Sexual health is an important part of an individual’s overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is a very common medical condition affecting sexual health. Impotence can be caused by diseases or the treatment for disease. Common causes are listed below.

Fortunately, there are many different treatment options for erectile dysfunction. This information sheet explains some of the causes and summarises treatment options available.

Common causes of erectile dysfunction:

• Vascular causes:
  These are very common and are the result of a lack of blood entering or being trapped in the penis. Risk factors for vascular causes are smoking, high blood pressure, diabetes, heart disease and alterations in cholesterol levels.
• Neurological causes:
  These interrupt the message from the brain to the penis and are usually obvious, for example spinal injury, multiple sclerosis and radical pelvic surgery.
• Hormonal causes:
  Are rare, for example lack of male sex hormones.
• Psychological causes:
  In this case the penile mechanism is normal but the erection is inhibited by psychological problems which may range from simple anxiety, for example the fear of failing to get an erection (performance anxiety), to relationship problems, depression or other psychological disturbances. Stress of any kind may disrupt sexual performance.
• Medications:
  Several medications, particularly those used to treat hypertension, cardiac disease and psychiatric disorders can interfere with the ability to have an erection.

Self-assessment: First of all assess your function in by answering the questions in the table below. Add the numbers corresponding to questions 1-5. If your score is 21 or less, you may be showing signs of erectile dysfunction and may want to speak to your doctor.

Circle the number of the response that best describes your own situation. Please be sure that you select only one response for each question. 

Over the past 6 months:

What treatments are available ?

• Counselling
  Most men who suffer from impotence will be affected psychologically, even when the cause is due to a physical disease. Counselling may help you and your partner to talk about the problem and even to overcome it. It may also help to reassure you both and ease the tension in your relationship. Counselling is required by most young men (under 40 years of age), as the cause of their problem is rarely physical.
• Psychiatric Advice and Treatment
  This may be necessary if you are suffering from depression or other psychological problems, which can cause impotence.
• Hormone Therapy
  A minority of men suffer from hormonal problems and they usually have a reduced sex drive. It is easy to give hormone replacement therapy using patches, tablets or injections. In rare cases patients suffer from a pituitary tumour which may require additional treatment.
• Oral Medication
  Sildenafil (Viagra®) is the first tablet that is clearly effective in the treatment of many impotent men. It acts upon the penis to enhance the blood supply and facilitates maintaining an erection. It improves the erection in approximately 40 –80% of men, depending on the type of impotence. It does not improve sexual desire. A tablet (25-50 or 100mg) is taken one hour before sexual activity. It may produce side effects such as headaches (15%), flushing (10%, gastrointestinal (7%) or visual disturbances (3%) and should never be used by men with a rare eye disease called retinitis pigmentosa. Men taking nitrates, which are normally prescribed for heart problems should not take sildenafil either and medical counselling is always required before starting treatment. Previous oral therapies were not very successful (for example Yohimbine) although recent developments indicate that other tablets may become available in the next few years. At present Viagra®, is only licensed in the United States but it is expected to be licensed in Europe in 1998/99 some deaths of patients taking Viagra®, have been reported but as yet little is known regarding their possible links to the drug.
•  Transurethral administration of Alprostadil
  A special system, the medicated urethral system for erection (MUSE®), has been designed for the local administration of medication to the penis through the urethra. This form of treatment involves inserting a small plastic cylinder (Figure 1), into the urethra (urine tube), and introducing a small pellet of alprostadil. You will need to pass urine immediately before this – to provide lubrication and also to help with the absorption of the drug. Enough of the active compound enters the penis to produce an erection. It is used ten to fifteen minutes before the erection is required and is effective in 43% of patients. It is often accompanied by a temporary burning sensation in the urethra. Discomfort occurs in a third of patients and minor bleeding from the urine tube in 5% of men. A condom should always be used when your partner is likely to conceive or is already pregnant.
• Intracavernosal Injection
  This involves the injection of a specific dose of the drug directly into the penis through a fine needle. The injection usually mimics the normal physical events that initiate and maintain a spontaneous erection. This technique can be easily learned by the patient for use at home and the doctor will determine the correct dose for each patient. The patient self-injects the drug ten to fifteen minutes before sexual activity and the dose is adjusted so that the erection lasts about one hour. The erection should not last more than four hours! If this happens, you must contact your physician immediately. Pain in the penis during the erection occurs in some patients, and there is a small risk of scarring of the penis with long-term use. Papaverine was the first drug to be used for injection treatment into the penis and has also been used in combination with phentolamine and alprostadil. Alprostadil (CAVERJECT® - Pharmacia & Upjohn, VIRIDAL® / EDEX® - Schwarz Pharma) is the most extensively used around the world, being highly effective and safe. Moxisylyte (ERECNOS® - Fournier, ICAVEX® - Sarget), a combination of papaverine and phentolamine (ANDROSKAT® - Byk Netherland bv) and a combination of vasoactive intestinal polypeptide and phentolamine (INVICORP® - Senetek) are also available in some countries. 

• Vacuum Devices
  This treatment uses a pump and cylinder to create a vacuum around the penis so that it engorges. The plastic cylinder is placed over the penis and against the body, using lubricating jelly to produce a seal. A hand or battery operated pump is used to draw air out of the cylinder. This causes blood to enter the penis and produces stiffness. A band is then slipped off the cylinder and around the base of the penis to trap the blood and maintain the erection, and the cylinder is then removed. The rubber band may safely be left in position for 20-30 minutes and will sustain an erection until it is removed. This technique takes a little while to learn and good communication between you and your partner is necessary. Many people have reported satisfactory results with this treatment. Some discomfort and bruising may occur. Orgasm is not altered but the constrictor band may prevent the sperm appearing at the time of ejaculation.
• Arterial Surgery
  This form of surgery aims to increase both blood and blood pressure within the penis. It is advisable for young patients who have had an accident, which has affected normal blood supply. It consists in connecting a healthy blood vessel (normally from the abdominal wall) to an artery of the penis and in this way by-passing the arterial block. At present it is only carried out in a very small number of cases (about1% of men with impotence).
• Venous Surgery
  This used to be a popular method of treatment but is nowadays considered, by most surgeons, to be ineffective except for selected patients. In this case the surgeon ties up or removes veins from the penis in a way, which is similar to that used in surgery for varicose veins.
• Penile Prostheses
  Two synthetic cylinders are placed inside the penis with an operation. They make the penis stiff enough for penetration. There are several types of protheses and the simple malleable prostheses are the cheapest although they have the drawback of giving the penis a permanent semi-erect state. Inflatable prostheses consist of a pump mechanism and a reservoir in addition to the penile cylinders and give better results and a more natural look to the penis. Although implants carry the risk of infection (particularly in diabetics) or mechanical breakdown, the failure rate is now very low and serious complications are unusual.

Further general information Your doctors and specialist nurses are in an ideal position to give you relevant information on your disease and treatment as they know your individual circumstances. Cancerbackup has a help line (0808 800 1234) and a prize winning video available in English, Italian, Urdu, Bengali, Gujarati & Hindi explaining Radiotherapy & Chemotherapy. Cancernet.co.uk has over 500 pages describing cancer, its management, practical tips and tool which patients, their carers and their doctors have found helpful during the cancer journey.