Introduction

Once it was "inability to perform". Then came "impotence", and now it's called "erectile dysfunction" (ED). Since effective medicines have become available, the numbers of men complaining of difficulty in getting and maintaining an erection have skyrocketed; 30 million men in the USA alone, according to recent estimates.

Along with many things, sex changes as we age. In healthy men the time it takes to get an erection and the time needed before the next erection get longer with the passing years. More direct stimulation of the penis is needed than in youth. By the time they are 40, as many as half all US men have difficulty getting an erection from time to time. While men have the advantage over women of being able to father children at any age, they may have difficulties with the sex act that become more frequent with age.

Causes

What are the causes of ED? Too often, increasing age is automatically - and incorrectly - blamed. Aging is accompanied by a gradual fall in testosterone (the male hormone) levels, but they remain in the normal range in 70% of older men. On the other hand, aging is associated with a number of conditions that impact significantly on sex - heart disease (heart attack, angina), stroke, diabetes, enlarged prostate, arthritis, Parkinson's disease, and chronic obstructive pulmonary disease (COPD) are examples. A future article on this site will discuss the sexual problems related to chronic diseases in both men and women.

Medications are quite a common cause of ED. For instance, at one time almost any blood pressure-lowering drug was likely to cause it. However, newer drugs don't have this distressing side effect - your physician can easily find one that doesn't cause this problem. Surgery (e.g. prostatectomy, rectal cancer surgery) is another reason for lessened sex in age, but it is a more common problem for women than for men.

About 90% of cases of ED that aren't caused by medications or surgery are due to medical conditions, such as blood vessel disorders (atherosclerosis, or narrowing of the arteries) involving the pelvis and penis, a complication of diabetes that affects the pelvic nerves, and hormone disturbances (thyroid disorders, diabetes, and low testosterone levels). Unfortunately, medical disorders can themselves produce mental "inhibition" that affects sexual ability. In this way, men with heart disease may worry that sex will cause a heart attack, and they become impotent.

A psychological or emotional cause is directly responsible for about 10% of cases of ED. This is diagnosed largely by making sure that there aren't any other causes. If someone has occasional erections at night, or on waking in the morning, the chances are fairly good that he doesn't have ED due to a medical condition. There are ways to test for erections during sleep, if necessary.

If a man has ED, it's important for him to visit his physician, not only to get appropriate treatment, but also because ED may itself be a symptom of a serious underlying disorder - e.g. advanced atherosclerosis, or diabetes.

Treatment

Obviously any underlying medical disorder, such as diabetes or COPD, should be treated energetically. But it's also important to make sure that the medical disorder isn't producing an added-on emotional sexual problem. That's why a full history of the problem must be given to the physician, so that all the necessary steps can be taken.

To begin in tackling the problem, a healthy lifestyle should be followed - no smoking, only moderate drinking, a healthy diet and plenty of regular exercise. This in itself can help in dealing with ED, and may help make the sufferer more attractive to his partner.

Provided a psychological cause can been ruled out, and there are no serious medical problems that prevent their use, there are several prescription drugs available that provide a safe and often effective way of overcoming ED. Correctly used, there should be no side effects to speak of. Unfortunately, such medications are sometimes used by people who shouldn't take them - either the drug has been prescribed incorrectly, or bought "on the street" or over the Internet, without a full physical examination beforehand. This can lead to severe adverse reactions in vulnerable men.

Newer medications that promise to be equally effective or even better than existing ones are being developed, and will soon be available. Some of them have similar methods of action, while others have different mechanisms, offering hope to those men who don't respond to present medications.

The effectiveness of oral medication in treating ED has pushed devices such as vacuum pumps and penis implants into the background. Many men ask about alternatives to prescription drugs, such as herbs and food supplements. In general, they are less likely to be effective than approved medications. There is a good, comprehensive discussion of such approaches in the book "The Viagra Alternative"¹

Premature ejaculation

This can be a problem for some men - the sufferer has a very early orgasm before his partner has had time to become fully aroused. It occurs in men with emotional stress, those taking certain medications, or those with urinary problems. Treatment is best directed at the cause, but sex therapy by a specialist can be helpful in stubborn cases.

Summary

A short article cannot do justice to this enormous topic. Men who are having difficulty with achieving satisfactory sex should first visit their family physician, to see if there are any underlying medical or medication problems. After these have been taken care of, referral to a specialist may be called for. ED caused by a physical problem can usually be helped by one or other of the newer prescription drugs available, provided there are no conditions prohibiting its use.

If the cause is psychological or emotional, then psychotherapy, marital counseling, group therapy and sex therapy can all be beneficial. These approaches can also be valuable in men with physical problems, because of the emotional carry-over of these into psychological hang-ups.

One must remember that focusing on genital contact, while it may be appropriate for young people, isn't enough as we age - it should give place to intimacy, mutual trust, friendship, and caring. Older people are still interested in sex, and want to remain sexually active (see " Aging and Sexuality"). Furthermore, men should realize that the old adage "use it or lose it" is relevant for their sexual activity as they get older.

Click here to read the article "Sex Problems in Women"