What is male sexual dysfunction (erectile dysfunction; impotence)?

Erectile dysfunction is the inability to develop or maintain an erection that is rigid enough to allow penetration of the vagina, and therefore functional sexual intercourse. Generally, the term erectile dysfunction is applied if this occurs frequently (75% of the time) over a significant period if time (several weeks to months). If this is the case, the term impotence may also be used.
Erectile dysfunction may present in different ways. Some men are completely unable to develop an erection. Some may develop an erection that does not remain rigid enough to allow satisfactory intercourse.
There are several causes of erectile dysfunction, including certain drugs (prescription and non prescription), psychological causes, and problems with the hormones, nerves or blood vessels that supply the penis.
Other problems with male sexual function include a lack of sexual drive or desire (libido), problems with ejaculation (ejaculatory dysfunction), and lack of pleasurable sensation (orgasm) during sex. These problems will not be discussed in detail.
Erectile dysfunction is a common problem. It is important that men who experience erectile dysfunction discuss it with their doctor, because the condition can have a negative impact on relationships and self esteem; serious underlying causes need to be excluded; and effective treatment is available.

Statistics on male sexual dysfunction

Erectile dysfunction is estimated to effect 150 million men worldwide, and more than one million men in Australia.Overall, 25% of Australian men report erectile dysfunction and 8.5% report severe erectile dysfunction.
In one study, 9.6% reported ‘occasional’ erectile dysfunction, 8.9% reported erectile dysfunction occurring ‘often’, and 18.6% reported erectile dysfunction occurring ‘all the time’. Of these, only 11.6% had received treatment.In another study, only 14.1% of men reported that they had received treatment, despite experiencing erectile dysfunction for longer than 12 months.
Erectile dysfunction is never ‘normal’, however it does become more common and more severe as men age. One Australian study reported the rate of erectile dysfunction in different age groups:

  • 20-29 years: 9.2%;
  • 30-39 years: 8.4%;
  • 40-49 years: 13.1%;
  • 50-59 years: 33.5%;
  • 60-69 years: 51.5%;
  • 70-79 years: 69.2%;
  • 80+ years: 76.2%.

Due to the ageing Australian population, erectile dysfunction is expected to become more common.
There is no difference between the prevalence of erectile dysfunction between “white-collar” and “blue-collar” workers in Australia.

Sexual dysfunction associated with cancer

Between 10 and 88% of patients diagnosed with cancer experience sexual problems following diagnosis and treatment. The prevalence varies according to the location and type of cancer, and the treatment modalities used. Sexuality may be affected by chemotherapy, alterations in body image due to weight change, hair loss or surgical disfigurement, hormonal changes, and cancer treatments that directly affect the pelvic region.
Sexual problems are reported in many patients with prostate and testicular cancer. They are also reported in patients with cancer that does not directly effect sexual organs, including lung cancer (48% of patients), Hodgkin’s disease (50%), and laryngeal (%60) and head and neck cancers (39-74%).

For more information, see Sexual Difficulties Associated with Cancer in Men.

Risk factors for male sexual dysfunction

Male sexual dysfunctionThe predisposing factors for erectile dysfunction are as follows:

If a man has the risk factors for cardiovascular disease during middle age (smoking, obesity, high cholesterol), he is at an increased risk of developing erectile dysfunction.
Exercise has been shown to have a protective effect.

Progression of male sexual dysfunction

Around one third of men who experience erectile dysfunction find that, without treatment, it becomes worse over time. Around a third of men find that erectile dysfunction improves without treatment.
Around half of men with severe erectile dysfunction remain impotent in the long term without treatment.
These figures vary depending on the cause of the erectile dysfunction. Even if men choose not to pursue treatment for erectile dysfunction, it is important that they be investigated by a doctor, as erectile dysfunction may indicate an increased risk of cardiovascular disease.

Symptoms of male sexual dysfunction

Temporary failure of erection is very common and is likely to resolve. If ongoing erectile dysfunction develops, the impact on relationships and self-esteem can be devastating. Men who suffer from erectile dysfunction are known to experience significant psychological distress. It is believed that sexual self-consciousness leads to:

  • Increased appearance related anxieties;
  • Interferes with attention, focus and concentration;
  • Impairs physical performance; and
  • Reduces awareness of our physiological arousals leading to sexual dysfunction.

