The first thing to know about erectile dysfunction is that it’s way more common that you probably think. Almost every man has problems in this area from time to time, and consistent erectile dysfunction affects men of all ages.
For straightforward advice you can trust on what causes erectile dysfunction and how you can go about treating it, we enlisted Dr Peter Stahl who’s on the medical advisory board for Hims, which sells prescription treatments for ED and hair loss after you fill in a detailed questionnaire and your answers have been reviewed by a doctor.
What is erectile dysfunction and what are the symptoms?
Erectile dysfunction (ED) is the inability to achieve or maintain an erection firm enough for satisfactory sex. Sometimes affected men are able to achieve a satisfactory erection but lose their erection prior to orgasm. In other cases, affected struggle to achieve a satisfactory erection at all.
How common is erectile dysfunction?
One in five men over the age of 20 have suffered from ED and it is an increasingly common problem among young men. Studies suggest that 10-30% of men younger than 40 are affected.
A huge part of our mission at hims is to educate men about this issue, to erase the stigma attached to it and to encourage men to speak openly about it with their doctors. It’s no longer just men in their 60s and 70s that are dealing with it, but men of all ages.
When should you see a doctor about ED?
Occasional difficulties with erection rigidity that self-resolve are normal and don’t require evaluation. But all men with consistent or recurrent ED should seek evaluation and treatment with a physician. The evaluation might result in diagnosis of a medically important condition, and treatment can certainly have an important impact on quality of life.
What causes erectile dysfunction?
Erections are complex neurobiological events mediated by chemical and hormonal signals that involve the brain, nerves, blood vessels and of course the structural components of the penis itself. Anything that interferes with any of these physiological components of the male sexual response can cause ED.
In young men, psychogenic erectile dysfunction is very common. Generalised or performance anxiety leads to production of adrenaline and similar neurotransmitters that turn on the sympathetic nervous system. This system is the “flight or fight” mechanism that is meant to save your life in a threatening situation. It works by shunting blood away from organs, like the penis, that aren’t helpful in a dangerous situation. That results in at first minor loss of rigidity, but awareness of the lost rigidity usually then results in more worry and distress, more adrenaline, and unfortunately a vicious cycle that often results in complete loss of an erection.
In other variants of psychogenic ED, arousal is insufficient to initiate the entire erection response. This can occur when a man isn’t sufficiently attracted to his partner, when he is distracted or tired, or in some cases when a man is used to unrealistic or alternative stimulation – ie pornography or unusual masturbatory habits.
Physical causes of ED are also common. In particular, the same processes that clog up the arteries to the brain and heart and predispose you to heart attacks and strokes can affect the penis and limit blood flow during an erection. The arteries to the penis are smaller than the coronary arteries and the penis is typically affected earlier than the heart. ED can therefore be an important warning sign of hidden cardiovascular disease. This type of ED is referred to as arteriogenic ED.
Other less common physical reasons for ED include hormonal abnormalities, nerve dysfunctions, and veno-occlusive dysfunction. Testosterone deficiency is the most common type of a hormonal abnormality. Affected men typically also report low libido, fatigue, difficulty maintaining their body composition, and poor physical strength and endurance. Nerve problems typically occur in patients with known neurological diseases or diabetes. Veno-occlusive dysfunction is a structural problem with the penis that results from impaired ability to trap blood and generate high pressures inside the corpora cavernosa – the erection chambers of the penis.
How do you treat erectile dysfunction?
There are two goals in treating men with ED. The first is for a doctor recognise and diagnose health-relevant conditions that may be associated with ED. For example, a 40-year-old patient who reports non-variable and consistent ED who hasn’t seen a doctor in a long time might have unrecognised cardiovascular disease. That patient should be notified of the importance of getting evaluated for things like high cholesterol, diabetes and hypertension. In other ED patients who have suggestive symptoms such as low libido, laboratory testing for testosterone deficiency might be advised.
One of the most exciting things about a platform like hims is that we have the ability to reach many patients who have avoided seeking help because of embarrassment. There’s the opportunity to assess these men and to make sure, when appropriate, that they get the medical care they need.
The second goal of ED treatment, of course, is to restore erection rigidity. This is typically accomplished by prescription of oral medications. Phosphodiesterase inhibitors, such as sildenafil and tadalafil, are pills that promote the relaxation of smooth muscle in the penis and thereby facilitate penile blood flow and better erection rigidity.
When appropriate, these can be combined with other treatments such as psychotherapy or testosterone replacement therapy. In some cases, such as psychogenic ED related to performance anxiety, treatment with oral medications can be temporary and part of a confidence restoration strategy. In other cases, long-term use of oral medications is required to treat unmodifiable physical conditions.
When pills don’t work, other effective treatments such as penile injection therapy and penile prosthesis surgery are available. These more invasive treatments are typically provided by a specialised urologist.