Since the discovery that the drug sildenafil (Viagra) – originally a heart drug – had an effect on men’s penile erections, most people have become aware of erectile dysfunction as a medical condition.
Men who have a problem with their sexual performance may be reluctant to talk to their doctor, seeing it as an embarrassing issue. However, modern medicine has revealed numerous medical and psychological explanations for erectile dysfunction, including the possibility of serious underlying conditions that it is important to address.
Doctors are used to dealing with potentially embarrassing issues in private consultations, and not only is erectile dysfunction now more clearly understood, there is also often a solution for the condition. If you or someone close to you has a problem with getting or maintaining an erection, this article offers helpful information.
What is erectile dysfunction?
A man is considered to have erectile dysfunction when he has regular difficulty in getting or maintaining a firm enough erection to be able to achieve sexual penetration, or which interferes with non-penetrative sexual activity.
Most men have occasionally experienced some difficulty with their penis becoming hard or staying firm, but this is not normally cause for a diagnosis of erectile dysfunction. This condition is only considered a concern if satisfactory sexual performance has been impossible on a persistent number of occasions for some time.
Broadly, two forms of erectile dysfunction can affect men’s sex lives – the main cause is either medical or psychosocial.
Here, psychosocial refers to the psychological effects – including the effects of social relationships – on sexual performance. Medical conditions can also affect psychological wellbeing, meaning that, while the primary cause of sexual impotence is typically either medical or psychological, there is often overlap between the two.
Erectile dysfunction used to be known more widely as ‘impotence’ before the causes became better understood and successful treatments came into use. Impotence is a term that is still in use, however, although it can be seen as pejorative.
Causes of erectile dysfunction
To understand the causes of erectile dysfunction, it helps to understand how an erection happens physically.
Relaxation of muscle (in parts of the penis and the walls of the arteries supplying it) allows blood to rush into the cylinder-shaped spongy tissue of the erection chambers, creating increased tissue pressure and an erection. Valves prevent the blood from flowing back out through the veins (which would cause a venous loss of pressure), and the resulting hardness persists until stimulation stops or ejaculation occurs.
This blood flow process is led by nervous and hormonal triggers activated when the brain is stimulated by touch or other stimuli; such brain signals can be suppressed by anxiety.
Normal erectile function can be affected by problems that compromise any of the following normal physiological contributions needed for an erect penis:
- Blood flow
- Nervous supply
Vascular causes that affect blood flow, and neurological causes that affect nerve signals are the major medical causes of erectile dysfunction, often due to the underlying disease processes of atherosclerosis and diabetes.
Smoking and diabetes often cause atherosclerosis, and this narrowing or ‘clogging’ of arteries in the penis is the most common vascular cause of erectile dysfunction.
Diabetes can also lead to neuropathy – damage to the nerves. Diabetic neuropathy is a common neurological cause of erectile dysfunction, as is nerve damage resulting from various types of surgery around the pelvis. Less common neurological causes are stroke, a type of epilepsy (partial complex seizures), multiple sclerosis, non-diabetic neuropathy, and spinal cord injury.
Reducing well-established risk factors for diabetes and atherosclerosis – including poor diet, lack of physical activity and other lifestyle factors such as smoking – could also prevent erectile dysfunction.
More about the vascular causes of erectile dysfunction
Erectile dysfunction can be caused by atherosclerosis – the thickening of the walls of the arteries that causes them to narrow and lose elasticity, restricting blood flow.
The smaller arteries in the penis are usually first affected by atherosclerosis – damage to the lining of the arteries (medically known as endothelial dysfunction) – as even a small amount of narrowing in these arteries can affect circulation.
The early damage of atherosclerosis prevents the arteries to the penis from dilating (widening) properly, in turn preventing the penis from filling with blood and so becoming hard.
Men tend to worry about anything affecting sexual performance – and penis size is a key concern for many men, but do their partners care about genital dimensions?
Erectile dysfunction can also be caused by another cardiovascular risk factor – hypertension.
The American Heart Association explains that high blood pressure can lead to erectile dysfunction because it damages arteries throughout the vascular system, impairing the blood flow necessary for achieving and sustaining an erection.
Physical causes of erectile dysfunction
It is always worth consulting a physician about persistent erection problems as the cause of erectile dysfunction could be any one of a number of serious medical conditions. Whether the cause is simple or serious, a proper diagnosis can help to address any underlying medical issues and can help resolve sexual difficulties.
The following list summarizes many of the most common physical/organic causes of erectile dysfunction:
- Heart disease and narrowing of blood vessels
- High blood pressure
(These first three are discussed above)
- High cholesterol
- Obesityand metabolic syndrome (which are also risk factors for diabetes)
- Parkinson’s disease
- Multiple sclerosis
- Hormonal disorders including thyroid conditions andtestosterone deficiency (hypogonadism)
- Structural/anatomical disorder of the penis, such as Peyronie disease
- Smoking,alcoholism and substance abuse, including cocaine use
- Treatments for prostate disease
- Surgical complications (surgeries include radical prostatectomy, cystectomy, transurethral resection of the prostate and rectalcancer surgery)
- Injuries in the pelvic area or spinal cord
- Radiation therapyto the pelvic region.