This improves when erectile dysfunction is successfully treated.
While studies are limited, it has been shown that male sexual dysfunction can also negatively impact the sexual function of female partners. A study comparing the sexual function of women with partners with erectile dysfunction to those without showed that sexual arousal, lubrication, orgasm, satisfaction, pain and total score were significantly lower in those who had partners with erectile dysfunction. Later in that study, a large proportion of the men with erectile dysfunction underwent treatment. Following treatment, sexual arousal, lubrication, orgasm, satisfaction and pain were all significantly increased. It was concluded that female sexual function is impacted by male erection status, which may improve following treatment of male sexual dysfunction.
It is essential to discuss erectile dysfunction with your doctor, so any serious underlying causes can be excluded and treatment options can be discussed. Many men are embarrassed discussing this issue with their doctor, or even their partner. Open communication with your doctor, and in your relationship, is important for effectively managing this common problem.
Effective treatment for erectile dysfunction is available, and for most men will allow the return to a fulfilling sex life. The side effects of the treatment for erectile dysfunction vary depending on the treatment that is used. Some may interrupt the spontaneity of sexual activity. For example, PDE-5 inhibitors typically need to be taken one hour before sex. Side effects may include headaches, indigestion, vasodilation, diarrhoea and blue tinge to vision. Other treatments such as penile injections may cause pain at the injection site, or an erection that will not go down. Treatment options need to be carefully discussed with your doctor to determine which one is best suited to you.

Clinical examination of male sexual dysfunction

Following a detailed discussion about the history of erectile dysfunction and its risk factors, your doctor will examine the testicles and penis to help determine the cause of erectile dysfunction. Your doctor will check reflexes and pulses in the area to see if problems with blood vessels or nerves are contributing to the erectile dysfunction. If necessary, your doctor will order tests to help diagnose erectile dysfunction.

How is male sexual dysfunction diagnosed?

Diagnosis is based on information provided to the doctor regarding the history of erectile dysfunction (how quickly it came on, how often it occurs, etc), the assessment of risk factors, and whether erections still occur overnight while a man is asleep. It is normal for a man to have 3-5 full erections overnight during REM sleep.
In order to establish whether normal erections are occurring overnight (nocturnal erections), the doctor may organise nocturnal penile tumescence (NPT) testing. This involves wearing a monitor overnight in your own home. The data from this monitor is then assessed to analyse how often erections occurred, how long they lasted, and how rigid and large the penis was during the erections. If NPT testing is normal, the cause of erectile dysfunction is usually psychological. If not, further testing of the blood flow in the genital area may be required to see if there is blockage or leakage. The doctor may also organise a blood test of levels of hormones such as testosterone, prolactin and thyroid stimulating hormone to see if these are contributing to the erectile dysfunction.

Prognosis of male sexual dysfunction

For the great majority of men, erectile dysfunction can be effectively treated.
It is essential that if you experience erectile dysfunction, you discuss it with your doctor. Serious underlying causes need to be excluded. Many treatment options are available, and your doctor can help you decide which one is most appropriate for you.
Some causes of erectile dysfunction such as hormonal problems or anxiety may be cured completely with treatment and/or therapy. Even if the underlying cause cannot be cured, medication may still allow a satisfactory erection. Ignoring the problem tends not to make it better, and can have a significant impact on relationships and self-esteem.

How is male sexual dysfunction treated?

