As part of EILE Magazine’s article series on sexual health, Dr Shay Keating explains the reasons behind male impotence, how easily treatable it can be, and why worrying is the last thing that will help the situation.
Erectile dysfunction (ED) or ‘male impotence’ is a sexual dysfunction characterised by the persistent or recurring inability to achieve and/or maintain an erection sufficient for satisfactory sexual activity. ED can have a profound effect on the patient’s overall quality of life and can be associated with anxiety, depression, loss of self esteem and self confidence. Partners too can feel rejected, unattractive and guilty.
Up to 80% of ED has organic (physical) cause and many cases have mixed organic and psychological components. Many chronic illnesses have been implicated in ED, high blood pressure, vascular disease, neurological disorders such as stroke or multiple sclerosis, kidney disease or hormonal diseases such as diabetes. Psychiatric diseases causing ED include depression, anxiety and alcoholism. Surgical causes include spinal cord or pelvic injury, penile and bladder trauma and surgery to the prostate.
Psychological causes of ED occur when erection fails as a consequence of thoughts or feelings rather than physical reasons. These include anxiety about sexual performance or identity, depression, relationship issues such as guilt, sexual problems in the partner, lack of sex education, history of psychological trauma or abuse and anxiety/stress disorder with maybe a financial or work component.
Lifestyle factors include abuse of alcohol, heroin, cannabis, cocaine, anabolic steroids and cigarette smoking. Some prescription drugs such as anti blood pressure medications and antidepressants are also implicated in ED. ED increases with age and by aged 70, more than 70% of men will be affected to some degree.
Successful treatment of ED can be associated with significant improvement in psychological well-being and can greatly improve the quality of relationships. Management includes treating depression and anxiety and changing medication where appropriate. Stopping smoking, exercising, losing weight, controlling blood pressure and improving blood sugar control in diabetics, curtailing excess alcohol and stopping illicit drug use can all improve ED. Where there is a significant psychological component, psychosexual therapy may play a role. Where organic causes are suspected, there are oral medications, topical and injectable preparations, including the possibility of surgical implants.
ED in HIV infected individuals pre-ART was attributed to lower testosterone levels reported in this group. The focus has now shifted to the effects of aging, ART use and concurrent non-HIV related illnesses. With the increasing life expectancy and the increased prevalence of HIV infection in those over 50, we may see an increase in ED in this cohort, as in the aged matched HIV negative cohort. ART agents can cause high cholesterol which in turn may lead to ED, and older ARTs have been implicated in causing nerve damage. Also, some ARTs may interact with the medications used to treat ED and these medications should only be used under strict medical supervision.
Finally, following a diagnosis of HIV, the anxiety surrounding the disease and possible infection of others can cause serious psychological morbidity and consequent ED. This can be alleviated with appropriate counselling around safer sex practices. Information about post exposure prophylaxis following sexual exposure to HIV can help minimise the worry of infecting others.
Dr. Keating is an Associate Specialist in Genitourinary Medicine for St. James’ Hospital, Dublin, and has his own practice at Harold’s Cross Surgery.