Great sex is an important part of most adults’ lives and it is possible to spend an inordinate amount of time thinking about it. Problems with sex can destroy a marriage or a relationship, or at least be a major source of tension and conflict. Having problems with achieving or maintaining an erection is a far more common problem than most men are prepared to admit. Under-diagnosed and under-treated, erectile dysfunction is a significant cause of male (and female) misery. 

So what causes it?  Primary erectile dysfunction, which is defined as never having had an erection adequate to achieve sexual intercourse, is very rare. Causes include anatomical abnormalities, nerve injury and disease.  

Secondary erectile dysfunction (ED) is the loss or impairment of erectile function in someone who has previously managed normal erections and intercourse. As men get older their ability to achieve erection diminishes.

An 18-year-old may experience erections as often as every 20 minutes and be capable of renewed erection minutes after an orgasm, whereas a 50-year-old may be able to achieve an erection fairly easily, but may then take many hours to be able to achieve a repeat performance.  

So why does it happen?  The bodily processes that lead to erection are complex and fascinating.  Psychological factors such as background libido (in itself complex and related to hormones including testosterone), state of arousal (how much you fancy your partner) and readiness for sex create signals to the large, blood-filled spaces (the corpus cavernosum) in the flaccid penis to engorge and fill with blood, thus creating an erection. Any stage in this process can go awry, thus leading to a frustrating failure.  

Erectile dysfunction may be the first sign that a man has cardiovascular disease. Along with diabetes, these are the most common physical causes of ED. Sedentary lifestyles and obesity are also linked with a decrease in testosterone levels. Some men may experience a decline in testosterone levels with age but, with a healthy lifestyle, this is by no means inevitable, unlike the female menopause. The predilections of certain European politicians are testimony to this.  

Smoking, especially in the long-term, has a direct and significant effect on the vascular system of the penis. The incredible ability of the corpus cavernosum to swell with blood can be diminished and erectile function lost as a diehard smoker ages.

Alcohol, as immortalised in the words of Shakespeare, “provokes the desire but takes away the performance” – this is true in the short-term, but also with chronic alcohol overuse.

All is not doom and gloom with this issue though, as treatment and help is at hand. The first step is to admit to and recognise the problem. Next, try to engage in honest, open and warm communication with your partner.  It is imperative that partners sympathise and take the issue seriously, as excessive psychological pressure never helped any man get an erection. Top tip: Do not laugh.

For sufferers, the first thing to do is take a look at your lifestyle and see what changes you could make that would make a difference. Make sure you see a doctor who you trust to take you seriously, as there are some possible physical causes for this problem.

Hypertension medication may be the cause. Commonly they’re anti-depressants but can also be some prostate drugs and drugs for high blood pressure. A full medical history and examination should

be done, along with any necessary tests.  

If no treatable physical or psychological causes can be found then medication may still help.  The biggest medical breakthrough in the management of erectile dysfunction was the discovery of sildenafil, a phosphodiesterase inhibitor, commonly known as Viagra.  

Originally studied as a treatment for angina, this drug was found to cause frequent erections and wasn’t much help with angina after all. So, Pfizer decided to market it for erectile dysfunction, correctly predicting enormous market appeal.

The drug works by improving blood flow to the penis. There are some significant interactions between these types of medicines and other drugs, so it is wise to get it prescribed rather than just picking it up at the local pharmacy or, as one can in Cambodia, the petrol station.    

Two other similar drugs are also on the market. Each has different profiles, with the biggest differences being the duration between taking the tablet and the onset of action.

In men without erectile dysfunction these drugs have little effect on sexual prowess, although this has not stopped many from abusing the drug. In general it is a fairly safe medicine, although it may occasionally and very painfully have the side effect of priapism – an erection that will not go away – which may require treatment with needle drainage of the engorged penis to prevent penile necrosis.

This side effect is more likely to occur if too much Viagra is taken or if the man taking it does not have erectile dysfunction.

In addition to drugs there are some other treatments for ED that may help, though drugs are really the first line.  These include hormone treatment, penile injections, vacuum devices and penile implants.  

If this article is making you wonder whether you or your partner should seek help for this condition, aim to move beyond denial or embarrassment and see a doctor. The link below offers some good tips on how to talk to your doctor about ED.

http://www.netdoctor.co.uk/sex_relationships/facts/ed_doctor.htm

Dr Laura Watson is the deputy CMO at the International SOS clinic in Phnom Penh. She is a qualified general practitioner from Britain.