Before starting treatment for erectile dysfunction, a doctor needs to check there is no underlying cardiovascular disease, and do other checks to determine the cause of the erectile dysfunction.
The most common treatment for erectile dysfunction is drugs known as phosphodiesterase-5 (PDE-5) inhibitors. These include tadalafil (Cialis), vardenafil (Levitra), and sildenafil citrate (Viagra). These are effective for about 75% of men with erectile dysfunction. They are tablets that are taken around an hour before sex, and last between 4 and 36 hours. Sexual stimulation is required before an erection will occur. The PDE-5 inhibitors cause dilation of blood vessels in the penis to allow erection to occur, and help it to stay rigid. Men using nitrate medication (e.g. GTN spray or sublingual tablets for angina) should not use PDE-5 inhibitors.
If testosterone levels are found to be low, erectile dysfunction should initially be treated with testosterone replacement therapy.
If PDE-5 inhibitors are not suitable or don’t work, other therapies include injections into the base of the penis, which cause flow of blood into the penis and a fairly immediate erection that lasts around an hour. The drugs injected are alprostadil (Caverject and Erectile dysfunctionex) and Invicorp (VIP and phentolamine). Alprostadil may also be inserted as a gel into the opening of the penis. This is not suitable if your partner is pregnant.
Vacuum erection devices use a pump mechanism to create negative pressure around the penis, encouraging it to become erect. An elastic device is then placed around the base of the penis to help maintain the erection.
As a last resort, penile prostheses may be considered. Malleable rods and inflatable versions are available. This option involves surgery to insert the device, and so has more risks than the other treatments.
Surgery to correct blocked or leaking blood vessels used to be popular, but is not very effective for long term erectile function unless it is being done to correct traumatic vascular damage in young men.
Erectile dysfunction experienced by obese men has been shown to improve considerably with weight loss and exercise.Other lifestyle changes that improve erectile dysfunction include reducing the use of alcohol, recreational drugs and cigarettes.
If erectile dysfunction is found to be caused by anxiety or depression, psychotherapy may be an effective treatment on its own or in combination with certain drugs (e.g. antidepressants). Sexual therapy counsellors specialise in this field.
If men are found to be taking a medication that is known to cause erectile dysfunction, their doctor may prescribe an alternative, equally effective therapy.

More information

Erectile dysfunction For more information on erectile dysfunction, types, causes and treatments of erectile dysfunction, and tips for dealing with it, see Erectile Dysfunction.

