Erection problems are common, but can be difficult to seek help for. Learn about the causes, diagnosis and treatment of erectile dysfunction.

Erection problems are relatively common among men. They can stem from a variety of health conditions, and can take a toll on quality of life, relationships, and efforts to get pregnant. Despite this, they can also be difficult to talk about and seek treatment for.

This article aims to shed light on the condition known as erectile dysfunction. Below, we cover everything from the condition’s main causes to the most effective treatment options.

What is erectile dysfunction (ED)?

Sometimes referred to as impotence, ED involves problems in either getting or keeping an erection that is firm enough for sexual intercourse. This type of male sexual dysfunction tends to affect mainly men over the age of 40, but can appear anytime after puberty.

It is a not uncommon problem affecting men’s health: one study estimated that 1 in 5 men in the USA had experienced the condition. Another American survey of men between 40 and 70 years of age found that 52% had at least some degree of erectile difficulty. A study from Switzerland additionally found that 30% of a sample of men between the ages of 18 and 25 had ED.

Unfortunately, perhaps due to embarrassment, the majority of men with ED are not treated for the condition. This is despite the fact that men generally report that the condition negatively impacts their sex life, quality of life and relationships. ED and the ways it affects a man’s sexual function and self-image can additionally lead to mental health problems such as anxiety, depression, and poor self-esteem.

Causes of erectile dysfunction

Physical Causes

A major cause of erectile dysfunction is buildup of plaque on artery walls, which leads to obstructed blood flow. Known medically as atherosclerosis, this health condition is due to genetic and lifestyle factors is estimated to account for a large proportion of ED cases in men over the age of 50. Other causes include:

Certain anatomical abnormalities may also lead to the condition. One of these is Peyronie’s disease, which is characterized by curvature or deformation of the penis in its erect state, and pain and formation of plaque in the penis. Peyronie's disease can arise due to injury to the penis, as well as due to certain connective tissue or autoimmune disorders. Another cause of ED is priapism, in which an erection is involuntarily maintained for a long time, causing damage to tissues and blood vessels in the penis.

Psychological causes

In some men, erectile dysfunction is caused mainly by psychological factors. This form is more common in men younger than 40. It may arise as a result of experiences such as premature ejaculation, painful sex (dyspareunia), or past sexual abuse. Conflict within a relationship, as well as performance anxiety, can be additional psychological contributors to ED. Anxiety and depression are also associated with the condition. Clues that the condition is psychological in origin may be that erections can be maintained during masturbation, and they occur as normal during sleep (devices are available to measure this).

Risk factors

General risk factors for erectile dysfunction include:

  • Older age
  • Atherosclerosis
  • High blood pressure
  • High cholesterol
  • Smoking
  • Obesity
  • Type 2 diabetes

In addition, medications and substances that may contribute to the condition include:

  • Alcohol
  • Antidepressants, especially those in the selective serotonin reuptake inhibitors (SSRI) category
  • Antihistamines
  • Antihypertensives (medications for high blood pressure)
  • Nicotine
  • Illicit drugs

As many of the risk factors for ED are implicated in cardiovascular disease (CVD), it is perhaps unsurprising that ED has been associated with an increased risk of CVD and related conditions such as coronary artery disease and stroke. It has also been found that ED tends to appear several years before heart disease, and thus can signal a window for diagnosis and intervention.

Diagnosis

A health care provider or specialist in urology will often do some of all of the following when diagnosing ED:

  • Take a medical history, including questions about past surgeries and current medications
  • Perform a physical examination of the genitals
  • Perform a psychological exam, checking for depression and other mental health difficulties
  • Request a urine sample to check for diabetes and other health conditions
  • Draw blood to assess hormone levels, as well as signs of heart disease
  • Use ultrasound to visualize blood flow in and around the penis

A doctor may also administer a questionnaire to help determine the extent of the problem. One commonly-used instrument is the International Index of Erectile Function (IIEF). This measure’s five questions assess:

  • A man’s general confidence about being able to get and keep an erection;
  • Whether his recent erections were hard enough for penetration;
  • How well his erections could be maintained after penetration;
  • How well his erections could be maintained to completion of intercourse; and
  • How satisfactory attempted intercourse was, from his point of view.

This questionnaire can also be administered repeatedly to assess whether erectile dysfunction treatment strategies, as outlined in the next section, have led to improvement in erectile function.

