Few complaints are kept quiet for as long as weakening erections. Men put them down to tiredness or age and wait for years before mentioning them to a doctor. Yet erections are one of the earliest indicators of the state of the blood vessels – a barometer that registers the change long before the storm.
Roughly one in two men between the ages of 40 and 70 has some degree of erectile dysfunction. Dr Penev explains why the problem often comes years before cardiovascular disease, what is checked at the consultation and what is up to you.
Why erections mirror the blood vessels
An erection is above all a vascular event: during arousal the inner lining of the arteries (the endothelium) releases nitric oxide, the erectile tissue (corpora cavernosa) relaxes and fills with blood, and the veins keep the blood inside. It is the endothelium that most often suffers – the tissue whose damage marks the beginning of atherosclerosis.
The arteries of the penis are about one to two millimetres in diameter – two to three times narrower than the coronary arteries – so the same degree of narrowing is felt there first. That is why erectile dysfunction comes roughly three to five years before the signs of coronary heart disease, and international consensus recommendations regard it – when there is no obvious psychological cause – as a cardiovascular risk factor comparable to smoking.
Diabetes, blood pressure and cholesterol – the silent culprits
Diabetes damages both the small blood vessels and the nerves, so in people with diabetes the problems start earlier and are more marked; quite often it is erection problems that lead to the discovery of undiagnosed diabetes. High blood pressure, raised blood fats, excess weight and smoking act in the same way – through the endothelium. Add to these sleep apnoea, low testosterone, depression and some blood pressure medicines and antidepressants, which should not be stopped on your own. Painful conditions of the prostate, such as chronic prostatitis, also often make erections worse.
What the urologist checks
The consultation begins with a conversation: when and how the problem started, whether you still have morning erections, whether there is any change in desire, what medicines you take. This is followed by a physical examination – blood pressure, waist measurement, examination of the testicles and the penis for plaques or curvature typical of Peyronie’s disease, and after the age of 40–45 an assessment of the prostate as well.
Laboratory tests are essential: fasting blood sugar or glycated haemoglobin (HbA1c), a lipid profile and total testosterone in a morning sample; if needed, prolactin, thyroid hormones and PSA. An ultrasound scan of the blood vessels of the penis is done only in selected cases, at the doctor’s discretion. If the cardiac risk is high, Dr Penev refers the patient to a cardiologist before prescribing treatment.
What you can change yourself
Lifestyle changes improve erections in a significant proportion of men and reduce cardiac risk. Regular physical activity – at least two and a half hours of moderate exercise a week – is the measure with the strongest evidence. Add to this weight loss, a Mediterranean-style diet, stopping smoking, moderate drinking and enough sleep. Good control of blood sugar and blood pressure protects the blood vessels of the penis, and pelvic floor exercises help some men.
Treatment is effective and discreet
When lifestyle changes are not enough, treatment helps most men. Tablets from the phosphodiesterase type 5 inhibitor group are the first line and are safe when contraindications are properly assessed; if the effect is not good enough, vacuum devices, injection treatment, shock wave therapy (for which the evidence is still building up) or an implant are discussed. Testosterone is given only when a deficiency has been proven, and the choice is always individual.
A conversation without embarrassment
For a urologist, a question about erections is as routine as one about passing urine – Dr Penev asks it at every preventive check-up. There is no need to choose your words carefully – “it doesn’t work like it used to” is enough to start with. Bring a list of your medicines and your most recent blood tests. The consultation at the practice in Plovdiv or at Vita Med Medical Centre, Karlovo, is completely discreet, and your partner is welcome.
When to see a doctor
Book a consultation if weak erections last more than three months, came on suddenly or after an injury, or come with reduced desire, curvature or pain in the penis. Do not put off seeing a cardiologist if you also feel tightness in your chest or shortness of breath on exertion. A painful erection lasting more than four hours is an emergency (priapism) – go to an emergency department or call 112 (the European emergency number), because delay damages the tissue. Thirst, weight loss and frequent urination call for a prompt blood sugar test. More warning signs that should not be put off are in the article when to see a urologist.
Weaker erections are not a life sentence but an early warning that gives you time to act – for your blood vessels, your heart and your quality of life. Book an appointment with Dr Penev in Plovdiv or Karlovo; the initial consultation is €50 and starts with an unhurried conversation.
Frequently asked questions
Is it normal for erections to get weaker with age?
Some slowing down and the need for more stimulation over the years are common, but a lasting inability to have satisfactory sex is not a normal part of ageing. It almost always has a specific cause that can be identified and treated.
If I have morning erections, does that mean the problem is only psychological?
Preserved night-time and morning erections show that the blood vessels and nerves are working and point to a psychological or relationship-related component. This does not rule out early changes in the blood vessels, so checking your blood pressure, blood sugar and blood fats is still recommended.
Can I take an erection pill without a consultation?
It is not a good idea. Tablets from the phosphodiesterase type 5 inhibitor group are safe for most men, but they must not be taken with nitrates for the heart, and your cardiac risk needs to be assessed. Products bought online without a prescription are often fake.
Should I have my testosterone tested?
With erectile dysfunction, at least one measurement of total testosterone in a morning blood sample is recommended, especially if you have reduced desire, tiredness or excess weight. Replacement treatment is only considered if levels are proven to be low and after contraindications have been assessed.
Can my partner come to the consultation?
Yes. Having your partner there often helps – both to describe the problem more accurately and to discuss the treatment options together. The decision is entirely yours.
The information on this website is for general education and does not replace an examination and consultation with a doctor. If you have urgent symptoms, seek medical help immediately or call 112.