References

  1. Dean R, Lue T. Physiology of penile erection and pathophysiology of erectile dysfunction. Urol Clin North Am. 2005; 32(4): 379-v.
  2. Burnett AL, Lowenstein CJ, Bret D, Chang TS, Snyder SH. Nitric oxide synthase: A physiologic mediator of penile erection. Science. 1992; 257: 401-3.
  3. Krane RJ, Goldstein I, Saenz de Tejada I. Impotence. N Engl J Med. 1989; 321(24): 1648-59.
  4. Burnett AL. Erectile dysfunction. Journal of Urology. 2006; 175(3 Pt 2): S25-31.
  5. Saenz de Tejada I, Goldstein I, Azadzoi K, Krane RJ, Cohen RA. Impaired neurogenic and endothelium-mediated relaxation of penile smooth muscle from diabetic men with impotence. N Engl J Med. 1989; 320(16): 1025-30.
  6. Virag R, Bouilly P, Frydman D. Is impotence an arterial disorder: A study of arterial risk factors in 440 impotent men. Lancet. 1985; 1: 181-4.
  7. Mills TM, Wiedmeier VT, Stopper VS. Androgen maintenance of erectile function in the rat penis. Biol Reprod. 1992; 46(3): 342-8.
  8. Bancroft J, Wu FC. Changes in erectile responsiveness during androgen replacement therapy. Arch Sex Behav. 1983; 12(1): 59-66.
  9. Kwan M, Greenleaf WJ, Mann J, Crapo L, Davidson JM. The nature of androgen action on male sexuality: A combined laboratory-self-report study on hypogonadal men. J Clin Endocrinol Metab. 1983; 57(3): 557-62.
  10. Spark RF, White RA, Connolly PB. Impotence is not always psychogenic: Newer insights into hypothalamic-pituitary-gonadal dysfunction. JAMA 1980; 243(8): 750-5.
  11. Michal V, Kramar R, Pospichal J. External iliac “steal syndrome”. J Cardiovasc Surg (Torino). 1978; 19(4): 355-7.
  12. Reynolds CF III, Frank E, Thase ME, Houck PR, Jennings JR, Howell JR, et al. Assessment of sexual function in depressed, impotent, and healthy men: Factor analysis of a brief sexual function questionnaire for men. Psychiatry Res. 1988; 24(3): 231-50.
  13. Morse WI, Morse JM. Erectile impotence precipitated organic factors and perpetuated by performance anxiety. Can Med Assoc J. 1982; 127(7): 599-601.
  14. Kaplan HS. Psychiatric evaluation and therapy: What’s new? In: World Book of Impotence, Lue TF (Ed), Smith Gordon, London 1992. p59.
  15. Cayan S, Bozlu M, Canpolat B, Akbay E. The assessment of sexual functions in women with male partners complaining of erectile dysfunction: does treatment of male sexual dysfunction improve female partner’s sexual functions? J Sex & Marital Ther 2004; 30: 333-341.
  16. Aytac IA, McKinlay JB, Krane RJ. The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences. BJU Int. 1999; 84: 50-56.
  17. Chew KK, Stuckey BG, Bremner A, Earle C, Jamrozik K. Male erectile dysfunction: Its prevalence in Western Australia and associated sociodemographic factors. J Sex Med. 2007; 5(1): 60-9.
  18. Chew KK, Earle CM, Stuckey BG, Jamrozik K, Keogh EJ. Erectile dysfunction in general medicine practice: Prevalence and clinical correlates. Int J Impot Res. 2000; 12(1): 41-5.
  19. Araujo AB, Mohr BA, McKinlay JB. Changes in sexual function in middle-aged and older men: Longitudinal data from the Massachusetts Male Aging Study. J Am Geriatr Soc. 2004; 52(9): 1502-9.
  20. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA. 1999; 281(6): 537-44.
  21. Bacon CG, Mittleman MA, Kawachi I, Giovannucci E. Sexual function in men older than 50 years of age: Results from the health professionals follow-up study. Ann Intern Med. 2003; 139(3): 161-8.
  22. Pinnock C, Stapleton A, Marshall V. Erectile dysfunction in the community: A prevalence study. MJA. 1999; 171(7): 353-7.
  23. Sullivan ME, Keoghane SR, Miller MA. Vascular risk factors and erectile dysfunction. BJU Int. 2001; 87(9): 838-45.
  24. Dhindsa S, Prabhakar S, Sethi M, Bandyopadhyay A, Chaudhuri A, Dandona P. Frequent occurrence of hypogonadotropic hypogonadism in type 2 diabetes. J Clin Endocrinol Metab. 2004; 89(11): 5462-8.
  25. Fung MM, Bettencourt R, Barrett-Connor E. Heart disease risk factors predict erectile dysfunction 25 years later: The Rancho Bernardo Study. J Am Coll Cardiol. 2004; 43(8): 1405-11.
  26. Baumhakel M, Bohm M. Erectile dysfunction correlates with left ventricular function and precedes cardiovascular events in cardiovascular high-risk patients. Int J Clin Pract. 2007; 61(3): 361-6.
