What is erectile dysfunction? What causes erection problems?
By Markus MacGill
Medical News Today
Since the accidental development of the drug sildenafil (Viagra) – originally a heart drug that researchers noticed had an effect on men’s penile erections – the condition of erectile dysfunction is something we have all become aware of.
Men who have a problem with their sexual performance may be reluctant to talk to their doctor about an embarrassing issue. But modern medicine understands that there are numerous medical and psychological explanations for erectile dysfunction, including the possibility of underlying conditions that are important to address.
The problem could also be one with a solution – and doctors are used to dealing with embarrassing issues in private consultations. If you or someone close to you has a problem with erections, this article offers helpful information.
What is erectile dysfunction?
A man has erectile dysfunction when his penis has regularly failed to give an erection that has been good enough to achieve or maintain sexual penetration.1-3
Most men have occasionally experienced some difficulty with their penis becoming hard or staying firm, but this is not erectile dysfunction, which is a concern only 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 means psychological effects – including the effects of social relationships – on sexual performance. Of course, medical conditions can also affect psychological wellbeing, and while the main cause of sexual impotence will be medical or psychological, there can be 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.
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 a persistent problem getting 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 be causes, too.
- Diagnosis with the help of a doctor will differentiate the likely cause by including a number of questions, blood tests for conditions such as diabetes and heart disease, and physical examination.
- First-line treatment of erectile dysfunction is with drugs called PDE-5 inhibitors, including the well-known pill sildenafil (Viagra).
- Mechanical devices are also available to help achieve an erection, and occasional cases that do not respond to medical treatment may be candidates for surgery, to fit a penile implant.
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 so-called erection chambers, and valves prevent the venous loss of this pressure. The resulting hardness persists until after stimulation has stopped or an ejaculation has happened.4
This blood flow process is led by nervous and hormonal triggers activated when the brain is stimulated by touch or other stimuli, and these 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.
Effects against any of the following normal physiological contributions needed for an erect penis could affect normal erectile function: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 diet, physical activity and other lifestyle factors such as smoking – could also prevent erectile dysfunction.
More about the vascular causes of erectile dysfunction
Atherosclerosis – the thickening of the walls of the arteries that causes them to narrow, restricting blood flow – can cause erectile dysfunction.
The earliest changes caused by atherosclerosis – damage to the lining of the arteries (medically known as endothelial dysfunction) – affect the penis first.6
While the downside to this is that the ability to get an erection is affected, the upside is that erectile dysfunction can be an early sign of artery disease, meaning that treatment and prevention of both heart problems and the sexual dysfunction itself can be sought early.
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.6
Another cardiovascular risk factor, hypertension, can also cause erectile dysfunction.
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
Full list of physical causes
Because an individual cause of erectile dysfunction could be any one of those listed here – and many are not – persistent erection problems are always worth talking to a doctor about. Whether the cause is simple or serious, a proper diagnosis will help to address any underlying medical issues as well as helping to solve the sex problem.
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 the below.5 Of course, people seeking to stop or change medication should always talk to a doctor or pharmacy professional first.
- 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 chemotherapy
- Prostate treatments, including treatments for cancer, and for benign disease (5α-reductase inhibitors). Anti-androgen drugs are also a cause, used in other conditions as well as prostate disease
- Anticholinergics – drugs with a wide range of uses that block a neurotransmitter (nerve signal molecule)
- Hormone drugs, including estrogens and drugs that act on luteinizing hormone-releasing hormone
- The peptic ulcer medication cimetidine
The organic causes account for as much as 90% of true (persistent) cases of erectile dysfunction – psychological causes are much less common.5
Psychological causes of erectile dysfunction
In the rare cases of erectile dysfunction having always been present (what doctors call ‘primary’ ED – when a man has never been able to have an erection), the cause is almost always psychological if it has not been caused by an obvious anatomical deformity:5
- Fear of intimacy
- Severe anxiety.
