A 64-year-old married mechanic sees his family doctor for "problems with my erections." He has gradually developed difficulty having firm erections but has a normal interest in sex. He is in good health except for psoriasis and enlargement of his prostate. He saw a urologist who prescribed finasteride (medication that shrinks the prostate) about 6 months ago. He typically has a glass of wine with dinner, and is not a heavy drinker. His wife accompanied him to the office, and both agree that they have a good marriage. What is likely going on?
This imaginary case is fairly typical for a man with erectile dysfunction (ED). If this patient has an otherwise unremarkable history and physical exam and his lab studies are normal, he most likely has an organic cause for his ED, which is probably a side effect from his prostate medication. It is not unusual for men to develop some degree of ED while taking it.
Alcohol abuse is a common cause of ED, but a single glass of wine each night is not enough to be a cause. In fact, a single drink in a day may reduce ED as a result of its vasodilatory effects and mild relaxation that may occur.
About 50% of men age 40 to 70 have some degree of ED, but only 10% have complete loss of erections. ED can be caused by organic factors such as medication side effects such as the one mentioned above. Psychological factors can also cause ED. Most commonly, ED is a mixed form in which both organic and psychological factors are at play.
Organic causes include diabetes, hormonal abnormalities, vascular disease, genital trauma, medications, excessive alcohol use, and others. Psychological causes include anger at the sexual partner, performance anxiety, spectatoring (intellectual assessment during sex rather than being more emotionally into it), sexual inhibitions due to cultural factors, and others.
ED is defined as an inability to achieve or maintain an erection that is satisfactory to both partners. It is not the same as lack of interest in sex, which is called a low libido.
Treatment depends on the cause. A history and physical exam should be performed by a physician. Select lab studies are done based on the findings of the history and physical exam. Examples include: morning testosterone, fasting blood sugar, thyroid tests, vascular ultrasound, etc.
Organic causes may require a change in medications, vascular surgery, weight loss, optimizing management of chronic diseases, and/or a treatment for ED per se. The most commonly used medications are the phosphodiesterase inhibitors such as Viagra. Side effects include flushing, headache, dyspepsia, priapism (erection lasting more than 4 hours, which is a urologic emergency), and, very rarely, vision changes.
Other organic treatments include urethral suppositories or injections, vacuum pump, vascular surgery, or penile implants. Such treatments are usually recommended by a urologist. Psychological factors are treated with psychotherapy directed at the factors involved. A therapist with special interest in sexual dysfunction may be necessary.
The bottom line is that ED is common and usually treatable. Men should not hesitate to speak with their physician if they have any concern about sexual functioning.
Peter M. Hartmann, MD
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