Why can't I get and keep an erection?

At some stage of their lives most men have temporary difficulty getting and maintaining an erection. This is usually due to stress, alcohol, or tiredness. However, persistent, long-term problems getting and maintaining an erection hard enough to have the type of sex you and your partner want is known as erectile dysfunction (ED) or impotence. It is a serious problem that can affect men of all ages, but is more common in men aged 40-70, more than half of whom have some degree of ED.

It is estimated that the majority of cases of ED have an underlying physical cause, although emotional and psychological factors may also be involved. Fewer than 20% of cases are purely psychological.

Erections occur because sexual stimulation triggers the release of chemicals that cause columns of tissue in the penis to become full (engorged) with blood. Anything that affects the mind, blood vessels or nervous system can cause ED.

It is important to dispel a few myths. ED does not occur because of:

• loss of interest in sex (libido),
• lack of strength or manhood,
• sterility, or
• reduced virility.

It is not a natural consequence of aging and there is no muscle in the penis to tire. However, it is more common in older men, with 1 in 5 men aged 70 having persistent ED.

If you can achieve an erection by masturbating, or sometimes get an erection in the morning or during the night naturally, then ED is probably due to psychological reasons, relationship problems, or drugs, rather than any other physical causes.

The most common causes of ED are outlined below.

• Physical - approximately eight out of 10 ED cases are due to physical causes. These can include aging combined with arteriosclerosis (hardening of the arteries) and smoking, but also diabetes, drug misuse, Alzheimer's disease, Parkinson's disease, hormone deficiency, kidney failure, Peyronie's disease, as well as neurological disorders, such as multiple sclerosis (MS), spinal, or back injuries, and other chronic (long-term) illnesses.
• Psychological - conditions such as depression, anxiety, stress, and trauma may be contributory causes of ED.
• Relationship issues - such as performance anxiety, poor communication, sexual inexperience, reduced attraction, fear of intimacy, and infidelity, may all contribute to ED.
• Medication, alcohol, and smoking - ED can also be caused by the use of antidepressants and antihypertensives, smoking, and regular heavy alcohol consumption.

Rarely, hormonal conditions can cause ED. For example:

• abnormally low levels of the male hormone testosterone (hypogonadism), or
• producing too much of the pituitary hormone prolactin (hyperprolactinemia).

Tests and treatments

Tests for physical causes of ED include genital examination, urine and blood tests, and a blood supply test (Alprostadil injection).

In the majority of cases ED can be treated. Treatment options are listed below.

• Medication - including Sildenafil (Viagra) and Apomorphine (Uprima).
• Injections into the penis - Viridal and Caverject.
• Urethral pellets - MUSE (Medical urethral system of erection).
• Hormonal treatment - testosterone replacement therapy.
• Vacuum devices - battery operated suction pump.
• Counseling and cognitive therapy - couples or relationship therapy.
• Psychosexual therapy - using the sensate focus technique.
• Surgery - penile implant.

Most men experience ED at one time or another. To decrease your chances of it becoming a persistent problem here are some lifestyle suggestions you could adopt:

• don't smoke, drink excessively, or use illegal substances,
• exercise regularly,
• maintain a healthy diet that is rich in fruit and vegetables,
• try to keep your stress levels low - if you do experience stress or depression speak to your doctor who can offer advice,
• get plenty of sleep, and
• have regular medical screenings and check-ups to make sure problems are detected early to avoid long-term complications.