Treatment

In determining a treatment strategy for erectile dysfunction, an important consideration is how much a man is bothered by the condition. This tends to be dependent on his sexual desire: if he has high desire for intercourse with a sexual partner, treatment is more worth pursuing. Other men may have low desire and thus lesser motivation to treat the condition. For couples with a wish for pregnancy and in which the man has ED, treating the ED may be one option, while assisted reproduction with sperm extraction techniques represent another.

Often, the first line of treatment for ED involves lifestyle changes, as well as oral medications. When these are not effective, procedural therapies can be attempted. Below, we discuss these options in turn.

Lifestyle modifications and supplements

This category of intervention includes:

  • Quitting smoking
  • Engaging in regular exercise
  • Weight loss, in the case of overweight or obesity

These lifestyle changes can address overall health, which can positively impact sexual health and function. In addition, they can improve low testosterone, which may help to resolve ED.

In addition, there is some evidence that ginseng, taken in supplement form, may be helpful in treating ED. More studies are however necessary to confirm this finding.

Oral medications

A number of drugs in the family of PDE-5 inhibitors are available in pill form. These help a man to maintain his erection once he has been sexually stimulated by increasing blood flow to the penis through vasodilation (widening of blood vessels). Specific medications include:

  • Viagra (sildenafil)
  • Cialis (tadalafil)
  • Levitra (vardenafil)
  • Stendra (avanafil)

These medications do not cure the underlying cause of ED.  They also need not be taken every day, but rather on an as-needed basis. They become effective within about an hour of ingestion. However, PDE-5 inhibitors do not work in all men with ED. Especially in more severe forms of the condition, the options in the next category may need to be considered.

Procedural therapies

As an alternative to the oral medications above, several alternative therapies have been developed to help stimulate erection.

Alprostadil, or prostaglandin E1 (PGE1) is a prescription drug that promotes relaxation of muscles in the arteries, increasing vasodilation and blood flow. It can be given in one of two forms: a self-administered injection into the side of the penis, or a pellet that can be placed in the urethra by means of an applicator. While the injectable form is more effective, this therapy can be unappealing to men, particularly those who have a fear of needles. A known side effect of alprostadil is penile fibrosis, whereby the penis develops scar tissue and a loss of elasticity. This necessitates discontinuation of the therapy.

Vacuum devices. These involve a tube placed over the penis. Lubricant is used to seal off the base, and the pump is used to remove air from the tube, while at the same time drawing blood into the penis and creating an erection. A ring is then slid from the base of the tube onto the base of the penis, maintaining the erection. To avoid damage to blood vessels, the ring should not be worn for more than 30 minutes. A drawback of this method is that the penis, while erect, can feel cool or cold because blood is not actively circulating.

Penile implants. The last line of treatment are protheses, or surgical implants. They come in a semi-rigid form, which are relatively simple to implant. Their disadvantage is that, due to the prosthesis, the penis always appears to be erect. Another option is inflatable protheses: these consist of two tubes implanted in the penis, with a pump in the scrotum. These carry a higher risk of mechanical failure, as well as infection.

Implants are considered to be a good option for men with Peyronie’s disease, as they can help to restore the shape as well as the erectile function of the penis.

Effect on fertility

Couples who wish to get pregnant face some challenges if the male partner has erectile dysfunction. When ED makes intercourse difficult, then it also has an indirect negative impact on male fertility and ability to attain pregnancy.

However, conceiving a baby is far from impossible. One thing to keep in mind is that ED does not automatically mean low sperm count or poor sperm quality. However, certain causes of ED, such as low testosterone, may also affect sperm production.

Some of the treatment strategies outlined above can make intercourse possible, enabling conception. Other routes that couples can consider include:

Takeaway

Erectile dysfunction is the inability to achieve or maintain an erection that is sufficient for satisfactory sexual intercourse. It is a not uncommon health problem, especially in older men, but its interference with sexual activity can negatively impact quality of life and psychological health as well as attempts to get pregnant. Causes include hardening of the arteries, damage from surgery, hormonal imbalances and other medical conditions.

Treatment options for ED include lifestyle changes, oral medications, and procedural therapies. There are also a number of options available to help couples affected by erectile dysfunction who wish to conceive.

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