Possible causes of erectile dysfunction and how to treat them

Erectile dysfunction is the inability to get and/or keep an erection that is firm enough for sexual activities. Formerly called impotence, this problem affects up to 20 million men in the United States. Erectile dysfunction is more common in older men, but in many cases, the issue can be successfully treated (1).

What are the possible causes of erectile dysfunction?
Most cases of erectile dysfunction are due to physiological (physical health) factors, but psychological (mental) factors can be the cause in some men, as well as compounding the problem in men with underlying physiological causes (1).

Physical causes of erectile dysfunction include:

• Reduced blood flow to the penis, which may be due to atherosclerosis (hardened arteries), endothelial dysfunction (when blood vessels cannot vasodilate efficiently), and other heart diseases. For more information about atherosclerosis, see our previous article here.
• Inability to trap blood during an erection
• Issues with the nerve signals from the brain or spinal cord to the penis. These can be caused by stroke, seizures, multiple sclerosis, spinal cord injuries, and surgeries (2).
• Cancer treatments near the pelvis (e.g., for prostate, colon-rectal, or bladder cancer)
• Medications for other health problems
• Low testosterone (also associated with reduced libido (sex drive)). We offer several tests to measure your testosterone levels (see list in the bottom section of this page). For more information about the signs of low testosterone in males, see our previous article here. 
• Structural disorders of the penis (e.g., Peyronie disease)

What factors are associated with an increased risk of erectile dysfunction?

• Smoking
• Older age (over 50 years)
• Diabetes (erectile dysfunction is 3.5 x more common in diabetics compared to non-diabetics (3))
• High blood pressure
• Heart disease
• High cholesterol
• Obesity
• Drug use
• Excess alcohol consumption
• Lack of physical activity
• Prolonged perineal pressure (e.g., from bicycle riding)
• Depression
• Anxiety (particularly related to sexual performance)
• Stress

How can erectile dysfunction be treated?
The treatment for erectile dysfunction often starts by treating the underlying cause. For example, if you are also affected by high cholesterol, your doctor may suggest making dietary changes, increasing physical exercise, and considering statin medications to lower your cholesterol levels. Diabetics may require more frequent glucose testing to ensure they are maintaining a healthy blood glucose level. Treatment of emotional problems may also be required, such as counseling and medication for depression.

Treatments directly targeted at erectile dysfunction include:

• Oral drugs (e.g., Viagra)
• Testosterone therapy (if low testosterone is detected)
• Penile injections (can be self-administered with appropriate training)
• Intraurethral medication (tiny pill placed inside the urethra)
• Vacuum erection devices
• Penile implants
• Surgery to bypass penile artery damage

References:
1. Hirsch IH. (Modified July 2020). Erectile Dysfunction. Merck Manual Professional Version.
2. What is Erectile Dysfunction? (Updated June 2018). Urology Care Foundation.
3. Shindel AW & Lue TF. (2017). Sexual Dysfunction in Diabetes. Endotext [Internet].