  27. Min JK, Williams KA, Okwuosa TM, Bell GW, Panutich MS, Ward RP. Prediction of coronary heart disease by erectile dysfunction in men referred for nuclear stress testing. Arch Intern Med. 2006; 166(2): 201-6.
  28. Chiurlia E, D’Amico R, Ratti C, Granata AR, Romagnoli R, Modena MG. Subclinical coronary artery atherosclerosis in patients with erectile dysfunction. J Am Coll Cardiol. 2005; 46(8): 1503-6.
  29. Thompson IM, Tangen CM, Goodman PJ, Probstfield JL, Moinpour CM, Coltman CA. Erectile dysfunction and subsequent cardiovascular disease. JAMA. 2005; 294(23): 2996-3002.
  30. Greenstein A, Chen J, Miller H, Matzkin H, Villa Y, Braf Z. Does severity of ischemic coronary disease correlate with erectile function? Int J Impot Res. 1997; 9(3): 123-6.
  31. Schwarzer U, Sommer F, Klotz T, Cremer C, Engelmann U. Cycling and penile oxygen pressure: The type of saddle matters. Eur Urol. 2002; 41(2): 139-43.
  32. Marceau L, Kleinman K, Goldstein I, McKinlay J. Does bicycling contribute to the risk of erectile dysfunction? Results from the Massachusetts Male Aging Study (MMAS). Int J Impot Res. 2001; 13(5): 298-302.
  33. Sommer F, Schwarzer U, Klotz T, Caspers HP, Haupt G, Engelmann U. Erectile dysfunction in cyclists: Is there any difference in penile blood flow during cycling in an upright versus a reclining position? Eur Urol. 2001; 39(6): 720-3.
  34. Wein AJ, Van Arsdalen KA. Drug-induced male sexual dysfunction. Urol Clin North Am. 1988; 15(1): 23-31.
  35. Ko DT, Hebert PR, Coffey CS, Sedrakyan A, Curtis JP, Krumholz HM. Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction. JAMA. 2002; 288(3): 351-7.
  36. Smith DE, Wesson DR, Apter-Marsh M. Cocaine and alcohol induced sexual dysfunction in patients with addictive disorders. J Psychoactive Drugs. 1984; 16(4): 359-61.
  37. Cocores JA, Miller NS, Pottash AC, Gold MS. Sexual dysfunction in abusers of cocaine and alcohol. Am J Drug Alcohol Abuse. 1988; 14(2): 169-73.
  38. Esposito K, Giugliano F, Di Palo C, Giugliano G, Marfella R, D’Andrea F, et al. Effect of lifestyle changes on erectile dysfunction in obese men: A randomized controlled trial. JAMA. 2004; 291(24): 2978-84.
  39. Seftel AD, Miner MM, Kloner RA, Althof SE. Office evaluation of male sexual dysfunction. Urol Clin North Am. 2007; 34(4): 463-82, v.
  40. Arduca P. Erectile dysfunction: A guide to diagnosis and management. Aust Fam Physician. 2003; 32(6): 414-20.
  41. Broderick GA. Evidence based assessment of erectile dysfunction. Int J Impot Res. 1998; 10 Suppl 2: S64-73; discussion S77-9.
  42. Travison TG, Shabsigh R, Araujo AB, Kupelian V, O’Donnell AB, McKinlay JB. The natural progression and remission of erectile dysfunction: Results from the Massachusetts Male Aging Study. J Urol. 2003; 177(1): 241-6.
  43. Goldstein I, Lue TF, Padma-Nathan H, Rosen RC, Steers WD, Wicker PA. Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med. 1998; 338(20): 1397-404.
  44. Rendell MS, Rajfer J, Wicker PA, Smith MD. Sildenafil for treatment of erectile dysfunction in men with diabetes: A randomized controlled dysfunction trial. JAMA. 1999; 281(5): 421-6.
  45. Schover LR, Fouladi RT, Warneke CL, Neese L, Klein EA, Zippe C, et al. The use of treatments for erectile dysfunction among survivors of prostate carcinoma. Cancer. 2002; 95(11): 2397-407.
  46. Zippe LD, Kedia AW, Kedia K, Nelson DR, Agarwal A. Treatment of erectile dysfunction after radical prostatectomy with sildenafil citrate (Viagra). Urology. 1998; 52(6): 963-6.
  47. Linet OI, Ogrinc FG. Efficacy and safety of intracavernosal prostaglandin in men with erectile dysfunction. N Engl J Med. 1996; 334(14): 873-7.
  48. Tomlinson J, Wright D. Impact of erectile dysfunction and its subsequent treatment with sildenafil: Qualitative study. BMJ. 2004; 328: 1037.
  49. Bolt JW, Evans C, Marshal VR. Sexual dysfunction after prostatectomy. Br J Urol. 1987; 59(4): 319-22.
  50. Slag MF, Morley JE, Elson MK, Trence DL, Nelson CJ, Nelson AE, et al. Impotence in medical clinic outpatients. JAMA. 1983; 249(13): 1736-40.
