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It's not a popular conversation topic among men – or even one most men will raise with their partner – but research shows erectile dysfunction has affected 61 per cent of Australian men over the age of 45.
Having an occasional problem getting or keeping an erection is normal. But when it happens often and it's severe – so you can't have sex with penetration – it's called erectile dysfunction.
But erection issues aren't only a problem in the bedroom, there is now strong evidence they are "the canary in the trousers" – a warning sign you may have high cholesterol, high blood pressure, diabetes or damaged arteries that may increase your risk of heart attacks.
Doug Lording has worked in the field for 30 years. He is Honorary Clinical Associate Professor of Medicine at Monash University and an andrologist at Melbourne's Cabrini Hospital. Here is what he has to say on some of the issues he knows men (and women) want answers to.
Do erection problems stem from psychological issues or physical factors?
It used to be thought erectile dysfunction was 80 per cent psychological and 20 per cent physical. We now know it's probably the other way around. There are some clearly psychological causes of sexual problems but they're the minority overall. There are often some pretty clear clues as to whether the problem is psychological; one is they still get their early morning or overnight erections. Often these problems are situational so they occur with a partner but might not occur with masturbation for instance. And often there's a clear precipitating cause – they've had an event and then they've struggled after that.
Usually if it's a physical issue, it will affect erections occurring at all times – whether they're spontaneous, masturbatory or provoked erections. In men with severe erection problems, it's nearly always physical.
Many men get a lot of comfort from knowing this is a medical problem. I think it helps men to know ED is just another symptom, like chest pain or something else that's indicative there may be some physical disease going on and it needs to be assessed, rather than something wrong with their... manliness as they often otherwise see it. But a physical cause can lead to secondary psychological problems too.
What effect does age have on the causes of erection problems?
At any age there can be a specific cause, it might be drug or alcohol abuse, it might be prostate cancer, it could be a drug you've been on, it could be low testosterone. Those things scatter across all ages.
Most men over 80 have erectile dysfunction. If you look at a man who's 80, his facial skin is sagging and wrinkly and his muscles have lost tone. Well, the same thing is happening in the penis. That's an ageing process.
But as men move through their 40s, 50s, 60s, there's also an increase in the prevalence of ED and in a big portion of this group it's frequently a vascular [blood vessel] problem.
It's not so much that there's necessarily heart disease at that point, but the factors that lead onto causing heart disease are now starting to show up in the penis. In a sense, the penis is a barometer because to get an erection and maintain it, you need to increase the blood flow by about 10 or even 15 times. There's no other organ in the body like that. So if you've got minor things affecting the vascular system, it will show up in the penis.
There's strong evidence if you develop ED in your 30s, 40s and 50s, you're at greater risk of having a heart event over next five years. Even minor erectile problems could be an indicator of future heart risks. I wouldn't say if you've got ED you should be sitting there thinking "oh I've got heart disease ", although that could be the case.
Why is it important for men to talk to their GP (even if they're really embarrassed)?
A lot of men like to go through channels where they can be anonymous but we discourage that. You can buy drugs on the internet without having a medical check-up. But there are quite a lot of inactive fakes. There have also been deaths from fakes contaminated with toxic substances.
Men can also go to some of these clinics where you can do a telephone consultation but really the process is all about selling medications, rather than medical assessment.
A check-up with your GP is important because it can pick up previously undiagnosed diabetes, hypertension, high cholesterol and so on. There are a lot of lifestyle issues, which when dealt with there and then might have a big effect of reducing the risk of heart disease [or its progression] and possibly restore erectile function. We don't have the data to prove this yet but it's logical to think it would be the case.
Does early treatment also avoid the situation of "use it or lose it"?
Here are some reasons you should go to your doctor sooner rather than later. Early intervention will potentially lead to better sexual function because you get a better responsiveness to drugs [that work to improve erections].
Once the penis has been inactive for a length of time, it gets changes in its structure. These make the tissues less malleable so it's harder to maintain an erection. You don't have to be having sex, just having an erection [to prevent these changes]. If you're getting night time erections as normal healthy men do, then that's fine. An erection has a value in that it's oxygenating and stretching out the penis and [this] allows it to work at its best.
The other good thing about early presentation is it means men get seen before the sexual life at home has changed too much. If you leave it a couple of years, it's not necessarily so easy to get those relationship issues back on an intimate basis. When you get ED, there's this stigma of "I can't perform, I'm not a man anymore" and it's quite damaging. Men often withdraw from having sex, they don't see anyone about it. The relationship deteriorates. So that's an important spiral to break.
Men often respond well to [the available erection] drugs and that's really good because it gives them an avenue where they'll be able to have good sexual activity if they want it.
Professor Doug Lording has worked on clinical trials that have received funding from Pfizer, Ely Lilly and Bayer Schering Pharma.
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