Erectile dysfunction (ED) is a common, treatable medical condition. Almost all men will have an episode of erectile dysfunction at some point in their lives. But just because it is common, does not mean it should be taken lightly. ED can be an indicator of a more serious medical condition and, if left untreated, it can lead to relationship and psychological issues. 

ED affects approximately 30 million men in the United States,¹ with nearly a quarter of them under the age of forty.² Despite the fact that there are very effective treatments available and more information available online than ever before, in a study of six million men with ED, only 25% actually received treatment.³

Erectile Dysfunction Symptoms

Erectile dysfunction is the inability to get and keep an erection firm enough for sex. It’s very common to occasionally have difficulty getting an erection, but when ED persists for weeks, it is likely due to a physical or psychological condition. Erectile dysfunction does not imply that you can never get an erection, only that the problem is frequent and persistent. 

Erectile dysfunction can occur alone or with other disorders, such as: 

• Low libido: a decreased interest in sex. Low libido may be pervasive or only occur with a single partner. It may be episodic or persistent and may indicate an underlying medical or psychological condition. 
• Premature ejaculation: ejaculating too soon after penetration. 
• Delayed ejaculation: taking a long time to ejaculate after penetration. 
• Anorgasmia: the inability to achieve orgasm after adequate sexual stimulation. 
• Hypoactive sexual desire disorder: when a person has little or no interest in sex and is concerned about their lack of interest. 

Erectile Dysfunction Causes

An erection is a complex physiological process involving the endocrine, cardiovascular, and nervous systems. Lifestyle factors and psychological conditions, whether temporary or chronic, can also play a role in ED.

An erection occurs when blood flows into the penis and becomes trapped in spaces known as the corpora cavernosa. As blood fills these chambers, pressure builds, causing the penis to stiffen. Although this process appears simple, it requires the ability to respond to sexual stimulation, maintain adequate blood flow into the penis, and have nerves that can respond appropriately to chemical signals in the body. ED can be caused by a breakdown in the psychological response, blood flow, nerve transmission, or brain messaging.

Physical Causes

The prevalence of ED rises with increasing age. According to the Massachusetts Male Aging study, one of the largest studies ever focused on men’s health, over half of men aged 40 to 70 had at least some degree of ED.⁴ In another study, over one-third of men over age 50 experienced erectile dysfunction within the previous three months.⁵ In older men, erectile dysfunction is more likely caused by physical factors than psychological.⁶ 

Nerve Damage Or Malfunction:

ED due to nerve damage or malfunction is typically more difficult to treat than ED due to other physical causes. However, there are suitable treatment options. If you believe that your ED is due to nerve damage or dysfunction, see your doctor or a urologist to receive a full evaluation and discuss your treatment options. 

• Spinal cord injury
• Multiple sclerosis
• Parkinson’s disease
• Lumbar disc disease
• Pelvic surgery and trauma
• Diabetes mellitus
• Nerve damage in the groin

Blood Vessel Disease:

About half of men with damage to the lining of blood vessels in their heart also have ED.⁷ After controlling for age, smoking, obesity, and medication use, men with ED were found to have a 75% higher risk of developing blood vessel disease.⁷

Blood vessel stiffness due to fatty deposits reduces blood flow into the penis. Since the blood vessels entering the penis are smaller than systemic ones, ED can be the earliest sign of blood vessel disease. ED usually develops three to five years before heart disease and can be a warning sign that medical treatment is needed.⁶ 

Oral and injectable ED treatment options are frequently used to treat ED secondary to diseases that affect blood vessels, such as: 

• High blood pressure
• Diabetes mellitus
• Abnormal blood lipids, high cholesterol
• Cigarette smoking
• Atherosclerosis
• Venous leakage syndrome

Endocrine Causes:

Hormone replacement therapy may be an effective treatment for endocrine associated ED. Testosterone levels decline with age and can be associated with decreased libido and ED. If you have thyroid disease or diabetes, treating these conditions first along with making any necessary lifestyle changes may improve ED symptoms. 

Endocrine disease associated with ED:

• Low testosterone 
• Hyperthyroidism
• Hypothyroidism
• Type 2 diabetes
• Hyperprolactinemia
• Obesity

Medication Use:

Medications that affect sex-hormone levels or decrease blood flow into the penis increase the risk of ED. If your ED symptoms began after starting a medication, talk to your doctor to see if a medication or dosage change would be appropriate. 

