Erectile dysfunction (ED) affects 50% of men between the ages of 40 and 70. This is according to one of the largest studies on this issue, the Massachusetts Male Aging Study (MMAS).

“ED is the persistent inability to achieve and maintain an erection satisfactory for sexual activity. The key differentiator is that it is a persistent inability, it is not a temporary thing, it is not an isolated event that happened after ten pints in the pub,” explains Dr Ivor Cullen.

Dr Cullen is one of the country’s leading urologists. Urology is the medicine of the male genital and urinary system. Dr Cullen has a subspecialty in andrology, the field of male reproductive health. The issues he primarily treats are infertility, ED, ejaculatory dysfunction issues and penile cancer.

The severity of a man’s ED is assessed and classified as either mild, moderate or severe. Only 10% of cases presenting are severe. But regardless of the severity, all forms of ED are distressing, says Dr Cullen.

“It can affect a man’s relationship, their virility, their self-confidence, their self-esteem; it can affect their understanding of what it is to be a man. They can be reluctant to address or deal with it.

“What I always say is that the penis essentially is a muscle, it is like your bicep or any other muscle. So it does need a regular workout. For it to work effectively it needs to have good erections on a regular basis.

“It is important that ED is dealt with promptly and effectively. Ultimately, if left untreated it generally progresses and causes considerable damage to the penis.”

Causes

  • General health has an influence on erectile function, so factors such as being overweight, smoking and high cholesterol can impact erectile function.
  • Often ED is secondary to cardiovascular disease due to restricted blood flow to the penis. This is one of the first things checked when someone presents with ED, explains Dr Cullen.

    • “We often say the penis is like the canary in the coalmine for the heart, because sometimes it is the first indication of someone developing problems with the blood vessels in their heart. It is very important that someone presenting with onset ED has a full workup and a cardio vascular assessment to make sure there is nothing else going on.”

  • Treatment for prostate and bladder cancer can leave men with ED. “Men that have had radiation therapy for prostate cancer, hormone therapy for prostate cancer or indeed prostate removal, almost all of those will have some degree of ED, sometimes complete ED after treatment.”
  • Anatomical problems cause ED. For example problems with the foreskin, problems with curvature of the penis and a condition called Peyronie’s disease that can cause ED later in life.
  • Psychogenic ED: “This is much more prevalent in younger men. It is essentially performance anxiety, leading to a cascade of hormone release, which inhibits erectile function. About 20% of the patients I see with ED have this. When we delve into it we find that the problem is actually psychogenic. We usually send them down the route of seeing a psychosexual therapist.”
  • Drug-induced ED. Some medications used for blood pressure can cause ED, for example.
  • Neurological conditions can often cause ED, including MS and Parkinson’s, as well as other conditions such as spinal cord injury and diabetes.

    • Dr Ivor Cullen works publicly at University Hospital Waterford (UHW) and privately at the Blackrock Clinic, Dublin; Aut Even Hospital, Co Kilkenny and UMPC Whitfield, Co Waterford.

    In treating ED there are a number of options that revolve around what are referred to as first-line, second-line and third-line treatments.

    First-line: medication

    The first step is to control any modifiable risk factors such as high BMI, cholesterol, smoking and blood sugar levels in diabetes. If this is not an option or ineffective, then treatment reverts to a family of medication, the best known of which is Viagra.

    “These medications revolutionised the landscape and management of ED because they work so well. We would usually start with medication. There are three or four drugs in that class. These are very safe medications and they work very well. They can be quite predictable in how they will work. The tablets dilate the arteries within the penis and also to relax the muscle.”

    Second-line: direct penile therapies

    This applies to people who are unresponsive to the medication outlined above. Direct penile therapies are available predominantly as an injection, where the patient directly injects the drug into the muscle of the penis about 20 or 25 minutes before sexual activity.

    There is also vacuum therapy, the simplest and crudest device for the management of ED. “Essentially it involves putting the penis into a vacuum chamber, drawing blood into the penis and trapping it there by means of a constriction ring.”

    Third-line: surgery

    Surgery is becoming a more common option now for men in Ireland. The majority of men Dr Cullen performs the following surgeries on would have had cancer somewhere in the pelvic region. There are two different types of penile prosthesis:

  • 1 This is the simpler type, which puts two malleable rods into the penis so it is permanently ridged, but bendy. It can be bent into position for normal life and bent into position for intercourse.
  • 2 The second type of implant is the hydraulic three-piece inflatable device, which is a more complex implant. It involves putting a pump into the scrotum, two rods into the penis and a reservoir in the abdomen. Nothing is visible externally. When the gentleman desires an erection he reaches down to the scrotum, finds the pump and squeezes it about a dozen times. Fluid travels from the reservoir into the two rods, which fill with saline and then become ridged.

    • Anyone who thinks they may be affected by ED should visit their GP, who will advise them further.