Men will dis­cuss chest pain, blood in the urine and con­sti­pa­tion with sur­pris­ing courage. Erec­tile dys­func­tion of­ten ar­rives in a whis­per. Some­times the pa­tient waits un­til the con­sul­ta­tion is al­most over.

“One more thing, Doc.”

Erec­tile dys­func­tion means re­peat­ed­ly be­ing un­able to ob­tain or sus­tain an erec­tion firm enough for sex­u­al ac­tiv­i­ty.

One bad night does not qual­i­fy. Fa­tigue, too much al­co­hol, anx­i­ety, an ar­gu­ment, poor sleep or plain dis­trac­tion can in­ter­fere with any­body. The trou­ble is when it keeps hap­pen­ing and a vi­cious cir­cle be­gins.

They avoid in­ti­ma­cy and stay up watch­ing crick­et. Some be­come ir­ri­ta­ble with their part­ners or blame them be­cause anger feels eas­i­er than em­bar­rass­ment.

The old word was im­po­tence. How­ev­er, it turns a med­ical prob­lem in­to a ver­dict on the whole man. A pe­nis has dif­fi­cul­ty and sud­den­ly the per­son feels stripped of mas­culin­i­ty, con­fi­dence and worth.

Erec­tile dys­func­tion is com­mon, treat­able and of­ten med­ical­ly im­por­tant. It be­comes more fre­quent with age, but one in four men seek­ing help for new­ly de­vel­oped erec­tile dys­func­tion is younger than 40.

An erec­tion re­quires de­sire, nerves, hor­mones, healthy blood ves­sels and a brain that is not busy think­ing about fail­ure. Dis­rup­tion of any part of the chain af­fects per­for­mance.

As ex­pect­ed, one un­suc­cess­ful at­tempt cre­ates wor­ry about the next en­counter. That con­cern re­leas­es adren­a­line, which is rather un­help­ful when try­ing to main­tain an erec­tion.

Stress, de­pres­sion, re­la­tion­ship con­flict, grief, ex­haus­tion and fear can wors­en the is­sue. This does not mean the prob­lem is “on­ly in his head”, but the brain is an es­sen­tial part of the sex­u­al sys­tem.

Of­ten, though, the cause is phys­i­cal.

Di­a­betes dam­ages nerves and blood ves­sels. High blood pres­sure, high cho­les­terol, obe­si­ty and smok­ing in­jure the cir­cu­la­tion. Kid­ney dis­ease, neu­ro­log­i­cal ill­ness, pelvic surgery, prostate can­cer treat­ment, low testos­terone and thy­roid dis­or­ders may con­tribute.

Sev­er­al med­i­cines can in­ter­fere, in­clud­ing some an­ti­de­pres­sants and blood pres­sure drugs. Do not stop pre­scribed tablets on your own.

Now for the part men need to hear. The pe­nile ar­ter­ies are small­er than the coro­nary ar­ter­ies. When blood ves­sels be­gin nar­row­ing, an erec­tion may be­come un­re­li­able years be­fore chest pain ar­rives. It should prompt a prop­er look at over­all car­dio­vas­cu­lar risk.

The as­sess­ment is not com­pli­cat­ed, al­though it re­quires hon­esty. When did the prob­lem be­gin? Is it oc­ca­sion­al or con­stant? Is sex­u­al de­sire still present? Are morn­ing erec­tions oc­cur­ring? Can an erec­tion be­gin but not last? Is there pain, cur­va­ture or re­duced sen­sa­tion? What med­i­cines, sup­ple­ments, al­co­hol or recre­ation­al drugs are in­volved?

Erec­tion, de­sire, ejac­u­la­tion and or­gasm are not the same thing. Men some­times say “noth­ing is work­ing” when the ac­tu­al prob­lem is pre­ma­ture ejac­u­la­tion, low li­bido, in­fer­til­i­ty or dif­fi­cul­ty reach­ing or­gasm.

A phys­i­cal ex­am­i­na­tion and ba­sic blood tests may fol­low.

Testos­terone treat­ment is for men with com­pat­i­ble symp­toms and re­peat­ed­ly con­firmed low lev­els af­ter prop­er as­sess­ment. Tak­ing it ca­su­al­ly can sup­press sperm pro­duc­tion, raise the red blood cell count, wors­en sleep ap­noea and raise liv­er en­zymes.

Treat­ment be­gins with iden­ti­fy­ing the cause and mak­ing lifestyle changes. Stop smok­ing. Re­duce ex­ces­sive al­co­hol in­take. Ex­er­cise. Lose some ab­dom­i­nal fat. Im­prove sleep. Con­trol di­a­betes and blood pres­sure. These are not glam­orous pre­scrip­tions.

Tablets in­clud­ing silde­nafil or tadalafil im­prove blood flow and are rec­om­mend­ed as first-line treat­ment for many men.

They do not man­u­fac­ture de­sire or pro­duce an au­to­mat­ic erec­tion. Sex­u­al stim­u­la­tion is still re­quired. Tim­ing and dose mat­ter. They are gen­er­al­ly ef­fec­tive and well tol­er­at­ed, but they are not suit­able for every­body. Men tak­ing ni­trate med­i­cines for angi­na must not com­bine them be­cause blood pres­sure can fall dan­ger­ous­ly.

Do not bor­row your cousin’s tablet. And be wary of “all-nat­ur­al” sex­u­al en­hancers sold on­line or be­neath the counter. “Nat­ur­al” does not mean “safe”.

Some prod­ucts se­cret­ly con­tain pre­scrip­tion-type drugs in un­pre­dictable amounts. Vac­u­um de­vices, in­jec­tions di­rect­ly in­to the pe­nis and im­plants are oth­er treat­ment op­tions.

A part­ner should not have to guess what is hap­pen­ing. Si­lence cre­ates its own di­ag­no­sis: re­jec­tion, in­fi­deli­ty or loss of at­trac­tion. A con­ver­sa­tion can re­move pres­sure from the bed­room. Treat­ment works bet­ter when sex stops feel­ing like an ex­am­i­na­tion the man ex­pects to fail.

Seek ur­gent care for an erec­tion last­ing longer than four hours. That is called pri­apism and can per­ma­nent­ly dam­age tis­sue. Sud­den loss of vi­sion or hear­ing af­ter tak­ing med­ica­tion al­so re­quires ur­gent med­ical at­ten­tion.

The hard­est part re­mains the first dis­cus­sion. How­ev­er, avoid­ing it does not pro­tect dig­ni­ty and gives dis­ease more time. Erec­tile dys­func­tion is not a punch­line, a pun­ish­ment or proof that a man is fin­ished. Some­times it is anx­i­ety, med­ica­tions, hor­mones or nerve dam­age. Very of­ten, it is a “dip­stick” of heart dis­ease.

Tell the doc­tor plain­ly and bring your part­ner when that feels right. Get your blood pres­sure, glu­cose and cho­les­terol checked. Ig­nore the guys of­fer­ing mir­a­cle roots and se­cret mix­tures.

The bed­room may be where the prob­lem ap­pears, but the cause may be some­where else en­tire­ly.