Medications that may have ED as a side-effect:

• Anxiolytics (treats anxiety disorders)
• Antihypertensives (treats high blood pressure)
• Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) (treats depression and related conditions)
• Anticonvulsants (treats seizures)
• Antihistamines (treats allergies)
• Antiparkinson (treat Parkinson’s disease)
• Antipsychotics (treat psychosis and schizophrenia)
• Beta-blockers (treat heart disease)
• Diuretics (treat kidney disease, heart disease, and high blood pressure)
• H₂ blockers (treat acid reflux disease and ulcers)
• Hormones and hormone-active agents (replace or regulate hormone levels)
• Immunomodulators (treat autoimmune disorders)
• Opiates (analgesics for pain control)

Lifestyle Factors

Lifestyle factors that increase the risk of blood vessel disease or metabolic disease are associated with an increased risk of ED.^5,6 Losing excess pounds, increasing physical activity, quitting smoking, and reducing alcohol intake may improve your ED symptoms. 

Lifestyle factors associated with ED:

• Smoking: smoking reduces nitric oxide, damages blood vessels, and increases inflammation. 
• Alcohol use: alcohol has many effects on sexual health and is the leading cause of impotence and sexual dysfunction.⁸ Excessive alcohol consumption is linked to an increased rate of ED.
• Drug use: illicit drug use increases the risk of blood vessel disease and ED.
• Sedentary lifestyle: there is an inverse relationship between physical activity and ED.

Read More: Diet and Exercise to Help with Erectile Dysfunction

Psychological Causes

Erectile function is a complex process that begins in the brain. Psychological causes of ED are more common in younger men. However, up to 87% of men under the age of 40 have a physical condition that contributes to ED.⁹ Factors that increase the likelihood of a psychological ED cause include a sudden onset of symptoms, intermittent function, a decreased libido, and good quality spontaneous or self-stimulated erections. 

Psychological causes of ED:

• Depression
• Performance anxiety
• Stress
• Post-traumatic stress disorder
• Exposure to negative sexual messaging
• Relationship issues

Erectile Dysfunction Treatment

Before starting any ED treatment, see your doctor for a complete physical exam. ED may be due to an underlying medical condition, and the earlier it is diagnosed and treated, the more likely you are to regain full erectile function. If you are taking medications, ask your doctor if they may be contributing to ED. 

Next, consider whether you can make any changes in your lifestyle. Increasing physical activity and losing excess pounds will improve your overall cardiovascular health and blood vessel function. 

Read More: Is there a cure for Erectile Dysfunction (ED)?

Oral ED Medications

There are many treatment options for ED. Their dosages and side effects vary, so it is important to talk with a healthcare provider to find the best medicine for erectile dysfunction (ED). 

PDE5 inhibitors are the first-line treatment for ED. PDE5 is an enzyme that breaks down cyclic guanosine monophosphate (cGMP). When cGMP levels are high, blood flows into the penis, resulting in an erection. PDE5 inhibitors keep cGMP levels high and can treat ED when it is due to decreased blood flow into the penis. However, PDE5 inhibitors cannot cause an erection without sexual stimulation. 

Sildenafil (Viagra)

Sildenafil is taken 30 to 60 minutes prior to sexual activity. Its effects peak in 60 minutes and last up to four hours. Headaches, facial flushing, upset stomach, and nasal congestion are the most commonly reported side effects.

Vardenafil (Levitra)

Vardenafil is taken 30 minutes before sexual activity and its effects last four to five hours. The maximum dosage is one tablet daily.

The most common side effects associated with Levitra are headache, flushing, runny nose, and indigestion. Drinking alcohol while taking Levitra can increase the risk of side effects.

Tadalafil (Cialis)

Tadalafil has two dosage options, daily or as needed. For as-needed dosing, men can take tadalafil 30 to 60 minutes before sexual activity. The other option is to take one tablet as directed daily. 

Tadalafil has a much longer duration of action than Sildenafil. It lasts up to 36 hours. Headaches, upset stomach, nasal congestion, and cough are the most commonly reported side effects.

Read More: Sildenafil vs. Tadalafil

Avanafil (Stendra)

Avanafil is taken 15 to 30 minutes before sexual activity. Its effects last up to six hours, and it should not be taken more than once daily. The most common side effects associated with Avanafil are headaches, flushing, nasal congestion, and sore throat.

Although PDE5 inhibitors are considered the first-line treatment for ED, the American Urological Association stresses that men should be informed of all treatment options as long as they are not medically contraindicated.

Penile Injections

Oral ED medications work for approximately 70% of men who use them. For those who switch to injectable ED medications, 95% get and sustain an erection suitable for sexual activity.

Injectable ED medications trigger increased blood flow into the penis. Unlike oral ED medications, they do not require sexual stimulation to work. 

Injectables should not be used 18 hours before or after taking oral ED medications such as Vardenafil, Avanafil, and Sildenafil, or within 72 hours of taking Tadalafil (unless directed otherwise by your doctor).

Papaverine

Papaverine is a vasodilator. It widens blood vessels entering the penis and increases blood flow by inhibiting PDE5 (works similarly to oral ED medications). Papaverine is not used alone for penile injections.