Most cases of erectile dysfunction, however, are ‘secondary’ – the man has had normal erectile function before, but now has problems. Causes of a new and persistent problem are usually physical, but in the less common cases of a psychological cause, the below are examples, and each can cause or worsen erectile dysfunction.
Ranging from treatable mental health illnesses, to everyday effects that most people experience at some time, many of the following psychological causes can also cause temporary erection problems that would not be classed as erectile dysfunction.
Psychogenic factors preventing an erection can sometimes 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.
Does riding a bicycle cause erectile dysfunction?
Questions about effects from riding a bicycle on men’s health – saddle effects – are still to be fully answered.
There have been concerns that regularly cycling for long hours could be linked to a higher likelihood of erectile dysfunction, and other men’s health issues of 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 has said men should not worry about the research because there is an overall benefit from riding that outweighs concerns, which have been raised but not proven: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 – that men cycling more than three hours a week who are concerned that this may be resulting in erection problems could simply stop the activity for a period, 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” ridden 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 – but for many men, the ability to have erections returns within the first few months after treatment.12
Treatment of non-cancerous, benign prostate disease can cause ED. Drugs called 5α-reductase inhibitors are used to treat benign prostatic hyperplasia – prostate enlargement – and they can cause erectile dysfunction.5
ests and diagnosis for erectile dysfunction
A man has erectile dysfunction when his penis has regularly failed to give an erection that has been good enough to achieve or maintain sexual penetration.1-3
Most men at some point experience some difficulty with their penis becoming hard, or with maintaining an erection, but this is not erectile dysfunction, which is considered a disorder only if satisfactory sexual performance has been impossible on a persistent number of occasions for some time.
Doctors may look for symptoms to have persisted for at least three months before investigating them further and considering a diagnosis of erectile dysfunction needing treatment.3
There is a simple test to offer some suggestion that the problem may have a medical cause rather than a psychological one – men with psychogenic erectile dysfunction usually have normal erections during sleep and as they wake up in the morning, whereas an organic cause will often prevent these erections.1,5
Known as the ‘postage stamp test,’ it checks for the presence of nighttime erections – of which men usually have three to five a night – by seeing if postage stamps applied around the penis before sleep have snapped off overnight.1,5
Other tests of nocturnal erection are the Poten test and Snap-Gauge test. These methods provide limited information, however, and simply lead the doctor in a diagnostic direction.1,5,13
It is always worth talking to your doctor about problems with erection because they can be the earliest signal of atherosclerotic disease – narrowing of the arteries, which can lead to heart disease.6
A patient information page produced by the American Heart Association is poetic about the importance of getting a diagnosis:6
“Talk with your doctor about a broken sex life, and you might be able to prevent a broken heart.”
What the doctor will investigate
The numerous potential causes underlying a presentation of erectile dysfunction mean that the doctor may ask a lot of questions and arrange blood tests – for example to check for heart problems, diabetes and low testosterone. They will also likely need to carry out a physical examination, including of the penis and private areas.5
The questions will help differentiate a potential cause in the history – this might include checking for prescription drugs and herbal products, alcohol use, pelvic surgery or trauma, and smoking.5
The 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.5
Depression should be checked in all patients, and the consultation might explore recent emotional events, and ask about relationships – including about any conditions the sex partner may have.5
Treatment of erectile dysfunction
In this section:
- Drug treatments
- Online pharmacies selling drugs for erectile dysfunction
- Vacuum devices
- Surgical treatments
- Dietary supplements and alternative treatments
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.
The best known treatments for erectile dysfunction are sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis).
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).5
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.5
There is a list of potential adverse side-effects associated with PDE-5 inhibitors, including flushing, visual abnormalities, hearing loss, dyspepsia and headache.5
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.5
Online pharmacies selling drugs for erectile dysfunction
It is possible to buy treatment over the internet for erectile dysfunction, but there are four items worth checking before trusting a website for any purchase. The US Food and Drug Administration has a consumer safety guide about this, including a recommendation to check that the online pharmacy:
- Is located in the US and licensed (check the list maintained by the National Association of Boards of Pharmacy)
- Has a licensed pharmacist to answer questions
- Requires a prescription
- Offers direct contact with a person who can discuss any problems.
