Erectile Dysfunction


Contributing Physician
Subir Chhikara, MD
Austin Urological Associates, PA

Erectile dysfunction, also called impotence, is the inability to attain or maintain an erection of the penis that is firm enough for penetration during sexual intercourse. To initiate and maintain an erection, the penis must fill with blood. Nerve signals stimulate this engorgement. They prompt the blood vessels in the penis to expand so blood can fill it. Meanwhile, other blood vessels constrict, trapping blood inside.

Causes of Erectile Dysfunction

Venous Leak: If the blood vessels (veins) which normally compress during an erection do not fully compress, an erection may not be attainable or may not last long. This can be caused by injury or diseases which prevent the full expansion of the vessels (arteries) which normally expand with blood.

Neurovascular Function: Erection cannot be attained if nerve signals do not prompt blood vessels to do their job or if blood flow to the penis is reduced. Nerve dysfunction can also diminish feeling in the penis, resulting in impotence. Many medications can cause erectile dysfunction by impairing either vascular or nerve function.

Medical conditions that can lead to neurovascular dysfunction include:

  • Diabetes: can interfere with nerve signals
  • Arteriosclerosis (hardening of the arteries): can reduce blood flow
  • Peripheral neuropathy, spinal cord injury, and surgery: can damage nerves

Psychological Factors: Psychological factors account for 10%-15% of erectile dysfunction cases. The brain initiates many of the nerve signals required for a successful erection. Problems in your relationship, feelings of guilt associated with sex, depression, anxiety, and stress can all lead to erectile dysfunction. Recent estimates suggest that roughly 20 million US men have erectile dysfunction. Erectile dysfunction increases with age, from about 5% at age 40, to 15%-25% at age 65 and older.]

 Risk Factors for Erectile Dysfunction

A risk factor is something that increases your likelihood of getting a disease or condition.  It is possible to develop erectile dysfunction with or without the risk factors listed below. However, the more risk factors you have, the greater your likelihood of developing erectile dysfunction. If you have a number of risk factors, ask your healthcare provider what you can do to reduce your risk.

Risk factors include:

Age:  The incidence of erectile dysfunction rises with age:

  • One in four for men in their 60s
  • Nine in ten for men in their 80s

Medical Conditions:  Certain medical conditions can increase your risk of erectile dysfunction, including:

  • Diabetes
  • Cardiovascular disease
  • Arteriosclerosis (hardening of arteries)
  • Chronic kidney disease
  • Cirrhosis
  • Chronic obstructive pulmonary disease(COPD)
  • Peyronie’s disease (bending of the penis caused by scar tissue)
  • Endocrine disorders (hypogonadism, hyperthyroidism, hypothyroidism, hyperprolactinemia,
  • Cushing’s syndrome)
  • Neurological disorders (such as multiple sclerosis, peripheral neuropathy, stroke)
  • Myotonic dystrophy
  • Hypertension (high blood pressure)
  • Psychiatric disorders (such as anxiety, depression, schizophrenia)
  • Psychological problems (stress, personal relationships, new partners)

Traumatic Conditions: 

Trauma, whether through an accident or surgery, can increase your risk of erectile dysfunction. Trauma includes:

  • Vascular surgery
  • Urologic surgery, such as prostate surgery
  • Pelvic surgeries (particularly for prostate cancer)
  • Spinal cord injury

Behaviors:  Certain behaviors can increase your risk of erectile dysfunction, including:

  • Alcohol use
  • Illegal drug use (e.g., heroin, marijuana)
  • Anabolic steroid use
  • Heavy smoking

Medications:  Certain medications can increase your risk of erectile dysfunction, including:

  • Antihypertensives
  • Antihistamines
  • Antidepressants
  • Tranquilizers
  • Antipsychotics
  • Histamine blockers
  • Nicotine

If you suspect a medication may be affecting your sexual functioning, talk with your doctor. Do not stop taking a medication without talking to your doctor first.

