Erectile dysfunction

What is Erectile Dysfunction?

Erectile dysfunction, sometimes called “impotence” is when a man is unable to gain an erection that is sufficient for penetrative intercourse. Although people sometimes laugh or make jokes about this, it is a common problem, affecting approximately 40-50% of men over the age of 40. The older you are, the more likely you are to have the problem.

The good news though is that treatments ARE available that can help with the condition. These vary from simple lifestyle changes to medicines and even implants in certain cases. But before looking at that I want to address a serious issue.

You NEED to see a specialist

As with all medical problems, there are many different causes for erectile dysfunction (ED), and understanding the underlying cause is critical to treatment. A specialist with experience in the field is best able to sort out the cause and give the correct treatment, and I have successfully helped hundreds of patients with ED over many years of practice as a consultant.

What causes erectile dysfunction?

Men are often very reluctant to seek advice regarding impotence. They worry that they are somehow “less of a man”, or are too embarrassed to seek help, or think that nothing can be done anyway, but this is really not the case at all. Difficulty in gaining an erection is common and treatable. Rather than putting up with the stress and anxiety you need to see a specialist and get the treatment you need. Difficulty in gaining an erection is not only very common but it is almost always treatable.

What causes erectile dysfunction?

There are many so called “risk factors” for ED. Some of these are:

  • Increasing age
  • Diabetes
  • Any risk factor for heart disease
  • High blood pressure
  • High cholesterol or lipids
  • Hormone problems such as a low testosterone level
  • As a side effect of many medicines
  • Surgery of the Prostate gland
  • Any surgery in the pelvis

Erectile dysfunction can also be due to psychological causes, particularly if patients are in the younger age group and can also be caused by underlying stress and anxiety, undiagnosed depression and relationship problems. Those patients with an underlying psychological cause for the problem can also be treated in combination with psychosexual therapy.

How is someone with Erectile Dysfunction assessed?

Privately I always see my patients personally at every visit. I pride myself on the personal 1-to1 care I give and patients of course appreciate this. In the NHS you may be seen either by myself or one of the trainee surgeons of my team – but their care and treatment is always under my supervision.

The first step is always to take what we call a “history” – to go through the symptoms in detail, how long it has been going on, other medical problems you might have as well as medications you are taking. Once I am clear on this background – which is really quite important – I will examine you and make a diagnosis of what is causing the problem. As part of the examination I will assess your weight and height as your Body Mass Index (BMI) is important as well examine the genitals in order to ensure that there is no physical abnormality with the penis or testicles.

I will often perform some simple blood and urine tests to check for diabetes as well as checking your blood hormone and lipid profiles.

Occasionally I will organise more involved tests, such as ultrasound Doppler examination of the penis to check the blood flow in the arteries. Other specialised test that are occasionally needed include specialised overnight studies which measure the erections whilst you are asleep. This is called Nocturnal Penile Tumescence Studies (NPT Studies) but for most people this is not necessary.

If you are able to gain an early morning erection then this indicates that the underlying physiological mechanisms are likely to be intact – that there is no physical cause for your symptoms. However if you are unable to gain any erection or achieve only a partial erection then it is likely that there is an underlying medical problem causing the erectile dysfunction.

For most patients I am able to give a definite diagnosis at the end of the first consultation; and for many patients I am able to start treatment right away too.

How is Erectile Dysfunction treated?

As you might expect, treatment of the problem depends very much upon the cause.

The Basics

Initially some lifestyle modifications often help with mild erectile dysfunction. These include weight loss, stopping smoking and reducing your alcohol intake. Regular exercise is often also helpful, both with tiredness as well as libido and erectile dysfunction.

Medicines to treat ED

Often medical treatment is required for men with erectile dysfunction. You will probably have heard of the medicines that can help with ED – Cialis®, Viagra® and Levitra®. All are prescription – only drugs and cannot be bought over the counter.

Provided that you are not taking certain medicines for your heart (“nitrates”), these are an effective first step to in treating erectile dysfunction.

For most people these drugs in conjunction with lifestyle modifications are very effective at treating ED and nothing else needs to be done.

