Erectile dysfunction: causes, diagnosis and treatment options

Erectile dysfunction — ED for short — is the inability to achieve or maintain an erection firm enough for sexual intercourse. It is not a diagnosis made after a single unsuccessful attempt; fatigue, alcohol, stress or lack of sleep can produce a similar result in almost any man from time to time. What matters is persistence, and whether it causes a problem for the man or the couple.

When does it count as a “problem”?

The rough criterion used is that the complaint has lasted at least three months and recurs in a significant share of attempts. One distinction matters for diagnosis: if morning erections and erections during masturbation are preserved and the problem appears only with a partner, the psychological component predominates. By contrast, if morning erections have also declined, this suggests the problem has a vascular or nerve-related basis.

How common is it?

Erectile dysfunction increases markedly with age; it affects a significant proportion of men over 40 to varying degrees and is the most common sexual dysfunction over the age of 60. Yet it also occurs in young men; in this group psychological causes, performance anxiety and certain medications come to the fore. Despite how common it is, few men see a doctor — and the real cost of delay is that underlying vascular disease goes unnoticed for years.

Causes: four main groups

1. Vascular causes

This is the most common group. An erection requires enough blood to reach the penis and that blood to be held in the tissue. Atherosclerosis (hardening of the arteries), high blood pressure, high cholesterol, smoking and diabetes narrow the small arteries of the penis and disrupt this flow. Smoking is a particularly harsh factor here: it directly impairs the function of the inner lining of the blood vessels.

2. Nerve-related causes

The signal has to travel from the brain to the penis. Diabetic neuropathy, multiple sclerosis, Parkinson’s disease, spinal cord injuries and pelvic surgery (especially radical prostatectomy) can interrupt this signalling. Recovery after surgery can take months, which is why mechanical support becomes important in the meantime.

3. Hormonal and metabolic causes

Low testosterone, thyroid disorders, high prolactin and metabolic syndrome all contribute. Low testosterone usually does not explain erectile dysfunction on its own; it is assessed together with reduced sexual desire.

4. Psychological and medication-related causes

• Performance anxiety. One unsuccessful attempt creates anticipatory anxiety for the next, and the cycle feeds itself.
• Depression and anxiety. Both the conditions themselves and some antidepressants affect function.
• Conflict in the relationship. Unspoken problems turn into sexual avoidance.
• Medications. Some blood pressure drugs (especially beta blockers and thiazide diuretics), antidepressants, antipsychotics and some drugs used for an enlarged prostate. Do not stop your medication on your own; ask your doctor about alternatives.
• Alcohol and substance use. Chronic alcohol use affects both the nervous and hormonal systems.

Erectile dysfunction can be a heart warning

The penile arteries are among the narrowest arteries in the body. Damage to the inner lining of blood vessels can show up in these narrow vessels years before it does in the coronary arteries that supply the heart. For this reason, urologists regard erectile dysfunction as an early warning sign of cardiovascular risk. That is why checking blood pressure, fasting blood sugar and blood lipids is routine when erectile problems first appear.

What will the doctor ask, and which tests are done?

1. Detailed history: how long the complaint has lasted, whether it began suddenly or gradually, the state of morning erections, differences between partnered and solo activity, current medications, smoking and alcohol.
2. Physical examination: genital examination, secondary sex characteristics, pulses and, if needed, a prostate assessment.
3. Blood tests: fasting blood sugar or HbA1c, lipid profile, morning total testosterone and, if needed, thyroid and prolactin.
4. Questionnaires: short questionnaires such as the IIEF-5 to track severity numerically.
5. Further tests in selected cases: penile colour Doppler ultrasound to assess blood flow.

Treatment steps

Although tablets are the first option most men think of, they have absolute contraindications: they cannot be used by men taking nitrate-type heart medication because of the risk of a dangerous drop in blood pressure. Their response rate also falls, especially with long-standing diabetes and after pelvic surgery.

Where a penile vacuum device fits in

A penile vacuum device does not try to change the cause of erectile dysfunction; it draws blood into the tissue with an externally applied pressure difference and holds it there with a ring. This mechanical approach has three practical consequences:

• It works largely independently of the cause — the same physics applies in vascular, nerve-related or medication-induced cases.
• It causes no drug interactions; it can be considered for a wide group, including men taking nitrates.
• It can be used to keep blood flowing to the tissue during the months of expected recovery after surgery.

On the other hand, the device requires a learning process and has aspects that take some getting used to, such as the cool feeling caused by the ring. Both sides should be weighed together when deciding; the Active3 Erection System page sets out the contents of the set and its technical details.

Lifestyle: the changes that really make a difference

• Quitting smoking. This brings the fastest improvement in the function of the blood vessel lining.
• 150 minutes of aerobic exercise a week. Walking included; it has a measurable effect on vascular health and testosterone.
• Reducing waist size. Abdominal fat converts testosterone into oestrogen, upsetting the hormonal balance.
• Blood sugar control. In diabetes, staying within the HbA1c target slows the progression of nerve and blood vessel damage.
• Treating sleep apnoea. Repeated drops in oxygen at night affect both the vascular and hormonal systems.
• Limiting alcohol.

Three frequently asked questions

Is erectile dysfunction permanent?

It depends on the cause. Medication-related, hormonal or psychological cases are largely reversible. Advanced vascular disease and nerve damage after surgery, however, can be permanent; in that case the goal is not a cure but supporting function.

Do herbal products work?

Some of the “herbal” capsules sold online have been found to contain undeclared drug ingredients not listed on the label; for a heart patient taking nitrates, this is a serious danger. Stay away from products whose contents are not regulated.

I am too embarrassed to see a doctor — what should I do?

This is the most common and the most costly kind of postponement. A urology consultation is a short, routine appointment; delay, on the other hand, narrows the treatment options and allows an unnoticed cardiovascular risk to progress.