Erectile dysfunction- Stay on top

Sex is an essential aspect of life. Besides the reproductive aspect, sex is also essential for our physical and psychological needs. It has been proven beyond doubt that sexual health and general health go hand in hand. Essential for sex is penile erection and its sustenance through intercourse. The penile erection is an interplay between multiple systems in our body like hormonal, neural (related to nerves), vascular and psychogenic factors. Therefore, it can be affected by any disease affecting one even one of these systems.


Erectile dysfunction or ED is quite common and it becomes more common with increasing age. Public awareness is quite lacking for this common problem and many consider it a normal aspect of ageing. Even many general practitioners and specialist do not consider it a serious health issue and dismiss it as a lifestyle problem. Therefore, a large number of patients do not seek medical help and may not even get diagnosed. In this article, we highlight the common queries about this problem for better understanding of the patients.

What is Erectile dysfunction or ED?

Erectile dysfunction is basically inadequate penile erection, sufficient enough for successful vaginal intercourse. It can either be an inability to attain or inability to maintain it long enough for intercourse.[1]
In simple terms, it is called impotence.

How common is Erectile dysfunction?

Erectile dysfunction is extremely common condition in males, especially over 40 years of age. The prevalence, or the percentage of individuals having ED at particular time, increases with increasing age. As per a study published in 2013[2], the percentage of individuals with ED rises sharply with age.

Age group Prevalence
<40 years                    1-10%

40-49 years                 2-9%

60-69 years                 20-40%

>70 years                   50-100%

It has been estimated that the worldwide prevalence of ED would increase from 152 million men in 1995 to an estimated 322 million men by 2025, which amounts to an increase of nearly 170 million men within a span of 30 years. The study also projected that the largest increase would be in the developing world, i.e. Africa, Asia and South America.[3]

What are the causes of Erectile dysfunction?

Penile erection, and maintenance of erection is a complex physiological process, and therefore can be affected adversely by multiple factors.

Age is a common factor, as can be seen by the increasing prevalence in elderly population.

Chronic medical conditions like Diabetes mellitus, Hypertension, chronic kidney or liver diseases are also very commonly associated with Erectile dysfunction. In a study from Poland, Erectile dysfunction was present in 78% of patients with Diabetes, 67.8% of patients with Hypertension, 70.3% of patients with atherosclerosis or Coronary artery disease and 70.5% patients with neurological or psychological illnesses.[4] In fact any chronic disease can increase chances of erectile dysfunction directly or indirectly.

Lifestyle factors like sedentary lifestyle, smoking, alcohol or drug abuse, sleep disorders, and obesity have all been associated with ED in a significant manner.

Psychogenic erectile dysfunction is also an important cause. Performance pressure or anxiety, depression, chronic stress, relationship problems, traumatic past experiences and family or social pressures all contribute to erectile dysfunction.

Another important cause is related to adverse affects of medications. Certain medicines used for hypertension, chemotherapy, and antifungals can cause ED.

How is Erectile dysfunction diagnosed?

Erectile dysfunction is basically diagnosed by a careful history and physical examination. History assessment includes the sexual history details, knowledge about sex, psychosocial history, and detailed medical and drug history including smoking, alcohol and substance abuse are key in establishing a diagnosis. The patient’s partner can also give specific inputs to help in establishing a diagnosis.
Routine blood tests for cholesterol, thyroid hormones, blood sugar levels, testosterone levels are also a part of routine evaluation for ED.

ED vs Pre-mature ejaculation: One of the confusing aspects of diagnosis is to differentiate it from pre-mature ejaculation and if ED is present, then whether it is psychogenic or because of some underlying cause. The first one is simple. In erectile dysfunction, ejaculation occurs after loss of stiffness and in premature ejaculation, penis becomes lax after ejaculation.

Nocturnal penile tumescence(NPT) test is helpful in differentiating the psychogenic from the organic causes of ED. This test is based on the fact that a male gets 4-6 erections during sleep, especially deep sleep. Men with psychogenic ED will get erections during sleep just like normal individuals.
Penile Doppler ultrasound helps in assessing the blood flow into the penis which is the basis of penile erections.

What is the treatment of Erectile Dysfunction?

Lifestyle modification is at the forefront, when it comes to treatment of erectile dysfunction. Weight loss in obese individuals
Smoking cessation
Regular physical exercise
Mental relaxation like meditation

Control of medical co-morbidities like Diabetes and Hypertension.

Psychosexual therapy, counselling, and couple therapy is helpful in overcoming ED due to psychogenic causes. It includes sex education and involves both the partners.

Medications like Sidenafil citrate have revolutionised the treatment for ED. Popularly known as Viagra(Pfizer, USA), it has become the mainstay of treatment. It is quite well tolerated. Common side effects are headache and flushing. Patients and clinicians need to be cautious about the possibilities of adverse cardiac events in patients with known history of cardiac illness, unstable angina and should also look for possible adverse interactions with other medicines like those for hypertension. Even though it is quite safe, a clinician opinion is advisable before taking this medication.

One third of the patients may not find adequately satisfactory results with this medicine for no apparent reasons, and may need other therapies like Vacuum constriction devices or Penile prosthesis.

Disclaimer: This is for the general awareness of the patients and cannot replace expert medical advice. Patient treatments need to be individualized and that can be decided based on clinical examination and evaluation by a trained physician.

1. National Institutes of Health. Consensus development conference statement. Impotence. December 7–9, 1992. Int J Impot Res 1993; 5: 181–284.

2. Rany Shamloul, Hussein Ghanem. Erectile dysfunction. Lancet 2013; 381:153-65

3. Ayta 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.

4. J Haczynski, Z Lew-Starowicz et al. The prevalence of erectile dysfunction in men visiting outpatient clinics. International Journal of Impotence Research (2006) 18, 359–363

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