Erectile Dysfunction

Accessible insights about Erectile Dysfunction (ED), its causes, types, risk factors, impacts on life, as well as testing and treatment options including PDE-5 inhibitors (i.e. Viagra).
Background
What is erectile dysfunction (ED)?
Erectile dysfunction, or ED, is a situation where a person has trouble getting or keeping an erection for sexual activity. Getting an erection involves many body systems working together, including the blood vessels, nerves, and hormones.
How common is ED?
ED is quite widespread. Several studies have shown that a large number of men experience ED, and the chances and severity increase as men get older. For example, about 40% of men in their 40s have some form of ED, and this percentage increases by about 10% every ten years. Severe ED, while rare in younger men, is found in about 15% of men in their 70s.
Are there different types of ED?
Yes, ED can be grouped into three categories: organic, psychogenic, or mixed. Organic ED has a physical cause and can be due to issues with the blood vessels, nerves, structure of the penis, or hormones. Psychogenic ED, on the other hand, is often linked to stress, anxiety about sexual performance, and mental health issues.
What are the risk factors for ED?
There are many risk factors for ED, some of which can be changed and others that can't. Aging, which we can't change, is a primary risk. Risk factors we can change or manage include diabetes, high cholesterol, high blood pressure, being overweight, metabolic syndrome, a lack of physical activity, and smoking. These are mainly associated with ED that's caused by blood vessel issues.
Can ED be a sign of other health problems?
Research suggests that ED can share common risk factors with heart disease and stroke. It might even be an early sign of potential heart or brain-related issues in some people. However, not all studies agree that ED can predict future heart or brain problems.
Can ED happen after injuries or treatments?
Yes, ED often happens after certain injuries or treatments. For example, it's common in men who've had injuries to the pelvic area or a broken penis, as well as after surgeries or radiation treatments, especially in the pelvic area. Studies show that about 79 out of 100 men who had prostate surgery and about 61 out of 100 men who had radiation therapy for prostate cancer had trouble getting an erection firm enough for sex two years after treatment.
Does ED affect more than just a man's ability to have sex?
Yes, ED affects much more than just the physical ability to have sex. It can also have a big impact on a man's mental health, overall sense of wellbeing, and quality of life, as well as his partner's. It can put stress on relationships and affect the happiness of the couple. Involving the partner during the process of diagnosing and treating ED has been found to help improve the patient's results.
Examination 
What aspects of my overall health should be assessed with a general exam in a doctor's office?
Your overall health assessment will involve checking your blood pressure, body shape and size, the presence of male secondary sexual characteristics (loss of facial hair or groin hair), your mood, and whether you have gynecomastia (enlarged breast tissue in males).
What other exams might a doctor complete? 
A doctor may check whether there are any hard lumps (plaques) in the penis, any issues with the foreskin (phimosis or tight foreskin), the tethering of the frenulum (the elastic band of tissue under the penis that helps with erection), narrowing of the urethral opening (meatal stenosis), and the quality of the pulses in your groin area.
Role of Lab Testing
What tests are suggested for patients with suspected blood vessel-related or unknown cause ED?
For patients whose ED may be linked to blood vessel issues or where the cause is unknown, doctors typically recommend certain blood tests as a first step. These tests can check for hidden or 'occult' diabetes and dyslipidemia, which is an abnormal amount of lipids (like cholesterol and triglycerides) in the blood. The tests include a hemoglobin A1C test, which shows average blood sugar levels over the past 3 months, a fasting glucose test, which measures blood sugar after not eating for at least 8 hours, and a lipid profile, which checks the levels of different types of lipids in the blood.
When should a patient consider having a testosterone test?
If a patient has symptoms that suggest low testosterone levels, or if the common ED medications known as phosphodiesterase type-5 inhibitors (PDE5is) don't work for them, they should consider having a testosterone test. This test involves taking a blood sample in the morning (when testosterone levels are highest) to measure the amount of total testosterone in the blood.
