by Kiran Bhagat, Cardiac Clinic

Although Erectitle Dysfunction (ED) can be caused by various conditions, about 7 in 10 cases are due to narrowing of the small arteries in the penis. This causes reduced blood flow to the penis. This is the same problem that can occur in other blood vessels. For example, narrowing of the blood vessels in the heart (the coronary arteries) is a cause of angina and other heart problems. Narrowing of blood vessels to the brain is a risk factor for having a stroke. Narrowing of blood vessels in the legs can cause peripheral vascular disease.

The root cause of the narrowing of the arteries is caused by atheroma. Atheroma is like fatty patches or 'plaques' that develop within the inside lining of arteries. (This is similar to water pipes that get 'furred up' with scale.) Plaques of atheroma may gradually form over a number of years in one or more places in the body, commonly in arteries going to the heart, brain, legs and penis. In time, these can become bigger and cause enough narrowing of one or more of the arteries to cause symptoms and problems.

Certain 'risk factors' increase the risk of more atheroma forming which can make atheroma-related conditions worse. Briefly, risk factors that can be modified and may help to prevent atheroma-related conditions from getting worse are:

 Smoking. Smoking is one of the biggest risk factors for developing heart disease. Smoking also roughly doubles your chance of developing ED. Young smokers may not be aware that they have a much greater risk of developing ED by middle age compared to non-smokers. If you smoke, you should make every effort to stop.

High blood pressure. Make sure your blood pressure is checked at least once a year. If it is high it can be treated.

If you are overweight, losing some weight is advised.

A high cholesterol. This can be treated if it is high.

Inactivity. We should all aim to do some moderate physical activity on most days of the week for at least 30 minutes. For example, brisk walking, swimming, cycling, dancing, gardening, etc.

 Diet. You should aim to eat a healthy diet. Details in a leaflet called 'Healthy Eating

 Alcohol excess.

Diabetes. If you have diabetes, good control of the blood sugar level and blood pressure can help to minimise the impact of diabetes on the blood vessels.

Note: ED caused by narrowed arteries commonly develops several years before any symptoms or problems develop due to narrowing of the coronary arteries (or other arteries). Therefore, ED is thought of as an 'early warning signal' that heart disease (or other cardiovascular diseases) may develop. This is why some of the tests listed below may be advised if you develop ED. Also, you are likely to be advised by your doctor on how to modify any 'risk factors' listed above with the aim of preventing heart disease from developing. 

What should I do if I develop persistent erectile dysfunction?

It is best to see your doctor. He or she is likely to discuss the problem, go over any medication you may be taking, and do a physical examination. This can help to identify, or rule out, possible underlying causes. Before treatment, the doctor may suggest some tests.

What tests may be done?

Depending on your symptoms, likely cause of the ED, age, etc, your doctor may suggest that you have some tests. These are mainly to check up on any 'risk factors' listed above which increase the risk of developing narrowing of the arteries. Tests may include:

·        A blood test to check the level of cholesterol and other 'lipids'.

·        Blood sugar level.

·        A check of you blood pressure.

·        A heart tracing (ECG).

·        Other heart tests are sometimes done, where appropriate, if heart disease is suspected.

Occasionally, ED is due to a hormone problem. This is more likely if you have a low sex drive (libido) in addition to ED. In this situation a blood test to check the level of testosterone or prolactin may be advised.

What are the treatment options?

A referral to a specialist is sometimes needed for assessment and treatment. The following gives a brief summary of treatment options. There is a good chance of success with treatment. There are pros and cons of each treatment, and your doctor will advise further.

Have you considered your other medication?

As mentioned, some medicines can cause ED. Check the leaflet that comes with any medication that you take to see if ED is a possible side-effect. Do not stop any prescribed medication, but see your doctor if you suspect this as the cause. A switch to a different medicine may be possible, depending on what the medicine is for.

Medication (tablets taken by mouth)

In 1998, the first tablet to treat ED was launched. This made a huge impact on the treatment of ED. There are now three different tablets licensed in Botswana to treat ED.

Three of the tablets work by increasing the blood flow to your penis. They do this by affecting the chemicals involved in dilating (widening) the blood vessels when you are sexually aroused (described above). They are sildenafil (trade name Viagra), tadalafil (trade name Cialis), and vardenafil (trade name Levitra). You take a dose before you plan to have sex. Because of the way they work, these medicines are called phosphodiesterase type 5 inhibitors (PDE5 inhibitors)

Pelvic floor muscle exercises

The pelvic floor muscles are a group of muscles that wrap around the underside of the bladder and rectum. One of these muscles also partly wraps around the base of the penis. This is involved with preventing blood escaping during an erection, (as well as being active during ejaculation, and when emptying the urethra of urine when finishing at the toilet). Studies suggest that strengthening the pelvic floor muscles in men can cure ED in some cases.

To identify your pelvic floor muscles: firstly, contract the muscles that you would use to stop passing wind from your anus; secondly contract the muscles that you would use to stop the flow of urine. These are the muscles that can be trained and strengthened. Ideally, discuss this option with your doctor. If this option is considered appropriate to try, then ideally you should see a physiotherapist for advice on exactly how to do the correct exercises.

Injection treatment

This was the most common treatment before tablets became available. It usually works very well. You are taught how to inject a medicine into the base of the penis. This causes increased blood flow, and an erection usually develops within 15 minutes. (Unlike with tablets, the erection occurs whether or not you are sexually aroused.)

Other treatments

Treating an underlying cause

For example, treating depression, anxiety, changing medication, cutting back on drinking lots of alcohol, or treating certain rare hormone conditions may cure the associated ED.

Lifestyle and other advice

As mentioned above, ED is often a marker that heart disease or other cardiovascular diseases may soon develop. Therefore, you should review your lifestyle to see if any changes can be made to minimise the risk of developing these problems. For example, stop smoking if you are a smoker, take regular exercise, eat a healthy diet, etc.