Erectile dysfunction (ED)

What is erectile dysfunction?

Erectile dysfunction – the correct medical term for this is erectile dysfunction – is the complete or partial inability to achieve and maintain an erection (stiffening) of the penis sufficient for satisfactory sexual intercourse or other sexual activity.
In the past, the term „impotence“ was often used. This term is no longer used because it is too often used pejoratively in colloquial language and equated with „lack of masculinity“.

How common are erectile dysfunctions?
Erectile dysfunction is very common and affects at least one in ten men. The frequency increases with age. According to recent studies, the proportion of men over 40 with erectile dysfunction is between 30 and 50 percent. This means that several million men in Germany are affected. However, so far only about 10 percent of them get effective treatment. This is often because those affected still cannot imagine that today most men with erectile dysfunction can be helped effectively or do not know a suitable doctor to contact. Many men are also ashamed to talk to anyone about their problem.

How does erectile dysfunction develop?
Probably every man experiences in the course of his life that an erection is not sufficient for intercourse or fails completely. Tension, stress, tiredness, anxiety, insecurity or excessive alcohol consumption are the causes. This is completely normal and no cause for alarm. For some people, however, such an experience can become the source of a larger problem, the build-up of „fear of failure“: these men become so consumed by the idea of „failing“ that it becomes impossible for them to relax and feel pleasure from sexual arousal. This reduces sexual arousal and prevents erections from occurring.
Until about 20 years ago, it was thought that erectile dysfunction was almost entirely psychologically caused in this way. Today, however, we know that in about 70 percent of all cases, physical factors (i.e. changes in the penis directly, its blood supply or the nerve pathways) are mainly responsible. However, sexuality is so complicated and central in human life that for most men mental and physical causes cannot be easily separated.

What are the physical causes?
If erectile dysfunction is mainly physical, there is often a gradual decline in the ability to achieve an erection and this happens during all sexual activities, whether sexual intercourse or masturbation. Physical causes include insufficient blood supply to the penis, excessive blood leakage from the penis („venous leakage“), nerve damage and injury to the pelvic region, multiple sclerosis and hormone imbalances. Risk factors such as heavy smoking, diabetes, high cholesterol and side effects of medications, alcohol and drug abuse, as well as severe chronic diseases such as liver or kidney failure can also lead to erectile dysfunction.

What are the psychological causes?
If erectile dysfunction develops very quickly and men get an erection in certain situations (e.g. in the morning or during masturbation) but not in others (e.g. when a partner is involved), there are often psychological causes. Often the reasons are obvious, e.g. a massive argument with the partner, a distraction due to private or professional problems or strong physical tension. Psychological causes also include: Dissatisfaction in the partnership, fear of not being able to satisfy the partner, sexual boredom, unclear own sexual orientation. Psychiatric illnesses play a special role, such as depression, in which erectile dysfunction or lack of sexual desire occur in over 90 percent of cases.

What should I do if I suffer from erectile dysfunction?
It is important to know that in most cases, sufferers can be helped effectively. However, before consulting your doctor, you should consider some aspects of your lifestyle. In addition to reducing tobacco use and the amount of alcohol, it is advisable to avoid anxiety and stressful situations. If such changes have no effect or are impossible for you, you should seek medical help.
A good first point of contact is your family doctor. If your family doctor does not have special experience or training in this area, he or she will in most cases refer you to a specialist, usually a urologist, or occasionally – depending on the problem – a psychotherapist (doctor or psychologist).

