Erectile dysfunction is a condition that makes it difficult to achieve or maintain an erection that is firm enough for satisfactory sexual intercourse. There are many causes of erectile dysfunction, some of which are reversible, some treatable, some partially treatable, and some that are difficult to treat.
When blood flows into the penis and is trapped in spaces called the corpora cavernosum, an erection results. Pressure builds as blood fills these chambers, which causes the penis to stiffen. Although this process sounds simple, it requires an ability to respond to sexual stimulation, adequate blood flow into the penis, and nerves that can respond to chemicals appropriately. A breakdown in the psychological response, blood vessel flow, nerve transmission, or brain messaging can cause ED.
ED, sometimes called impotence, occasionally happens to most men. In the United States, about 30 million men experience ED at least 50% of the time. Approximately one in every ten men will experience ED at some point in their lifetime. Although ED is a common medical condition, it should not be considered a normal part of aging. It is important to identify the underlying cause
The specific criteria for the diagnosis of ED in DSM-5, a reference manual used by healthcare professionals, include:
Experiencing one of these symptoms
The symptoms must have been present for at least six months, be causing significant distress, and not be better explained by another condition.
In many cases, ED is a side effect of medications or substance use or secondary to lifestyle or psychological factors.
Medications can negatively impact blood flow or nerve impulses to the penis. Medications to treat high blood pressure and diabetes commonly have ED as a side effect and are one of the most common reasons men stop taking these medications.
Medications that can cause ED
Illegal drugs that can cause ED
Overweight and Obesity
Being overweight or obese can cause ED because it affects hormone levels such as estrogen and testosterone. Aromatase is an enzyme that irreversibly converts testosterone to estradiol, resulting in decreased testosterone and increased estrogen levels. With increased obesity, there is increased aromatase activity.
Being overweight also increases the risk of high blood pressure, cardiovascular disease, and type 2 diabetes. Each of these is a risk factor for ED and cardiovascular disease.
Nicotine and Smoking
Nicotine is one of the thousands of chemicals in cigarette smoke. It is a known cause of ED because it constricts blood vessels, decreasing blood flow into the penis. Cigarette smoke also decreases the release of nitric oxide, a small molecule that has an important role in maintaining blood flow into the penis.
The relationship between alcohol use and ED is not as clear-cut as nicotine use. Some studies show it increases the risk of ED and others show no effect. Some studies indicate that low-to-moderate alcohol consumption can relieve anxiety and decrease the risk of ED.
Lifestyle Factors that can cause ED
Psychological or emotional factors can also cause ED. They are a more common cause of ED in younger men. Performance-related anxiety, a history of trauma, relationship stresses, and depression can all affect sexual function.
Cardiovascular disease, especially when it affects blood vessels, is a significant cause of ED. In fact, having ED may be an early warning sign of cardiovascular disease. About half of men with damage to the lining of blood vessels in their heart also have ED. 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.
Taking steps to improve your cardiovascular health such as eating healthy foods, engaging in physical activity, not smoking, and treating risk factors such as high cholesterol and high blood pressure can improve the symptoms of ED and decrease your risk for heart disease.
Treatable cardiovascular causes of ED
Psychological causes of ED can be more difficult to diagnose because they tend to cause ED more abruptly and intermittently than physical causes. One differentiating factor is that when psychological or emotional issues are the underlying cause of ED, erections during rapid eye movement (REM) sleep are not affected. Only erections associated with sexual stimulation are impacted.
Treatable psychological causes of ED
Hormones are chemical messengers that travel through the bloodstream and affect end organs, such as the penis. Low levels of testosterone, high prolactin levels, or abnormal thyroid or cortisol levels can all adversely affect sexual function.
Treatable endocrine causes of ED
In some cases, nerve damage to the penis can cause non-curable ED. Getting and maintaining an erection requires nerve stimulation from the brain and spinal cord to the nerves inside and surrounding the penis. An interruption in the transmission of messages from the brain to the penis will result in non-curable ED.
Radiation and surgery can damage blood vessels and, therefore, blood flow into the penis.
Scarring in the penis or curvature of the penis due to scarring can affect its ability to straighten for an erection. In some cases, scar tissue can be removed, or an implant placed inside the penis, but these do not really cure ED.
The best place to start when developing a treatment plan for ED is to take a hard look at any potential medications or lifestyle factors that may be contributing to ED. There is a strong link between ED and cardiovascular disease. Therefore, any risk factors that you can mitigate to improve ED symptoms are likely to decrease your risk for cardiovascular disease, as well.
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 do not work unless preceded by sexual stimulation.
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.
Approximately 30% of men who have tried oral ED medications report that they did not work well for them. For these men, penile injections may be a good option. Injectable ED medications trigger increased blood flow into the penis. Unlike oral ED medications, they do not require sexual stimulation to work.
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Vacuum devices work by putting a tube over the shaft of the penis and sealing it at the base. The vacuum pump pulls blood into the penis as it sucks the air out of the tube. Once the penis is erect, a constricting ring is slid off the tube and encircles the base of the penis. This constricting ring keeps the blood in the penis. However, it should never be in place for more than 30 minutes, as it can damage the penile tissue. Vacuum devices work for three out of four men once they learn how to use the device properly.
When other potential treatment options have been exhausted, some men consider a surgically implanted penile prosthetic. 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.
For men with low testosterone levels, a condition called hypogonadism, restoring testosterone levels to normal can improve libido.
Maintaining good psychological, cardiovascular, and endocrine health can prevent the onset of ED. Like any medical condition, preventing it is a much better strategy than treating the results of poor lifestyle choices after the fact.
Several healthy lifestyle changes are associated with a decreased risk of ED, including:
In most cases, ED is a treatable condition. Involve your partner in your quest to learn more about ED and the treatment options available. Talking about your symptoms and treatment options will likely decrease anxiety and prevent misunderstandings that may compound the problem.
Open and honest communication with your partner and doctor can help reduce stress and speed up the process of regaining full erectile function.
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.