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Monday’s medical myth: erectile dysfunction is all in your mind

It’s perfectly normal for men to have an occasional problem gaining or sustaining an erection. But for some men, these difficulties are frequent and severe, making penetration impossible. This condition…

Around 90% of men with erectile dysfunction have a predominantly physical basis for their condition. Horia Varlan

It’s perfectly normal for men to have an occasional problem gaining or sustaining an erection. But for some men, these difficulties are frequent and severe, making penetration impossible. This condition is known as erectile dysfunction, or ED, and occurs when there is a reduced blood flow to the penis at the time of erection.

We now know that erectile dysfunction is in the pelvis, not in the mind – but this understanding is relatively recent.

During my formative years in medical training (late sixties, early seventies) I was taught that 90% of ED (then referred to as impotence) was psychological. All the educational sessions featured psychiatrists or psychologists, and most men who presented were sent to these experts for treatment.

Few treatments were available at the time. There were penile implants, vacuum constriction devices and testosterone therapies, but none were particularly effective. There was also a societal attitude that men should accept their time had come to cease having a sex life.

During the eighties there was evolving appreciation of the role of nitric oxide and endothelial cell function, which increased our understanding of penile neural and vascular mechanisms. This stimulated great interest for scientists working in ED medicine.

But undoubtedly the biggest catalyst for change came from Big Pharma. When Pfizer trialed sildenafil (Viagra) for the treatment of angina, the researchers fortuitously found that the male participants got erections. The pharmaceutical industry saw the potential for a safe and effective oral medication for the treatment of ED and got the drug to market.

Funds then flowed to facilitate more research about the causes of ED and the general implications for health. Large epidemiological studies showed that ED was much more prevalent than previously thought, affecting at least one third of men over 40 and increasing with age.

Researchers also uncovered strong links between ED and diabetes, high cholesterol, cigarette smoking, hypertension, obesity and heart disease. In retrospect, the association with conditions that affect the blood vessels and cause heart disease isn’t surprising, given the vascular nature of the erection process. There needs to be about a ten-fold increase in blood flow to sustain a hard erection.

A major development in ED medicine was the finding in 2005 that ED predicted a risk of heart disease. The researchers followed men aged over 50 for seven years and noted that if a man developed ED, he was at risk of subsequent coronary artery disease. Over a five year period this risk was 11%, indicating ED was a potent and significant predictor of high risk. Numerous studies have confirmed these findings.

Most recently, an Australian study showed the same increased risk applied to men in the 20-to-50 age range. It’s also been shown that among diabetic men, those who have ED are much more likely to have significant undiagnosed coronary artery disease – and the severity of ED predicts the severity of the heart disease.

As well as these vascular conditions, ED can also be caused by prescription medicines, drug and alcohol abuse, hormonal problems, prostate and bowel surgery and pelvic injuries, and spinal cord diseases. In some men, of course, the cause may be purely psychological, or related to depression and anxiety disorders.

It’s now estimated that 90% of men with ED have a predominantly physical basis for their condition – so we’ve come full circle in our understanding of erectile dysfunction. But this doesn’t preclude the possibility that these men might suffer from secondary psycho-sexual consequences, or that targeted psycho-sexual treatment will be helpful.

The knowledge that ED might be a symptom of a physical health problem should serve as yet another reminder for men to seek help for this treatable condition. The good news is that with the right information – and the right attitude – men can (and should) overcome it.