Phentolamine

Phentolamine relaxes the smooth muscle lining blood vessels by reducing the activity of the sympathetic nervous system. Phentolamine is not used alone for penile injections.

Prostaglandin E1

Prostaglandin E1 relaxes the smooth muscle lining blood vessels, which increases blood flow into the penis by increasing cAMP levels. Prostaglandin (alprostadil) is FDA-approved to treat ED. 

Combination Injectables

Trimix injectables are a combination of three different medications—phentolamine, papaverine, and alprostadil—that synergistically increase blood flow into the penis. 

Bimix is a combination of papaverine and phentolamine.

Quadmix is a combination of papaverine, phentolamine, prostaglandin E1, and atropine. 

Read More: Trimix Injections for ED: The Risks and Benefits

Priapism and fibrosis are the most common serious adverse effects of using penile injection therapy. Priapism is a prolonged, painful erection. To reduce your risk of priapism, your doctor will probably start with a low dose of medication and gradually increase it as needed. 

Fibrosis is the formation of plaques or bands of fibrous tissue under the skin of the penis. It does not seem to be associated with the number of penile injections, but whether pressure was held to the injection site for a full five minutes after injection.¹⁰ 

Suppositories

Prostaglandin E1 (alprostadil) is available as a suppository. The most common side effects are urethral burning and pain. In rare cases, this medication can cause fainting.¹⁰ 

Vacuum Erection Devices

A vacuum device is a non-surgical option to treat ED. A cylinder is placed over the penis to create a vacuum and draw blood into the corpora cavernosum. A band is left at the base of the penis when the cylinder is removed. The band prevents blood from exiting the penis. The band must be removed within 30 minutes, or damage to the penis may occur.

Penile Implants And Other Surgical Options

Some men have an internal penile pump (IPP) or penile prosthetic implanted when other treatment options have been exhausted. Semimalleable prosthetics are implanted in the corpora cavernosa. Other options include inflatable prostheses or blood vessel surgery. Blood vessel surgery may be an option for younger men with ED who have had a history of injury to the groin.

Looking for medications to help with your sexual health? See how Invigor Medical can help today!

DISCLAIMER

While we strive to always provide accurate, current, and safe advice in all of our articles and guides, it’s important to stress that they are no substitute for medical advice from a doctor or healthcare provider. You should always consult a practicing professional who can diagnose your specific case. The content we’ve included in this guide is merely meant to be informational and does not constitute medical advice.

References

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2. Capogrosso P, Colicchia M, Ventimiglia E, et al. One Patient Out of Four with Newly Diagnosed Erectile Dysfunction Is a Young Man—Worrisome Picture from the Everyday Clinical Practice. The Journal of Sexual Medicine. 2013;10(7):1833-1841. doi:https://doi.org/10.1111/jsm.12179

3. Doherty K. Most men with erectile dysfunction don’t seem to get treatment. Medical Express. https://medicalxpress.com/news/2013-05-men-erectile-dysfunction-dont-treatment.html

4. Levy J. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. The British Journal of Diabetes & Vascular Disease. 2002/07/01 2002;2(4):278-280. doi:10.1177/14746514020020040801

5. Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Glasser DB, Rimm EB. Sexual Function in Men Older Than 50 Years of Age: Results from the Health Professionals Follow-up Study. Annals of Internal Medicine. 2003/08/05 2003;139(3):161-168. doi:10.7326/0003-4819-139-3-200308050-00005

6. Ostfeld RJ, Allen KE, Aspry K, et al. Vasculogenic Erectile Dysfunction: The Impact of Diet and Lifestyle. The American Journal of Medicine. 2021/03/01/ 2021;134(3):310-316. doi:https://doi.org/10.1016/j.amjmed.2020.09.033

7. Montorsi F, Briganti A, Salonia A, et al. Erectile Dysfunction Prevalence, Time of Onset and Association with Risk Factors in 300 Consecutive Patients with Acute Chest Pain and Angiographically Documented Coronary Artery Disease. European Urology. 2003/09/01/ 2003;44(3):360-365. doi:https://doi.org/10.1016/S0302-2838(03)00305-1

8. Mendelson JH, Mello NK. Biologic Concomitants of Alcoholism. New England Journal of Medicine. 1979/10/25 1979;301(17):912-921. doi:10.1056/NEJM197910253011704

9. Nguyen HMT, Gabrielson AT, Hellstrom WJG. Erectile Dysfunction in Young Men—A Review of the Prevalence and Risk Factors. Sexual Medicine Reviews. 2017/10/01/ 2017;5(4):508-520. doi:https://doi.org/10.1016/j.sxmr.2017.05.004

10. Nik-Ahd F, Shindel AW. Pharmacotherapy for Erectile Dysfunction in 2021 and Beyond. Urologic Clinics of North America. 2022/05/01/ 2022;49(2):209-217. doi:https://doi.org/10.1016/j.ucl.2021.12.002

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