Erectile Dysfunction: Symptoms, Causes and Treatment

Erectile dysfunction is a condition whose incidence increases with age. By itself it isn't serious, but it's accompanied by a strong social stigma that motivates people to go to the doctor.

Written and verified by la psicóloga Paula Villasante.

Last update: 11 July, 2021

Erectile dysfunction is a common male sexual dysfunction. It involves an alteration in any of the components of the erectile response, including relational, organic and psychological.

Erectile dysfunction is when a man has trouble getting or maintaining an erection. It’s a problem that becomes more common as you age, and, in fact, mainly affects men over 40 years of age. However, it isn’t considered a normal part of aging.

In addition to the classic causes that can lead to this problem, such as diabetes mellitus or high blood pressure, there are other related factors. These are lifestyle, obesity, limitation or an absence of physical exercise, as well as urinary tract problems.

Interventions to alleviate the symptoms of this disorder include lifestyle modifications, vacuum erection devices, or injected vasodilator agents.

Male erection and erectile dysfunction

The erect penis has always been a symbol of a man’s virility and sexual prowess. Although it isn’t a life-threatening condition, the interest around erectile dysfunction and its remedies has been constant throughout history.

Thus, erectile dysfunction is defined as the i nability to achieve or maintain an erection that would be sufficient for satisfactory sexual intercourse. It affects a considerable proportion of men, even occasionally.

Two main aspects may be involved in erectile dysfunction: reflex erection and psychogenic erection. Both can be involved in the dysfunction and are subject to therapeutic intervention.

• Reflex erection is achieved by directly touching the shaft of the penis and is under the control of the peripheral nerves and the lower parts of the spinal cord.
• The psychogenic erection is achieved through erotic or emotional stimuli. The limbic system of the brain is directly related to this process.

Causes of erectile dysfunction

Erectile dysfunction used to be considered a purely psychogenic disorder. However, current evidence suggests that more than 80% of cases have an organic etiology. The causes of organic erectile dysfunction can be divided into endocrine and non-endocrine.

Non-endocrine causes

Among the non-endocrine organic causes of erectile dysfunction we can find the following:

• Vasculogenic (affecting blood flow). This is the most common cause and can involve arterial flow disorders and venous flow abnormalities.
• Neurogenic (affecting nerve innervation and function).
• Iatrogenic (related to medical or surgical treatment).

Endocrine causes that lead to erectile dysfunction can be linked to serum testosterone levels.

Often, organic erectile dysfunction involves a psychological component. Regardless of the triggering event, erectile dysfunction has negative effects on interpersonal relationships, mood, and quality of life.

Risk factors

There are certain risk factors that can enhance the appearance of erectile dysfunction:

• Metabolic syndrome
• Benign prostatic hyperplasia
• Cardiovascular disease
• Smoking
• Central neurological conditions
• Spinal cord injury
• Depression or stress
• Diabetes mellitus 

Erectile dysfunction symptoms

The symptoms of this pathology can be divided into psychogenic symptoms and organic symptoms.

Psychogenic symptoms

• Sudden appearance
• Intermittent function
• Nocturnal erection
• Most likely, the response to conventional medications, such as phosphodiesterase type 5 inhibitors, will be effective in reducing symptoms

Organic symptoms

• Gradual start
• Often progressive
• Consistently poor response
• The erection is better in a standing position than lying down (in the presence of venous leakage)

Diagnosis of erectile dysfunction

The main goals of evaluating these patients are to establish whether the disorder is truly erectile dysfunction and to determine risk factors and life-threatening comorbid disorders associated with erectile dysfunction.

Clinic history

The mainstay in diagnosing erectile dysfunction is an adequate and complete medical and sexual history. During the initial visit, the primary care physician should attempt to obtain a detailed psychosocial history, focusing on the patient’s assessment of his own sexual performance and his general attitude and knowledge about sex.

It is also often advisable to interview the couple. Occasionally, a medical history can reveal psychological problems, which can lead to psychiatric referral.

Patients who complain of weak erections may be suffering from premature ejaculation. In erectile dysfunction, a loss of erection occurs before orgasm, while in premature ejaculation it occurs afterward.

It’s important to determine whether the dysfunction is organic or psychogenic. In general, the presence of hard erections in the morning or at night, or getting hard erections just thinking about something sex-related suggests a mainly psychogenic cause.

