Erectile Dysfunction

Overview

Erectile dysfunction (ED) is defined as the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity. It is a common condition — affecting a significant proportion of men over the age of 40, with prevalence rising progressively with age — and one that has meaningful implications for quality of life, relationships, and psychological wellbeing.

ED is not simply a mechanical problem; it is often a symptom of underlying health conditions. Its presence — particularly in younger men or men without an obvious explanation — should prompt a broader assessment of cardiovascular and metabolic health.

Causes of erectile dysfunction include:

• Vascular — the most common cause; reduced arterial blood supply to the penis due to atherosclerosis, hypertension, or diabetes
• Neurogenic — damage to the nerves involved in erection; may occur after prostate surgery (radical prostatectomy), pelvic radiotherapy, or with neurological conditions such as multiple sclerosis
• Hormonal — low testosterone (hypogonadism), thyroid disease, or hyperprolactinaemia
• Medication-related — antihypertensives (particularly beta-blockers and thiazides), antidepressants, antipsychotics, and antiandrogens
• Psychological — anxiety, depression, relationship difficulties, or performance anxiety; often coexists with physiological causes

Symptoms

ED may present in different ways:

• Difficulty achieving an erection from the outset
• Ability to achieve but not maintain an erection
• Reduced rigidity sufficient for penetration
• Loss of morning erections (which are a useful indicator of vascular and neurological integrity)

The onset may be gradual (more typical of vascular and hormonal causes) or sudden (more typical of psychological causes or medication changes). Assessing sexual desire (libido) helps distinguish hormonal from other causes.

Diagnosis

Assessment includes a thorough medical and sexual history, examination, and investigations:

• Hormonal profile — testosterone (ideally early morning), LH, FSH, prolactin, thyroid function
• Metabolic screen — fasting blood glucose (HbA1c), lipid profile
• Cardiovascular risk assessment — blood pressure, BMI, smoking status
• Psychological assessment — screens for depression, anxiety, and relationship factors
• Specialist investigations — in selected cases, penile Doppler ultrasound to assess arterial and venous function of the penis

The International Index of Erectile Function (IIEF) questionnaire is a validated tool used to quantify symptom severity and monitor treatment response.

Treatment

Treatment follows a stepwise approach:

Lifestyle modification

• Stopping smoking, reducing alcohol consumption, increasing physical exercise, and achieving a healthy weight can significantly improve erectile function — particularly when vascular risk factors are present
• Addressing and optimising any identified medical conditions (diabetes, hypertension, hypercholesterolaemia)

First-line medical treatment

• PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) — oral medications that enhance the natural erectile response; effective in the majority of men with ED from various causes; usually prescribed by a GP or sexual medicine specialist
• Testosterone replacement — for men with confirmed hypogonadism

Second-line treatments

• Vacuum erection devices — mechanical devices that draw blood into the penis using suction; effective and non-invasive
• Intracavernosal injections (alprostadil) — self-injected medication that reliably produces an erection regardless of arousal; suitable when oral medication has not worked

Surgical treatment

• Penile prosthesis (implant) — a surgically implanted device that provides reliable, on-demand erections for men in whom all other treatments have been unsuccessful or are unsuitable; available as semi-rigid or inflatable (three-piece) devices; represents a definitive treatment for refractory ED

Dr Hadjipavlou offers specialist andrological assessment and surgical treatment, including penile prosthesis implantation, for men who have not responded to first- and second-line management.