Erectile dysfunction, also referred to as ED or impotence, occurs when a man can’t get or keep an erection firm enough for sexual intercourse. Occasional ED isn’t uncommon, particularly during times of stress. In fact, more than half of men over age 40 experience some degree of ED. (1)

However, frequent ED may be an early sign of more serious health problems, such as disease in the blood vessels elsewhere, including the heart or the brain.

For some men, ED may be the first symptom of diabetes, even if they have not yet been diagnosed, particularly in men younger than 45. (2)

Men with diabetes are three times more likely to experience ED than men without diabetes and it affects them 10 to 15 years earlier in life. (1,3)

ED precedes coronary artery disease (CAD) in almost 70 percent of cases. In fact, ED usually comes three or more years before a heart attack, making it a common first sign for men that they have heart disease. (4)

What are the risk factors for ED?

The most common risk factors for ED are:

  • Age over 50
  • Cardiovascular disease
  • Diabetes
  • High blood pressure
  • High cholesterol
  • Smoking

Over a period of time these diseases can lead to a degeneration of the penile blood vessels, leading to the restriction of blood flow through the arteries and erectile tissue damage. This allows leakage of blood through the veins during erection.

Abnormally low levels of circulating testosterone may cause ED, although low testosterone is found in a minority of men who develop ED. Low levels of sexual desire, lack of energy, mood disturbances, loss of muscle strength, and depression can all be symptoms of low testosterone. A simple blood test can determine if the testosterone level is abnormally low. Low levels of testosterone can be replaced by using a number of different delivery systems (e.g., shots, skin patches, gels, sub-dermal implants).

The choices made in life can lead to degeneration of the erectile tissue and the development of ED. Smoking, drug abuse, or alcohol abuse, particularly over periods of time, will compromise the blood vessels of the penis. Lack of exercise and a sedentary lifestyle also contribute to the development of ED. Modifying these risk factors may contribute to overall health and, in some individuals, may correct mild ED.

Patients undergoing surgery or radiation therapy for cancer of the prostate, bladder, colon, or rectum are at high risk for the development of ED. Drugs used to treat these risk factors listed above may also lead to or worsen ED.

Another cause of ED is peripheral neuropathy in which the nerves leading to the penis fail to send coordinated signals to the penis. Peripheral neuropathy can be caused by diabetes, human immunodeficiency virus (HIV) infection, certain medications and other less common conditions.

What causes ED?

ED can result from medical, physical, or psychological factors. ED may be caused by a combination of factors that could also include medicine, alcohol, or drugs. The physical and medical causes of ED include three basic problems:

  • Not enough blood flows into the penis. Many conditions can reduce blood flow into the penis, such as heart disease, diabetes, and smoking. The penis cannot store blood during an erection. A man with this problem, which is called venous leak or cavernosal dysfunction, cannot maintain an erection because blood does not remain trapped in the penis. This condition can occur in any man regardless of age.
  • Nerve signals from the brain or spinal cord do not reach the penis. Certain diseases, injury or surgery, in the pelvic area can damage nerves in the penis. Sexual activity requires the mind and body to work together.
  • Psychological, emotional, or relationship problems can cause or worsen ED. These include but are not limited to:
    • Depression, relationship conflicts, stress at home or work, and anxiety about sexual performance.

Many prescription and over-the-counter medications may have side effects that often cause erection difficulties. Using drugs such as marijuana, heroin, cocaine, and alcohol can lead to sexual problems.

If your ED is due to a hormonal problem, such as low testosterone or diabetes, you may be referred to an endocrinologist. Your health care provider may also refer you to a mental health professional. These specialists treat psychological or emotional causes of ED. Even if your ED is not caused by these factors, it may contribute to them. It may be helpful to get counseling, alone or with your partner, in addition to medical therapy for ED.

How is ED diagnosed?

ED is diagnosed by a urologist or another medical professional. For most patients, the diagnosis will require a simple medical history, a physical examination, and a few routine blood tests.

What are the treatment options for ED?

For ED, there are several treatment options, with varying degrees of success and reliability, including medications and surgical procedures. Because each option offers unique features, potential risks and benefits, men should talk to their doctor about which treatment option best meets their individual needs and the problems they are experiencing. (5).

Sources:

  1. Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol. 1994 Jan;151(1):54-61.
  2. National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes and Sexual and Urologic Problems. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/sexual-urologic-problems. Accessed May 3, 2017.
  3. Malavige LS, Levy JC. Erectile dysfunction in diabetes mellitus. J Sex Med. 2009 May;6(5):1232-47.
  4. Gandaglia G, Briganti A, Jackson G, et al. A systematic review of the association between erectile dysfunction and cardiovascular disease. Eur Urol. 2014 May;65(5):968-78.
  5. Erectile dysfunction (ED). www.auanet.org/content/education-and-meetings/med-stu-curriculum/ed.pdf. American Urological Association Web site. Accessed January 21, 2013.
  6. VIAGRA™ Prescribing Information. Pfizer Inc. Revised January 2010:8-9.
  7. CIALIS™ Prescribing Information. Lilly USA, LLC. Revised 2011:18-20.
  8. LEVITRA™ Prescribing Information. Bayer HealthCare Pharmaceuticals Inc. 2011:19-20.
  9. Walsh TJ, Hotaling JM, Smith A, et al. Men with diabetes may require more aggressive treatment for erectile dysfunction. Int J Impot Res. 2014 May-June;26(3):112-5.
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