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.
Contents of this article:
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.1-3
Communication difficulties and relationship stresses can lead to problems initiating or maintaining an erection.
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.
Fast facts on erectile dysfunction
Here are some key points about erectile dysfunction. More detail and supporting information is in the body of this article.
- Erectile dysfunction is defined as persistent difficulty achieving and maintaining an erection sufficient to have sex.
- Causes are usually medical but can also be psychological.
- Organic causes are usually the result of an underlying medical condition affecting the blood vessels or nerves supplying the penis.
- Numerous prescription drugs, recreational drugs, alcohol and smoking can all cause erectile dysfunction.
- Diagnosis, with the help of a doctor, can identify the likely cause by taking a history, discussing symptoms, performing blood tests to establish the presence of conditions such as diabetes and heart disease, and physical examination.
- Typical first-line treatment of erectile dysfunction involves the use of medications called PDE-5 inhibitors, including the well-known drug sildenafil (Viagra).
- Mechanical devices are also available to help achieve an erection. Patients experiencing occasional erectile dysfunction and who do not respond to medical treatment may be candidates for surgery to fit a penile implant.
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.4
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.4
A healthy lifestyle can prevent erectile dysfunction since the problem can be caused by preventable conditions such as diabetes and vascular disease.
Normal erectile function can be affected by problems that compromise any of the following normal physiological contributions needed for an erect penis:1
- 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.5
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.5
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.5
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.
Average penis size
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?
While the downside to atherosclerosis is a reduced ability to get an erection, the upside is that erectile dysfunction can be an early warning sign of arterial disease. This means that a person can seek early treatment and prevention of heart problems while also treating sexual dysfunction.
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.7
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:1,5,8
- Heart disease and narrowing of blood vessels
- High blood pressure
(These first three are discussed above)
- High cholesterol
- Obesity and metabolic syndrome (which are also risk factors for diabetes)
- Parkinson's disease
- Multiple sclerosis
- Hormonal disorders including thyroid conditions and testosterone 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 rectal cancer surgery)
- Injuries in the pelvic area or spinal cord
- Radiation therapy to 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):5
- Drugs to control high blood pressure (antihypertensives such as beta-blockers and clonidine)
- Heart medications such as digoxin
- Some diuretics (known as 'water pills' that increase urine output)
- Drugs that act on the central nervous system (on the brain or spinal cord), including some sleeping pills and amphetamines
- Anxiety treatments (anxiolytics)
- Antidepressants, including monoamine oxidase inhibitors (MAOIs), selective serotonin 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
- The peptic ulcer medication cimetidine
Organic (physical) causes account for some 90% of true (persistent) cases of erectile dysfunction, with psychological causes much less common.5
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:5
Psychological factors are the cause of most cases of problems reaching climax - ejaculation occurring too soon, too late, or not at all.
- 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.5
The psychological causes include:1,4,5,8,9
- 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.
Recent developments on erectile dysfunction from MNT news
Drinking two to three cups of coffee every day could lower a man's risk of erectile dysfunction. This is according to a new study published in the journal PLOS ONE.
Erectile dysfunction can be one of the most distressing conditions a man experiences. But a new study suggests eating more foods rich in flavonoids - such as blueberries, strawberries, blackberries and citrus fruits - could reduce the risk of erectile dysfunction for middle-aged men by more than a fifth.
Does riding a bicycle cause erectile dysfunction?
Questions remain over the effects on men's health of riding a bicycle (saddle effects).
Some research has raised concerns that men who regularly cycle for long hours could have a higher risk of erectile dysfunction, in addition to other men's health issues such as infertility and prostate cancer.
The most recent study to investigate this found that there was no link between riding a bike and erectile dysfunction, but it did find an association between longer hours of cycling and the risk of prostate cancer.10
However, the lead author stated that men should not worry about the research because the overall benefits from cycling outweigh these unproven concerns:11
"Men should cycle as much as they did before. The benefits for your heart, lungs, whole body, and mental health are much more important."
Guidelines followed by doctors in the UK offer a practical suggestion: men cycling more than three hours a week who are concerned that this is contributing to erection problems can temporarily stop cycling and look for any improvement as a result.3
They add that if it is not possible to stop cycling, preventive measures could be tried, such as the use of a properly fitted bicycle seat and ensuring that they ride in a suitable position.3
Prostate disease and erectile dysfunction
Treatment of prostate cancer can cause erectile dysfunction, although the cancer itself does not cause the problem.
Prostate surgery to remove cancer - even when nerves are spared and procedures are done by the finest surgeons - can result in erectile dysfunction, as can radiation therapy to treat prostate cancer.12
This is because of trauma to the delicate nerves and blood vessels that are necessary for erections. For many men, the ability to have erections returns within the first few months after treatment, as the nerves and blood vessels heal.12
Treatment of non-cancerous, benign prostate disease can also cause ED. Drugs called 5α-reductase inhibitors are used to treat benign prostatic hyperplasia - prostate enlargement - and they can cause erectile dysfunction.5
On the next page we look at tests and diagnosis and the available treatments for erectile dysfunction.