The FDA also offers tips for spotting the dangers of an unsafe website, including watching out for these clues:
- There is no way to contact the website by phone
- Prices are dramatically lower than those offered by legal online pharmacies
- Prescription drugs are offered without requiring a prescription – which is illegal
- Personal information is not protected.
The FDA adds that these illegal sites may send drugs of unknown quality and origin, even sending the wrong drug or a dangerous product.
Vacuum erection devices are a mechanical way of producing an erection for men who do not want or cannot use drug treatments or find they are not working.
The penis is made rigid by the use of a vacuum pump sealed around it that draws up blood – this is prevented from then leaving the penis by the use of an accompanying band – a rubber ring is rolled to the base of the organ and sexual penetration can begin.9,12
The potential problems against personal preference for such mechanical devices are obvious, including a lack of spontaneity. Other potential disadvantages include:5
- Bruising of the penis
- Tissue damage caused if the ring is left on for too long
- Coldness of the tip of the penis.
Penile implants are a final option reserved for men who have not had any success with the drug and non-invasive options above.
These prostheses are surgically placed mechanical implants, taking the form of a device inflated by fluid when needed, or one that is simply moved into the upward position but keeps the penis hard at all times while not upright.5,12
The most complex of these implants is the three-piece version that is totally concealed within the body and gives a normal appearance, both when in operation and for the flaccid penis. It is triggered by a release valve that fills the implant with fluid.14
Guidelines drawn up by specialist urology doctors have outlined the following risks to consider when planning to have implant surgery:15
- The possibility and consequences of infection and erosion (“infection is a devastating complication of any prosthetic surgery” but anti-infection measures applied to implants have improved)
- Mechanical failure of the device, which would need another operation
- How the normal flaccid and erect penis will appear, and whether there will be “penile shortening”
- If the device is subsequently removed, other therapies may have reduced effectiveness.
Another surgical option for some men is vascular surgery, which attempts to correct some blood vessel causes of erectile dysfunction.
Arterial reconstructive surgery is an option limited to only very specific cases of erectile dysfunction – the American Urological Association sets it out as an option only in healthy men who have recently acquired erectile dysfunction that has been caused by a focal arterial occlusion (a blocked artery at a certain point), “and in the absence of any evidence of generalized vascular disease.”15
Another type of surgery has been used but is not recommended by guidelines from urology specialists. Surgery to restrict the venous outflow of the penis (return of blood from the penis) is not a good option for the types of erectile dysfunction it is aimed at, the American Urological Association says.15
Dietary supplements and alternative treatments for erectile dysfunction
No guidelines followed by doctors, nor any established sources of evidence, support the use of dietary supplements for erectile dysfunction, such as herbal pills.5,8,9,15
In addition to there being no evidence in favor of non-prescription alternatives for ED, the US Food and Drug Administration has warned of hidden risks of ‘treatments’ sold online for erectile dysfunction.16
While many of these products are sold as ‘natural,’ they illegally contain, in a third of cases uncovered by the FDA, prescription drugs such as sildenafil (Viagra) – giving false claims to herbal effectiveness and presenting users with unregulated risks.
The FDA has published a list of products to avoid. These products may be dangerous and will not be as effective as prescribed treatments available from doctors.16
The Mayo Clinic cites four alternative therapies that are tried by people with erectile dysfunction, but while each may not be harmful (as long as patients check with their doctors for possible interactions with other therapies and conditions) none has any good evidence to support its use:8
- Korean red ginseng (brand name: Panax)
- Dehydroepiandrosterone (DHEA)
Written by Markus MacGill