If these medicines do not improve the erections, then there are alternative treatments which can be tried. These include injecting medication directly into the side of the penis (prostaglandin injections, Alprostadil). A very fine needle is used and the most popular preparation is easy to use as it is available in a pre-filled syringe.  An alternative option is to place the drug into the opening of the penis, the urethra. Again this is an easy technique to learn and is preferred by some patients who do not want injections into the penis (“intra-cavernosal injections”).


Treating Erectile Dysfunction with Viagra


If all these medical treatments fail then there is an option of undergoing surgery. This involves the insertion of an implant into the penis. This is an artificial device which provides rigidity and girth for penetrative intercourse.

Two types are available: The first is a semi-rigid implant which involves  an operation to implant two semi-rigid rods into the penis; this provides permanent rigidity and is the simpler of the two operations that can be performed. The alternative is a three piece inflatable penile implant which consists of two inflatable cylinders, together with a special pump which is placed in the scrotum. This is used to inflate and deflate the implant when an erection is required. This is a more complex procedure to perform but the overall satisfaction rate is over 85% amongst those patients who need surgery. I would stress though that for the majority of patients with erectile dysfunction this can be treated without the need for surgery.


The semi-rigid penile implant


The inflatable penile implant

So what happens after the consultation?

Once I have assessed you and made a firm diagnosis I will start you on treatment. For most men this will be advice on lifestyle changes and a course of tablets – Cialis®, Viagra® or Levitra®.

Because ED can be a side effect of over medical problems or medicines if necessary I will ask another specialist in that field to review you or change some of your medication if possible as this can also be very helpful in treating ED.

I will then follow you up in the clinic with the results of any blood tests you might have needed and to see how you are getting on with the treatment. If there has not been any benefit then we will consider moving on to the next stage of treatment. Using this approach I have successfully treated almost everyone with erectile dysfunction.

Why should I consult with Mr. Muneer?

It always pays to see an expert. So whilst many urologists – surgeons who treat problems of the kidneys and urinary tract – do treat erectile dysfunction, this is my particular area of expertise. For many years I have concentrated on investigating and treating such problems as erectile dysfunction and reversal of vasectomy, and this is why I been so successful in treating men with these problems. It also means that I am able to provide a complete “one stop shop” for the investigation and treatment of this embarrassing and distressing condition. I am able to provide the whole range of treatment form medication all the way through to surgery and fitting implants if required without having to refer you to another specialist.

How do I make an appointment to be seen?

Making an appointment is very straightforward.

If you wish to see me privately contact my secretary Julie Jones at (020) 7034 8464 and she will take your details and book the appointment. I can usually see you within a day or two at a time and date to your convenience, and we can usually start treatment that day. (see Making an Appointment for more details)

If you would like to see me through the NHS you will need to see your GP and ask him to refer you to me at University College London Hospital.

Case Study

A 60 year old diabetic had been through all the medical treatment options including tablets and injections into the penis. These had now failed. He opted for a penile prosthesis and was shown both a malleable prosthesis and an inflatable prosthesis. Eventually he underwent surgery using an inflatable prosthesis as it provided a more natural erection. Having made an uncomplicated post-operative recovery he was able to manipulate the device after 2 weeks and use it for intercourse at 6 weeks.

What patients say

“I was in my mid 50s when I underwent surgery for prostate cancer. Following the operation I needed radiotherapy. Unfortunately one of the side effects of this treatment was the loss of my erections which put a strain on my relationship with my partner. Having already tried tablets and failed with injections I went to see Mr. Muneer who advised that I was suitable for a penile prosthesis. He showed all the different ones available and once I made the decision he arranged for the surgery. I was in hospital overnight and 6 weeks later I was able to use the implant and have never looked back! It was the best decision I’d made.”

Initials, London

“Diabetes has been in my family for generations and I was diagnosed diabetic at the age of 35. Having been treated for 8 years I found that I was developing impotence. I wasn’t sure as to what to do but Mr. Muneer started me on tablets which have worked very well for the last 5 years. He has given me hope that even if the tablets fail, I can have other options to keep me going.”

Initials, London.