Numerous prescription medications are also an organic cause of erectile dysfunction, including those below (anyone taking prescription medications should consult their physician or health care practitioner prior to stopping or changing their medications):
- Drugs to control high blood pressure (antihypertensives such asbeta-blockers and clonidine)
- Heart medications such as digoxin
- Some diuretics (known as ‘water pills’ that increase urine output)
- Drugs that act on thecentral nervous system (on the brain or spinal cord), including some sleeping pills and amphetamines
- Anxietytreatments (anxiolytics)
- Antidepressants, including monoamine oxidase inhibitors (MAOIs), selectiveserotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants
- Opioid painkillers
- Some cancer drugs, including chemotherapeutic agents
- Prostate treatments, including treatments for cancer, and for benign prostatic hypertrophy (such as 5α-reductase inhibitors). Anti-androgen drugs used for prostate disease and other conditions, can also cause erectile dysfunction
- Anticholinergics – drugs with a wide range of uses that block a neurotransmitter (nerve signal molecule) that affects muscle tone
- Hormone drugs, including estrogens and drugs that act on luteinizing hormone-releasing hormone
- Thepeptic ulcer medication cimetidine
Organic (physical) causes account for some 90% of true (persistent) cases of erectile dysfunction, with psychological causes much less common.
Psychological causes of erectile dysfunction
In rare cases, erectile dysfunction has always been present, with a man never having achieved an erection. This is called primary ED, with the cause almost always psychological if there is no obvious anatomical deformity or physiological issue that could be causative; such psychological factors can include:
Psychological factors are the cause of most cases of problems reaching climax – ejaculation occurring too soon, too late, or not at all.
Learn about premature ejaculation and delayed ejaculation
- Fear of intimacy
- Severe anxiety.
Most cases of erectile dysfunction are ‘secondary’, i.e. erectile function has been normal, but is now problematic. Causes of a new and persistent problem are usually physical; less commonly, psychological factors cause or contribute to erectile dysfunction, with such factors ranging from treatable mental health illnesses, to everyday emotional states that most people experience at some time or another.
Some psychological causes can also cause temporary erection problems that would not be classed as erectile dysfunction, while others may be related to a particular place, time, or partner.
The psychological causes include
- Depression- which can cause a loss of interest in sex (lower libido) as well as erectile dysfunction – and other mental health disorders
- Stress, fear, anxiety, or anger
- Stress can include work, financial, and emotional problems
- Performance anxiety – repeated feelings of doubt and failure in which worrying about getting an erection can cause a cycle of anxiety that prevents one from being possible
- Poor communication with a sex partner
- Other relationship problems such as pressure from a sex partner – for example, because expectations make sex a task instead of a pleasure.
What the doctor will investigate
The numerous potential causes of erectile dysfunction means that a doctor will typically ask a lot of questions and arrange for blood tests to be performed. Such tests can check for heart problems, diabetes and low testosterone, among other things. The doctor will also usually carry out a physical examination, including of the genitals.
The questions will help to determine any potential cause in the patient’s history – this might include checking for use of prescription drugs, herbal products and alcohol, pelvic surgery or trauma, and smoking.
The patient’s medical records will be checked for diabetes or high blood pressure, and the doctor will also want to rule out atherosclerosis and symptoms of vascular, hormonal, neurological, and psychological disorders.
All patients should be checked for signs and symptoms of depression, and the consultation might explore recent emotional events, and relationship status, including asking questions about any conditions the sex partner may have.
Treatments for erectile dysfunction
In this section we take a look at the available treatment options for erectile dysfunction, from drugs to vacuum devices, surgery treatments and dietary supplements.
Drug treatments for erectile dysfunction
The first option for the treatment of erectile dysfunction – once the condition has been established as a persistent problem, rather than a one-off or temporary one – is a group of drugs called PDE-5 (phosphodiesterase-5) inhibitors.
All except one of these pills are taken 30 to 60 minutes before sex – the best known being the blue-colored pill sildenafil (Viagra). Other options are vardenafil (Levitra), tadalafil (taken as a once-daily pill; Cialis), and avanafil (Stendra).
PDE-5 inhibitors must be prescribed by a doctor, who may check for heart conditions and use of other medications. For example, a cardiologist may need to advise on the best timing for the use of erectile dysfunction drugs in men who keep nitrate drugs for rare occasions of angina chest pain caused by coronary artery disease.
There is a range of potential adverse side-effects associated with PDE-5 inhibitors, including flushing, visual abnormalities, hearing loss, dyspepsia and headache.
Less commonly used drug options include prostaglandin E1, which is applied locally, into the penis (either injected into it or inserted down the opening into the urethra, as with the suppository alprostadil, brand named Muse). Most men prefer a pill, however, so these locally acting drugs tend to be reserved for men who cannot take oral treatment.