Erectile dysfunction that starts suddenly, has an intermittent course, or is short-lived also suggests psychogenic factors in its etiology. On the contrary, one that begins gradually, that has a progressive course, or a prolonged duration suggests a predominantly organic cause.

It’s also important to review relevant drug history, including the use of alcohol, tobacco, or illicit drugs, and decreased or altered sexual desire.

Standardized questionnaires

Standardized questionnaires are frequently used to confirm that the disorder is really erectile dysfunction and to measure its severity. There are several questionnaires available for these cases, but two of the most practical are the International Index of Erectile Function and the Sexual Health Inventory for Men.

Physical examination

The physical examination in erectile dysfunction is a good method to explore any misconceptions the patient may have about the relationship between this problem and penis length and masculinity. Two aspects, general and local, are generally taken into account in the physical examination:

General physical exam

• Secondary sexual characteristics
• Pulses and sensations
• Scars from previous surgeries or trauma

Local physical exam

• The penis: Size, scars, fibrosis of the urethral meatus and elasticity are evaluated.
• Scrotum: Testicular size and consistency.
• Rectal examination: Size and consistency of the prostate and seminal vesicles, evaluation of the tone of the anal sphincter, and the bulbocavernous reflex.

Laboratory evaluation

Regarding the relevant blood tests for the diagnosis, the following are taken into account:

• Sugar analysis
• Total testosterone

Low free or total testosterone levels require additional hormonal evaluation, including luteinizing hormone and prolactin.

Other more specific investigations can be carried out to execute the diagnosis, which include certain questionnaires and tests.

Erectile disfunction treatment

Generally, the most used treatment is through PDE5 inhibitors. Other treatment modalities include lifestyle modification, injection therapy, testosterone therapy, penile devices, and psychotherapy.

Psychosexual and couples therapy

Psychosexual therapy is indicated when significant psychological problems are recognized. The most commonly used techniques include the following:

• Sensory focus
• Sex education
• Interpersonal therapy

Lifestyle modification

In this disorder, it’s important to treat lifestyle factors such as:

• Alcohol consumption
• Smoking
• Obesity
• Limited physical activity

Oral PDE5 inhibitors

Oral PDE5 inhibitors are considered the first-line treatment. These drugs facilitate erection by inhibiting the PDE5 enzyme, which is specifically responsible for the breakdown of cyclic guanosine monophosphate (cGMP) in the muscles of the smooth cavernous region.

This inhibition results in prolonged cGMP activity, which further lowers intracellular calcium concentrations, maintains smooth muscle relaxation, and thus results in hard penile erections. Currently, the PDE5 inhibitors available are as follows:

• Sildenafil (Viagra)
• Tadalafil (Cialis)
• Vardenafil (Levitra)
• Udenafil (Zydena)
• Sildenafil (Mvix)

Testosterone

Although testosterone is important in order to achieve proper erections, its role in treating this problem is limited. Testosterone replacement therapy is recommended in men with erectile dysfunction who have confirmed low levels of available testosterone.

Vacuum constriction devices

These types of devices work by applying continuous negative pressure to the shaft of the penis, which helps draw blood into the corpora cavernosa. However, erections created with this method aren’t natural. They’re mechanical, and give the penis a cold sensation on the penis, and almost half of the patients aren’t satisfied with this method.

Generally, this type of treatment is reserved for patients with stable relationships. These tend to have a history of failure with PDE5 inhibitor treatment and refuse other more invasive options such as intracavernous injection or implantation of penile prostheses.

Intracavernous injection and transurethral therapy

This is a considered second-line treatment for this problem. Its main advantage is that the erection achieved is predictable and occurs quickly. The erection usually occurs in less than 10 minutes, regardless of sexual desire.

Penis prosthesis

The implantation of a penile prosthesis is usually the last resort for the treatment of erectile dysfunction, when other modalities have failed or the patient doesn’t like them. There are two main types of penile prostheses:

• Semi-rigid prosthesis: This is usually easier to implant and lasts longer. However, it can’t produce a fully erect penis.
• Inflatable prostheses: These are usually made of two or three parts, which allows you to achieve a hard erection.

Erectile dysfunction is sometimes a predictor of cardiovascular disease. However, more research is still needed to determine a more effective treatment for this type of problem.

It’s a complex and frequent problem, which, of course, requires adequate attention. In case of suffering symptoms related to this condition, it’s advisable to go to the urologist as soon as possible for a proper assessment.