How might the visit to the doctor go?
First of all, every doctor will have a conversation with you. This is to try to get an idea of the most likely cause of your erectile dysfunction and to get an impression of your general health. So he will ask you specific questions about your erections and accompanying circumstances. He will also ask you about any general illnesses and medications you are currently taking. It is also very important to know what your sex life was like when your erections were fine and, if appropriate, what your partnership is like. In any case, it would be useful if your partner accompanied you to this first appointment, as sexuality usually always involves two. Afterwards, your doctor will examine you physically, measure your blood pressure, check the blood flow to your legs and possibly check your reflexes. Of course, he will examine your penis and scrotum (also with ultrasound), perhaps take a urine sample. Then your doctor will take a blood sample to check blood lipids, liver, kidney values and testosterone levels (the male sex hormone). After these basic tests, the urologist will then often carry out a test at a further visit, in which they will inject a small amount of a drug into the penis that can trigger an erection. This is done to determine the extent to which your penis is functional. Some doctors also carry out these tests as part of a short inpatient stay. If the first dose is not enough, it is gradually increased until a sufficient erection is achieved.
In some cases, your doctor may consider further tests necessary: Measurements of your erections at night, measurements of blood flow in the penis or stiffness measurements of the penis. This is done to find out the best possible treatment option and is more likely to be the norm in a few cases.

What are the treatment options?
In recent years, a variety of treatment options have been developed that can help most patients significantly improve their sex life. Your doctor will work with you and your partner to decide which treatment he or she thinks is best for you. In addition to psychotherapies, the options available include medication in tablet form, injection therapy, vacuum pumps, transurethral therapy, hormone treatments, penile prostheses and other surgical interventions.

What medicines are available in tablet form?
There are currently several medications available in tablet form for the treatment of erectile dysfunction. The active ingredients SILDENAFIL, TADALAFIL and VARDENFIL are taken about 30 to 60 minutes before the planned sexual activity. These tablets do not work without sexual stimulation. Another active ingredient is APOMORPHIN; these tablets must be taken about 20 minutes before the planned sexual activity. You put them under your tongue and let them melt there. However, they also do not work without sexual stimulation (information sheets on all these agents are available from the ISG).
The compound yohimbine is extracted from the bark of an African tree and has been found to be effective in enhancing erections. However, yohimbine does not work for all patients and must be taken regularly to be effective.

How does the injection therapy „SKAT“ work?
SKAT is a very effective form of treatment. The abbreviation SKAT has nothing to do with playing cards here, but stands for erectile tissue auto-injection therapy. Shortly before the time when sexual activity is planned, the patient (or his partner) injects a small amount of a drug into the corpus cavernosum (the part of the penis that becomes hard during an erection) with a very thin needle. After about 15 minutes, the penis becomes hard and normal sexual intercourse is possible. As a rule, the erection lasts for an hour. It is easy to learn how to use. Several preparations are available (another information sheet on this topic is available from the ISG).

How do vacuum erection aids work?
There are now several models of so-called vacuum erection aids. In principle, the device consists of a glass cylinder connected to a pump (which is operated either by hand or by battery). The penis is inserted into the cylinder and the pump sucks out the air, creating a vacuum. This causes more blood to flow into the penis, creating an erection. If this is sufficient, a tension ring is placed over the penis to keep the blood in the erectile tissue. The cylinder can then be removed. It is important that the ring is removed again after 30 minutes. If a couple gets used to using the pump, this can be a safe and simple method without any further intervention in the body (another information sheet on this topic is available from the ISG).

What is transurethral therapy?
This treatment does not involve injecting a medicine, but rather inserting a small pellet (a type of elongated tablet) of a medicine into the urethra with an applicator. The medication is then absorbed through the wall of the urethra into the erectile tissue and – if the patient responds to the medication – an erection is seen after about 10 minutes (a further information sheet on this topic is available from the ISG).

When does hormone therapy make sense?
In only a few patients is erectile dysfunction caused by a hormonal disorder, e.g. a lack of the male sex hormone testosterone. This can be effectively remedied by administering the necessary amount of testosterone. However, it is negligent and, above all, ineffective to take testosterone without a corresponding hormone deficiency determined by the doctor. You can read more about this in our information sheet „Hormone replacement therapy in men“.