  51. Spark RF, White RA, Connolly PB. Impotence is not always psychogenic: Newer insights into hypothalamic-pituitary-gonadal dysfunction. JAMA. 1980; 243(8): 750-5.
  52. Buvat J, Lemaire A. Endocrine screening in 1,022 men with erectile dysfunction: Clinical significance and cost-effective strategy. J Urol. 1997; 158(5): 1764-7.
  53. Earle CM, Stuckey BG. Biochemical screening in the assessment of erectile dysfunction: What tests decide future therapy? Urology. 2003; 62(4): 727-31.
  54. Kloner RA. Cardiovascular risk and sildenafil. Am J Cardiol. 2000; 86(2A): 57F-61F.
  55. Bain CL, Guay AT. Reproducibility in monitoring nocturnal penile tumescence and rigidity. J Urol. 1992; 148(3): 811-4.
  56. Lewis RW. Venous surgery for impotence. Urol Clin North Am. 1988; 15(1): 115-21.
  57. Rosen RC, Jackson G, Kostis JB. Erectile dysfunction and cardiac disease: Recommendations of the Second Princeton Conference. Curr Urol Rep. 2006; 7(6): 490-6.
  58. DiMeo PJ. Psychosocial and relationship issues in men with erectile dysfunction. Urol Nurs. 2006; 26(6): 442-6, 453; quiz 447.
  59. Wespes E, Wildschutz T, Roumeguere T, Schulman CC. The place of surgery for vascular impotence in the third millennium. J Urol. 2003; 170(4 Pt 1): 1284-6.
  60. Siroky MB, Azadzoi KM. Vasculogenic erectile dysfunction: Newer therapeutic strategies. J Urol. 2003; 170(2 Pt 2): S24-9; discussion S29-30.
  61. Swindle RW, Cameron AE, Lockhart DC, Rosen RC. The psychological and interpersonal relationship scales: Assessing psychological and relationship outcomes associated with erectile dysfunction and its treatment. Arch Sex Behav. 2004; 33(1): 19-30.
  62. Riley A. The role of the partner in erectile dysfunction and its treatment. Int J Impot Res. 2002; 14 Suppl 1: S105-9.
  63. Gamba A, Romano M, Grosso IM,Tamburini M, Cantú G, Molinari R, et al. Psychosocial adjustment of patients surgically treated for head and neck cancer. Head Neck. 1992; 14(3): 218-23.
  64. Spranger MAG, Te Velde A, Aaronson NK, Taal BG. Quality of life following surgery for colorectal cancer: A literature review. Psychooncology. 1993; 2(4): 247-59.
  65. Joly F, Brune D, Couette JE, Lesaunier F, Héron JF, Pény J, et al. Health-related quality of life and sequelae in patients treated with brachytherapy and external beam irradiation for localized prostate cancer. Ann Oncol. 1998; 9(7): 751-7.
  66. van Basten JP, van Driel MF, Jonker-Pool G, Sleijfer DT, Schraffordt Koops H, van de Wiel HB, et al. Sexual functioning in testosterone-supplemented patients treated for bilateral testicular cancer. Br J Urol. 1997; 79(3): 461-7.
  67. Lilleby W, Fosså SD, Waehre HR, Olsen DR. Long-term morbidity and quality of life in patients with localized prostate cancer undergoing definitive radiotherapy or radical prostatectomy. Int J Radiat Oncol Biol Phys. 1999; 43(4): 735-43.
  68. Potosky AL, Legler J, Albertsen PC, Stanford JL, Gilliland FD, Hamilton AS, et al. Health outcomes after prostatectomy or radiotherapy for prostate cancer: Results from the Prostate Cancer Outcomes Study. J Natl Cancer Inst. 2000; 92(19): 1582-92.
  69. Arai Y, Kawakita M, Okada Y, Yoshida O. Sexuality and fertility in long-term survivors of testicular cancer. J Clin Oncol. 1997; 15(4): 1444-8.
  70. Aass N, Grünfeld B, Kaalhus O, Fosså SD. Pre- and post-treatment sexual life in testicular cancer patients: A descriptive investigation. Br J Cancer. 1993; 67(5): 1113-7.
  71. Heidenreich A, Hofmann R. Quality-of-life issues in the treatment of testicular cancer. World J Urol. 1999; 17(4): 230-8.
  72. Ginsburg ML, Quirt C, Ginsburg AD, MacKillop WJ. Psychiatric illness and psychosocial concerns of patients with newly diagnosed lung cancer. CMAJ. 1995; 152(5): 701-8.
  73. Marks DI, Friedman SH, Delli Carpini L, Nezu CM, Nezu AM. A prospective study of the effects of high-dose chemotherapy and bone marrow transplantation on sexual function in the first year after transplant. Bone Marrow Transplant. 1997; 19(8): 819-22.
  74. Sullivan AK, Szkrumelak N, Hoffman L. Psychological risk factors and early complications after bone marrow transplantation on adults. Bone Marrow Transplant. 1999; 24(10): 1109-20.

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