Erectile dysfunction is a persistent or recurring inability to get or keep an erection firm enough for satisfying sex. The old term “impotence” is used less and less – in most cases the condition can be treated successfully.
The problem is far more common than people talk about: roughly every second man over forty has some degree of difficulty. An erection is a sensitive indicator of the state of the blood vessels, nerves and hormones, so when it gets worse this is often the first sign of a disease that has no other symptoms yet. Dr Penev sees men with erection problems in Plovdiv and Karlovo discreetly and without unnecessary embarrassment.
What is erectile dysfunction?
An erection is a vascular event controlled by the nervous system: during arousal, the nerve endings relax the smooth muscle in the corpora cavernosa (the erectile chambers of the penis), the arteries widen, and the tissue, now filled with blood, presses on the veins and keeps the blood in. Testosterone maintains desire and the sensitivity of the system, while the mind can switch it on or block it.
A problem with any of these elements leads to a weaker, shorter or absent erection. In most men the causes are mixed: a physical cause to which anxiety and the expectation of failure are added. The problem often goes hand in hand with premature ejaculation or reduced desire.
Symptoms
- getting an erection is harder or needs longer stimulation;
- the erection is not firm enough for penetration or fades during sex;
- the absence of morning erections points to a physical cause, while morning erections that are preserved despite failure with a partner point to a psychological factor;
- reduced sexual desire, which may suggest a hormonal problem;
- curvature or pain during erection – possibly Peyronie’s disease.
When it is urgent: an erection lasting more than four hours, whether or not you have taken a medicine, is priapism and permanently damages the tissue of the penis – go to an emergency department immediately. Sudden pain with a cracking sound and rapid swelling of the penis during sex suggests a penile fracture, which needs emergency surgery. Chest pain and shortness of breath during sex are a reason to call 112 (the European emergency number).
Causes and risk factors
Vascular causes are the most common in adulthood: atherosclerosis, high blood pressure, diabetes, high cholesterol and smoking damage the small arteries of the penis years before they affect the heart, which is why erectile dysfunction is considered an early warning sign of cardiovascular risk – more in the article erections as a barometer of health.
Neurological causes include diabetic neuropathy, multiple sclerosis, spinal cord injuries and operations in the pelvis. Hormonal causes include low testosterone, raised prolactin and thyroid disease. Psychogenic factors – stress, anxiety, depression, fear of failure, conflict in the relationship – are the leading cause in men under forty.
A number of medicines suppress erections: some blood pressure medicines, antidepressants, anti-androgens and medicines for an enlarged prostate, as well as alcohol and drugs. Chronic prostatitis, excess weight, physical inactivity and lack of sleep also contribute.
Diagnosis
The most important part of the consultation is the conversation: Dr Penev will ask when the problem started, whether you have morning erections, how your desire and ejaculation are, what medicines you take and what other conditions you have; a standardised questionnaire helps to assess how severe the problem is. The urology consultation includes an examination of the genitals, a prostate examination when indicated, and measurement of your blood pressure and waist circumference.
Laboratory tests look for a hidden disease: blood sugar or glycated haemoglobin (HbA1c), a lipid profile and testosterone in a morning blood sample, with further hormone tests if anything is abnormal; in men over forty-five, a PSA test is also discussed.
Additional tests – Doppler ultrasound of the penis with an erection induced by medication, or recording of night-time erections – are needed mainly in younger men after an injury, when medicines have not worked, and before surgery. If your risk profile calls for it, Dr Penev refers you to a cardiologist or an endocrinologist.
Treatment
Treatment is chosen together with you and, if you wish, with your partner. It starts with the causes that can be removed: changing a medicine that suppresses erections, treating a hormone deficiency, controlling blood sugar and blood pressure, stopping smoking, exercise and losing excess weight – lifestyle changes improve erections in some men and strengthen the effect of any other treatment.
The first-line medicines are phosphodiesterase type 5 inhibitors (PDE5 inhibitors). They do not cause an erection on their own but strengthen the natural response to arousal; there are short-acting and long-acting preparations. The effect is judged after several attempts with correct use, and mild side effects – headache, flushing, a blocked nose – usually wear off. They must not be taken together with nitrates, and in severe heart disease it is first assessed whether sexual activity is safe.
When tablets do not help or cannot be used, there are other options: vacuum devices; injections into the corpora cavernosa or medicines inserted into the urethra; low-intensity shock wave therapy, which may improve the blood supply in mild vascular forms, although the evidence is still accumulating. With proven low testosterone, hormone replacement is discussed; with psychogenic dysfunction, psychosexual therapy; and when erections suffer because of chronic prostatitis, treating it is part of the overall plan.
The last option for severe dysfunction that does not respond to other treatment is a penile prosthesis (implant) – an operation carried out in hospital.
When to see a urologist
See a urologist when the problem keeps recurring, when your morning erections have disappeared, when there is pain or curvature, or when your desire has decreased. Do not put it off either if you are over forty and have diabetes or high blood pressure, or if you smoke – in that case the consultation is also a chance to check your cardiovascular health.
Prevention
Everything that protects the heart also protects erections: regular exercise, a healthy weight, a balanced diet, not smoking and drinking alcohol in moderation. Controlling blood sugar, blood pressure and cholesterol, getting enough sleep and managing stress complete the picture, and a preventive check-up after the age of forty picks up problems early.
Erectile dysfunction is a medical condition like any other – with clear causes and effective treatment – not something to be ashamed of. Book an appointment with Dr Penev in Plovdiv or Karlovo to find the cause and choose the solution that is right for you.
Frequently asked questions
Is it normal for an erection sometimes not to happen?
Yes. Occasional failures due to tiredness, stress or alcohol happen to most men and are not a disease. We speak of erectile dysfunction when the problem keeps recurring for at least three months.
Are erection pills dangerous?
In healthy men and at the right dose, phosphodiesterase type 5 inhibitors are well studied and have a good safety profile. However, they must not be taken together with nitrates for the heart, they require a doctor's assessment beforehand, and products of unclear origin bought online are often fake.
Can erectile dysfunction be purely psychological?
Psychological factors play a role in almost every man with an erection problem, and in younger men they are often the main cause. Signs of this are preserved morning erections and a normal erection during masturbation.
Should my testosterone be tested?
Yes, measuring testosterone in a morning blood sample is part of the standard assessment. A low value is confirmed with a repeat test and further hormone tests before hormone treatment is discussed.
Can erectile dysfunction be cured completely?
When the cause can be removed – for example a medicine, a hormone deficiency or a psychological factor – erections often recover fully. With vascular and neurological causes, treatment keeps the problem under control in most men, but it is usually long-term.
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.