What is psychosexual therapy?
If your doctor is convinced that psychological factors (such as fear of failure) or partnership conflicts are an important cause of erectile dysfunction, he or she may advise you to undergo psychotherapy, which is usually of short duration. This usually consists of discussions (with both partners together wherever possible) in conjunction with a specific exercise programme designed to improve the sexual relationship.
It can also often be very important, if there has been a long period of sexual „radio silence“ due to erectile dysfunction, to first slowly build up a new sexual relationship. This is why it is sometimes recommended to combine psychotherapy or couples therapy with other forms of treatment for erectile dysfunction.

When can penile prostheses help?
Penile prostheses are implants that are surgically placed in the penis to artificially stiffen the part of the penis that becomes hard during erection. There are basically two types of prostheses: so-called semi-rigid implants keep the penis stiff enough to allow sexual activity. However, it is still flexible enough to be bent when not needed and hardly noticeable to the outside.
The second type are hydraulic implants, where a pump (implanted in the scrotum) can be used to pump fluid into artificial erectile tissue, making the penis sufficiently stiff. Implantation of penile prostheses results in the destruction of the natural erectile tissue. This is why your doctor will only advise you to take such a step if other therapies have had no effect.

What about other operations?
Very few forms of erectile dysfunction that are the result of abnormal blood flow (e.g. a „venous leak“) can be treated by other surgical procedures.

Should I discuss my problem with my partner?
Absolutely. The proverb knows that „a sorrow shared is a sorrow halved“. And this definitely applies to erectile dysfunction. Often the partner quite unconsciously creates a lot of „pressure to perform“ in a sexual relationship. And this pressure can then lead to a reinforcement of existing erection problems. So just addressing such a problem can take away a lot of tension, sometimes even normalise the sexual relationship completely. Since sexuality is always a matter that concerns two people, it is often helpful if your partner accompanies you to the doctor. It may take a great deal of effort to bring up such a problem – but not bringing it up, sneaking around, is almost always much more stressful for a relationship in the long run.

Is there an age limit for successful treatment?
The process of ageing leads to an increased likelihood of developing erectile dysfunction. However, advanced age is not a reason not to pursue treatment. Rather, it is a matter of attitude. While certain couples accept the loss of erectile function as part of ageing and take it for granted, others are unhappy to give up a part of their lives that is so important to them. Whereas in the past people preferred not to talk about sexuality in old age, today it is taken for granted that sexuality does not stop when you reach retirement age. Therefore, age alone should not be an argument against treatment. Nowadays, even 90-year-olds are treated with the same success and the same methods as younger patients.

Will the health insurance pay for the treatment?
Under pressure to cut costs in the health system, the Federal Committee of Doctors and Health Insurers (the authority charged by the legislature with monitoring costs) has decided that drug-based methods of treating erectile dysfunction will not be prescribed on a health insurer’s prescription. Unfortunately, you have to assume that if your doctor recommends such a treatment, you will have to pay for it yourself. In individual cases, however, health insurance companies have paid for drug therapy for certain diseases (e.g. diabetes). It is therefore advisable to ask your health insurance company again. Psychotherapies, vacuum erection devices and penile prostheses are currently still covered by health insurance.

What should I do if a treatment is not successful?
As with all forms of treatment in medicine, there is no guarantee of success in the treatment of erectile dysfunction. If a treatment does not work for you at all, or if the erection does not last long enough or is not hard enough, you should discuss this with your doctor. There are a number of other effective erectile dysfunction treatment options that can help you if an initial treatment method does not work for you.

Penile implants
Erectile dysfunction treatment
It is important to discuss with your urologist which treatment is right for you. Discuss all the treatment options, possible risks and side effects. Remember that you want a treatment that is accepted by you and your partner. This will give you confidence in the effectiveness and partnership acceptance of this form of treatment.

Penile implants
Implants were inserted into the penis as early as the early 1930s to stiffen it. For about 30 years now, technically sophisticated implants have been available that enable men with severe erectile dysfunction (ED) to have an erection sufficient for sexual intercourse.

