Dr Chinnadorai Rajeswaran, consultant endocrinologist explains about erectile dysfunction. Please email him, if you need more information

Erectile dysfunction (ED), is also known as impotence.  This means that you are not able to initiate or sustain an erection sufficient enough for sexual activity. This condition can have a significant effect on your sex life and confidence. Prevalence of ED is common among older men. Around 7 in 10 men aged 70 years and above have some degree of erectile dysfunction.

Erectile dysfunction is usually treatable; however, the underlying cause needs to be ascertained.

What are the underlying causes for erectile dysfunction? 

• Obesity
• Diabetes
• Hormonal causes
• Neurological causes
• Regular long-distance cycling
• Alcohol intake
• Drug abuse
• Injury to the nerves going to penis
• Reduced blood supply to penis
• Medications like beta blockers and antidepressants
• Anxiety
• Depression
• Stress

What is the physiology of erection?

In the first instance you need to understand the physiology behind an erection. The penis has a very rich blood supply. In the right circumstances following mental and sensory stimulation, brain sends impulses through the nerves to the penis. Blood vessels in the penis start to relax when the input comes from the brain. The lining of the blood vessels or the endothelium releases nitric oxide, which causes smooth muscles in the penis to relax.  Relaxation of the smooth muscles helps to fill the chambers in the penis with blood, thereafter blood gets trapped under high pressure within the penis leading to an erection.

Ejaculation is a reflex action which is triggered when the sexual act reaches its peak. The process of ejaculation is controlled by the brain and spinal cord.

How exactly the above reasons affect my erection?

There are several pathological mechanisms which can lead to ED. Some of them are mentioned below:

Nerve damage or neuropathy: Medical conditions like Parkinson’s disease, excess alcohol, diabetes, stroke, or multiple sclerosis can lead to nerve damage. Injury to the nerves going to penis could be due to radiotherapy, spinal injury, genital injury, fracture of pelvis or long distance cycling. ED develops gradually when the nerve is damaged except when there is an injury, in which case there may be an immediate impact on erection.

Reduced blood supply to the penis: A number of medical conditions and ageing leads to reduced blood supply to the penis. Arteries supplying blood to the penis are narrowed with ageing and hence ED is more common in older men. In addition to ageing narrowing of blood vessels and reduced blood supply to penis is seen in diabetes, smokers, hypertension and those who have elevated cholesterol.

Hormonal causes: Low testosterone leads to low sex drive and ED. Testosterone is produced by the testicles and this process is controlled by the pituitary gland, which is located in the brain. So, any condition affecting the testicles or pituitary gland can interfere with testosterone production. This also includes injury to the testicles and head.

Medications: Several medications can cause ED, including antidepressants (sertraline, citalopram etc), Antipsychotics, beta blockers (atenolol, propranolol etc), diuretics, antihistamines, sedatives and many more.

Psychological reasons: There are a number of psychological causes which leads to problems with initiation and sustaining erections. Psychological causes for ED are more common than physical causes. These include: relationship problems, anxiety, stress and depression. Performance anxiety in itself can be an important cause for ED.

How does obesity cause erectile dysfunction?

There are several reasons why obese men are troubled with erectile dysfunction. Obesity, itself is an inflammatory condition and can lead to damage of the blood vessels. Obese men are more prone to type 2 diabetes, hypertension, elevated cholesterol, which in turn can lead to ED.

Some obese men are troubled with performance anxiety, low self-esteem and under confidence which all contribute to ED. Moreover, due to the size of the body and exercise tolerance, some men are physically unable to perform the sexual act.

Men who are obese and troubled with ED, have low testosterone. Hormonal imbalance occurs due to the fat tissue converting testosterone to oestrogen, a female hormone. Normally the testicles are supposed to be kept cooler than the body temperature, so that it functions well. In obese men, testicles, due to body habitus are kept warm and do not function well.

Weight loss significantly improves sex drive and sexual function.

When to seek help?

There are times when most men have had problems with achieving adequate erection. You may not be able to initiate or sustain an erection especially if you are stressed, tired, sleep deprived, distracted or have had too much alcohol. However, when you are not in any of these situations’ erection may not be a problem so it is temporary and you do not need any help. You need to have a clear plan and strategy and avoid being tired, stressed, sleep deprived and also not consume excess amount of alcohol.

If, however ED is an ongoing problem when sexually aroused and happens most of the time, you need to seek help from an endocrinologist.

What are the treatment options available?

If ED is temporary and you are able to identify the underlying cause and address it successfully, you do not need to see any one. For example, if the ED was due to some stress or sleeplessness and you have overcome that and you feel better, you may not need any help. However, if ED persists, you should see your GP.

Your doctor may do some baseline tests and if appropriate may give you some tablets like sildenafil (Viagra), tadalafil (Cialis) or any other tablets which belongs to the same class. These tablets will only work if there is sexual arousal. It is always important to discuss with your doctor if you can take these tablets as it is contraindicated in some medical conditions and should not be taken if you are on some medications especially blood pressure lowering medications. Usually a baseline blood test is done. If there are hormonal problems, you should get yourself referred to an Endocrinologist near you for further investigations and treatment.

Other forms of treatment include:

• Injections
• Creams
• Testosterone replacement
• Vacuum devices

Some patients may need a referral to Urologist for surgical interventions including penile implants.

Weight management: Weight loss which is sustained and associated with improving lean body mass helps in the management of ED.

Dr Chinnadorai Rajeswaran is a consultant Physician specialising in Endocrinology, Diabetes and Obesity. As a private endocrinologist he  has private endocrine, diabetes and weight loss clinics in Harley Street, London, Chennai (India), Claremont Hospital, Sheffield, Nuffield Hospital, Leeds and Simplyweight, Bradford.

He has face to face consultations with people from Barnsley, Rotherham, Chesterfield, Doncaster, Wakefield, Huddersfield, Bradford, Harrogate, Leeds, Sheffield, London and Chennai (India). He also offers video consultations.