If you suffer from erectile dysfunction, you’re not alone. Worldwide, 100 million men have some degree of it. (It’s a good thing for women they’re not all on the same continent.)

And the number is going to grow as the male population ages, because erectile dysfunction is largely a disease of the older man. Over the age of 60, about 60 per cent of men have some degree of ED.


Erectile dysfunction is what used to be called impotence, before that term became politically incorrect and outdated (suggesting sexual inadequacy – when the condition is really mostly a physical disability).

Despite what many people believe, it’s usually not a consequence of some psychological or personality problem, but of the body wearing out.

Getting an erection depends on a good blood and nerve supply to the penis. A sexual stimulus activates nerves that dilate blood vessels, allowing more blood to flow into the network of veins in two expandable sponge-like shafts in the penis called the corpora cavernosa. Valves prevent the blood flowing back out so the penis stays hard until after either ejaculation or the removal of the sexual stimulus.

Degenerative diseases of old age damage the nerves and blood vessels of the penis (as they do elsewhere in the body) so that not as much blood flows in after sexual stimulation. Conditions like heart and blood vessel diseases, diabetes, and degenerative diseases of the nervous system, such as multiple sclerosis, can cause ED. As time goes on and the underlying condition progresses, the man finds it harder and harder to get and keep an erection.

In other cases, erectile dysfunction may be temporary and reversible. Sometimes it can be a side effect of certain medications, like blood pressure or cholesterol-lowering drugs, diuretics, some antipsychotics, antidepressants and epilepsy medications.

Recreational drugs like alcohol, tobacco, marijuana, cocaine, heroin, barbiturates, and amphetamines can cause ED because they depress the brain’s response to a sexual stimulus. A heavy alcohol intake and smoking can also cause ED by damaging the nerves and arteries of the penis.

Erectile dysfunction may also be a consequence of surgery – on the prostate, bladder or bowel, for example – when the nerves supplying the penis are damaged as a side effect.

Sometimes it’s a normal phenomenon, a consequence of drunkenness, general anxiety and lack of sleep.

Only in one in 10 cases is there an underlying psychological problem. In these cases it’s usually stress, caused by things like problems at work or financial worries. Depression, anxiety states and other psychiatric conditions can also produce ED, as can anxiety about sexual prowess (commonly called performance anxiety).

Alternatively, erectile dysfunction may be a symptom of a relationship that’s not working due to sexual boredom, tension or anger, or lack of intimacy and communication between partners.

A clue that the cause is psychological rather than physical is if the man still gets an erection on waking or is able to get one when masturbating.

In some cases, erectile dysfunction results from a combination of physical and psychological causes: there’s a physical cause that causes the man to become anxious about his performance, which makes the problem worse.


The good news is that there have been huge advances in the treatment of ED in the past 10 years or so. Most men can be helped, but because there are many different causes and treatments available, the best option should be worked out in consultation with a doctor.

Psychotherapy or counseling from a GP, psychologist or psychiatrist can help if the underlying cause is psychological. Counseling (for both partners) may help solve a relationship problem, and can also help a man whose confidence is low because of an underlying physical cause.

In men whose erectile dysfunction stems from a physical cause, treating the underlying cause may help: changing medications, for example, may eliminate ED if it’s a side effect of a drug. Moderating alcohol intake, stopping smoking, and exercising regularly will help.

Medication. If these measures don’t work, the most effective treatments are drugs such as Viagra (sildenafil), Cialis (tadalafil) and Levitra (vardenafil). These drugs – a class of medication known as phosphodiesterase inhibitors, or PDE5 inhibitors – have revolutionised the treatment of ED. They work by inhibiting a particular enzyme in the penis, enhancing the erectile response to normal sexual stimulation. There appears to be no difference in effectiveness across the three drugs (Levitra is quicker acting than Viagra, while Cialis is longer lasting).

ED medications need to be taken at least one hour before sex, so they’re not much good on the run. After a large meal or after drinking a lot of alcohol they can be slow to be absorbed, so take even longer. Also, they may have side effects like facial flushing, nasal congestion, headaches and indigestion.

There have been some deaths during sexual intercourse in men taking these drugs, but this is thought to have been due to the physical exertion during sex, not the drugs themselves. So if a man has heart disease, his doctor needs to assess how fit he is before prescribing these drugs. ED drugs can’t be used in men with heart disease who are on nitrate therapy or men who use amyl nitrite ‘poppers’.

Drugs like Viagra work in 50 to 70 per cent of cases of ED. They work best if there’s an underlying physical cause. They don’t improve a man’s performance. If there isn’t an erectile problem to begin with, they’re useless. Nor do they enhance a man’s libido or attractiveness.

For men who don’t respond to medication, there is a range of other treatments to consider.

Devices. Some treatments involve using a device, such as a vacuum pump placed over the penis to draw blood into it, with a rubber ring fitted around the base of the penis to stop the blood draining out and so keeping the penis engorged. But these devices can be cumbersome, and they take time to learn how to use. They need to be fitted and a doctor needs to explain how to use them.

Penile injections. Before the arrival of the Viagra-type drugs, this used to be the most popular and effective treatment. It involves the man or his partner injecting a drug that relaxes the blood vessels in the penis, allowing them to expand. It can create an erection within five to 10 minutes which lasts for up to one hour. Men must be taught how to do it and to use the right dose – too much can cause a painful erection that lasts for hours. There are also possible complications from repeated injections, such as bleeding and scarring. But many men have used them successfully for years.

Penile prosthesis. This is a device that is surgically implanted into the penis. It’s inflated with saline to enlarge the penis. Because it’s not reversible, it’s usually a last-resort treatment if other treatments haven’t worked.

Surgery. In a few select cases surgery can be used to correct nerve damage, or to correct defects in blood vessels in the penis. It’s not always successful and the surgery often needs to be redone.

The impotence industry

Because erectile function is such an important part of many men’s perception of themselves, men are easy prey for peddlers of bogus but expensive ‘cures’ with no scientific basis.

Some men’s health clinics peddle the notion that ED is a result of the natural reduction in testosterone levels that occurs as a man ages – they call it the ‘male menopause’. They advocate testosterone replacement with tablets or injections.

While it’s true that testosterone levels decline slightly as a man gets older, it’s not true that this causes ED. Testosterone tablets make no difference and may even be harmful over the long term.

There are some rare conditions, such as a condition called hypogonadism, in which the testicles don’t produce enough testosterone. These cases do benefit from testosterone supplements, but the cases are rare and need to be proved by blood tests.

Other clinics sell various concoctions of unspecified drugs, often as nasal spays or puffers, with no scientific evidence for their effectiveness and safety.

Even the manufacturers of effective treatments have been accused of aggressively marketing them to men who don’t need them. The makers of Viagra, for example, have been accused of marketing Viagra to consumers via an impotence ‘public awareness campaign’, to encourage men to pressure their doctors to prescribe the drug.

So ignore those billboards, late-night TV ads and the spam. Anyone who has persistent difficulty getting and/or keeping an erection should see a GP, who may refer them to a specialist andrologist or urologist if necessary.

The best chance for a man to get In Like Flynn well into old age is to stay fit and healthy: eat a high-fibre diet low in saturated fats and sugars, exercise regularly, don’t smoke and keep that alcohol intake moderate.