvic surgery can all also affect erections.
But one of the biggest misconceptions is that the causes of ED 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.