What is a penile implant?
Penile implants are systems made of different types of plastic. There are one-piece (cylinder only), two-piece (cylinder with pump) and three-piece (cylinder, pump and fluid reservoir) penile implants. Fixed or refillable cylinders are inserted into both erectile tissues of the penis through a minor surgical procedure. In the case of refillable (hydraulic) penile implants, a pump is also implanted in the scrotum and a fluid container in the lower abdomen.

How does a penile implant work?
With bendable (semirigid) penile implants, the member is permanently stiffened and can be bent upwards for an erection.
Fillable (hydraulic) penile implants most closely resemble a normal erection. When an erection is desired, fluid is pumped via the pump into the two cylinders in the erectile tissue, causing them to expand in circumference and length, stiffening the penis. By pressing the release valve in the scrotum, the fluid from the cylinders is pumped back into the reservoir and the penis becomes flaccid.

Why a penile implant?
In severe ED, where the erectile tissue is destroyed and no longer responds to medication, the only way to produce an erection is with a penile implant.

Which type of penile implant is best?
Flexible (semirigid) penile implants permanently stiffen the penis. They are very easy to implant and inexpensive (about €1,100). Technical defects are very rare. Fillable (hydraulic) penile implants come closest to a normal erection, with the three-piece fillable prostheses currently being the best implants. These implants are technically complex and more expensive (about €6,000) than pliable implants. Fillable implants are not visible during sports or in the sauna, come closest to the naturally stiffened or flaccid state of the penis and are very well accepted by both partners.

How is a penile implant inserted?
The cylinders are inserted into the two erectile tissues through an incision in the scrotum or above the penis in a minor operation lasting less than an hour. In the case of refillable penile implants, the same incision is used to place the pump in the scrotum and the fluid reservoir in the lower abdomen next to the urinary bladder. A hospital stay of 5 – 7 days is usually necessary.

How does an erection occur?
In the case of flexible implants, an erection occurs when the penis is erect. With inflatable implants, fluid is pumped into the cylinders by the pump, causing them to stiffen. This erection should be sufficient for you and your partner to have sexual intercourse. Blood does not fill the glans with this treatment, but it still often occurs during sexual arousal.

How long does an erection last?
The erection caused by a penile implant can be maintained for any length of time. After sexual intercourse, the fluid from the cylinders flows back into the reservoir by activating the release valve, so that the penis becomes completely flaccid again.

When can I use a penile implant after the operation?
About 6 weeks after the operation the implant is fully healed and can be used.
Refillable penile implants need to be filled and emptied every day for the first 6 weeks after surgery to create enough space for the fluid reservoir and cylinders.
It may take up to a year after the operation for you to have an orgasm.

How long does a penile implant last?
Penile implants can be used indefinitely. If there are no technical defects, infections or migration of the implant to the outside, a penile implant does not need to be removed or replaced.

What are the side effects of a penile implant?
If the penile implant becomes defective, the entire prosthesis or defective individual parts can be replaced.
If an infection occurs, it is necessary to change the implant or remove it completely. In rare cases, the cylinders of a penile implant can pass through the wall of the erectile tissue and come out through the skin or the urethra. In such a case, this defect must be closed and the implant removed if necessary. Allergies to the plastic used are rare.

Are there side effects for the partner?
There are no known side effects for the partner. A penile implant that can be filled is not visually visible from the outside.

How can I get a penile implant?
Penile implants should only be inserted by specialists. You should discuss the advantages and disadvantages of the different implants in detail with your urologist and surgeon before having surgery. Penile implants are offered by the companies AMS and Mentor and are available in a wide range of sizes.

Do health insurance companies pay for penile implants?
According to the current state of knowledge, the costs for a flexible penile implant are covered by the statutory health insurance funds. Due to the considerable additional costs of the inflatable (hydraulic) penile implant, a case-by-case examination with the health insurance company and, if necessary, a personal co-payment is necessary.