Treatments
What lifestyle changes can improve ED?
For all patients with ED, especially if other health conditions or lifestyle habits are affecting their erectile function, some changes can help. These include increasing physical activity, quitting smoking, reducing alcohol and cannabis use, and adjusting the diet.
What about supplements like L-arginine and citrulline?
L-arginine and citrulline, which can help produce a substance called nitric oxide that's important for erections, have been studied in relation to ED. However, more research is needed before they can be recommended for ED.
Should I consider sexual counselling if I have ED?
Yes, sexual counselling can be beneficial for patients with ED, especially if there's a psychological aspect involved. It can support medical treatment and may improve relationship satisfaction and overall sexual functioning.
Low-Intensity Shockwave Therapy (Li-SWT)
What is low-intensity shockwave therapy (Li-SWT)?
Li-SWT is a treatment option suggested for patients with mild to moderate ED. The therapy uses a device that looks like a wand to deliver low-intensity shockwaves to different areas of the penis in multiple sessions.
How does Li-SWT work?
Li-SWT is thought to work by stimulating the growth of new blood vessels and the regeneration of nerves in the penis. This process can help improve erectile function by reversing some of the physical changes that contribute to ED.xp
Is Li-SWT approved for clinical use for ED?
Even though Li-SWT is widely offered in many centers in Canada, often by non-urologists, it's not approved for clinical use for ED by Health Canada or the FDA (U.S. Food and Drug Administration).
Viagara, Cialis and Levitra
What are phosphodiesterase type-5 inhibitors (PDE5is)?
PDE5 inhibitors are oral medications that help with ED by relaxing the blood vessels and smooth muscle in the penis, which allows for an erection in response to sexual stimulation. These medications approved by Health Canada include sildenafil, tadalafil, and vardenafil.
What side effects should I expect from PDE5is?
Possible side effects from these medications can include headache, flushing, indigestion, and a stuffy nose. Some more specific side effects can include changes in color vision (with sildenafil and vardenafil) and muscle aches (with tadalafil).
Are there any reasons why I shouldn't take PDE5is?
Yes, you shouldn't take these medications if you're using nitroglycerin or organic nitrates regularly or occasionally, or if you're allergic to any component of the tablet.
What if PDE5is don't work for me?
If you're not satisfied with the results from these medications, talk with your healthcare provider about how you're using the medication and whether a dose adjustment might be needed.
How effective are PDE5is?
PDE5is are a first line medication for ED because of their strong effectiveness and safety for a wide range of patients. Reviews of clinical trials have shown a significant average improvement in erection function scores for sildenafil, tadalafil, and vardenafil.
How safe are PDE5is?
These medications have a strong safety profile. Out of 1000 patients taking the drug, on average, eight will experience a serious adverse event with sildenafil, seven with tadalafil, and eight with vardenafil.
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References
Rew KT, Heidelbaugh JJ. Erectile Dysfunction. Am Fam Physician. 2016 Nov 15;94(10):820-827. PMID: 27929275.
Domes T, Najafabadi BT, Roberts M, Campbell J, Flannigan R, Bach P, Patel P, Langille G, Krakowsky Y, Violette PD. Canadian Urological Association guideline: Erectile dysfunction. Can Urol Assoc J. 2021 Oct;15(10):310-322. doi: 10.5489/cuaj.7572. PMID: 34665713; PMCID: PMC8525522.
Yafi FA, Jenkins L, Albersen M, Corona G, Isidori AM, Goldfarb S, Maggi M, Nelson CJ, Parish S, Salonia A, Tan R, Mulhall JP, Hellstrom WJ. Erectile dysfunction. Nat Rev Dis Primers. 2016 Feb 4;2:16003. doi: 10.1038/nrdp.2016.3. PMID: 27188339; PMCID: PMC5027992.
Sooriyamoorthy T, Leslie SW. Erectile Dysfunction. [Updated 2022 Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562253/
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