Reducing Your Risk of Erectile Dysfunction

A risk factor increases your chance of getting a disease. Some risk factors can be avoided, such as smoking. Other risk factors you may have no control over, such as your genetic make-up. If you have a risk factor for erectile dysfunction that you can and do change, you may reduce your risk.  To reduce your risk of becoming impotent:

  • Manage your medical conditions.
  • Talk to your doctor about changing medications.
  • Maintain a healthful diet and exercise program.
  • Quit smoking.
  • Do not use recreational drugs.
  • Consider counseling.

Manage Medical Conditions:  Some cases of erectile dysfunction are due to chronic diseases of the lungs, liver, kidneys, heart, nerves, arteries, or veins. With your physician’s help, you can manage conditions that could affect your ability to have an erection, such as high blood pressure, diabetes, cardiovascular disease, and depression.

Talk to Your Doctor About Medications:  If you suspect that your medications may be the problem, ask your doctor about changing or adjusting them. Medications for the following conditions are most commonly associated with erectile dysfunction as a side effect:

  • High blood pressure
  • Depression
  • Anxiety
  • Schizophrenia

Maintain a Healthful Diet and Exercise Program:   Eat a healthful diet, one that is low in saturated fat and high in fruits, vegetables, and whole grains. Begin and stick to a regular exercise plan. Choose exercises you enjoy and will make a regular part of your day. Strive to maintain an exercise program that keeps you fit and at a healthy weight. For many people, this includes walking or participating in an aerobic activity for 30 minutes per day. Exercise also can help you manage stress. Check with your doctor before starting any exercise program.

Quit Smoking:  Excessive tobacco use can also damage penile arteries. Quitting smoking reduces your risk of erectile dysfunction.

Do Not Use Recreational Drugs:Chronic use of alcohol, marijuana, or other drugs, like cocaine, speed, or heroin, often causes erectile dysfunction, along with decreased sexual drive.

Consider Counseling:  Psychological factors, such as stress, anxiety, and depression, account for 10%-5% of erectile dysfunction cases. Counseling can help you manage or prevent these emotions and interpersonal conflict. You may also want to try couples counseling.

Special Considerations:  Before quitting any medications, and even alcohol or tobacco if you are addicted, consult with your doctor about the safest way to do it.

Symptoms of Erectile Dysfunction

Penile erection is a complex interaction of both halves of your autonomic (automatic) nervous system, your blood circulation, and your emotions. Therefore, the patient may have symptoms suggestive of a psychological problem, such as depression, and/or a medical problem, such as diabetes. Any one of these conditions can lead to erectile dysfunction.
Symptoms include:

  • A less firm penis
  • Fewer erections
  • Fewer spontaneous nighttime erections

Your penis is made up of cylinders with tough linings. These linings can hold large amounts of blood at sufficient pressure to keep it stiff for a period of time. Normally, when stimulated either locally or from your emotions, blood vessels that empty your penis constrict. This prevents blood from exiting. Blood vessels inside your penis open to accept more blood.

Diagnosis of Erectile Dysfunction

The doctor will ask about your symptoms and medical history and will perform a physical exam. Be prepared to identify every medication you are taking. As many as 25% of erectile dysfunction cases are due to medications. Expect questions about the frequency, quality, and duration of your erections. Your answers may help determine if primarily psychological and/or physiological factors are causing your impotence.  The doctor will examine your penis, testes, and rectum. If a physical cause is suspected, laboratory tests may be ordered. The following factors will be evaluated:

Routine Laboratory Tests —Blood count, urinalysis, and a battery of blood chemistry tests will evaluate your general health.

Testosterone —If you are over 50 years old or if your doctor suspects hypogonadism (small testes and reduced bodily hair), a blood test for testosterone will be ordered.

Endocrine Tests —Other endocrine tests may be ordered such as: TSH, prolactin, and fasting blood sugar.

Nocturnal Erections —Potent men have spontaneous erections at night. If you do not remember them because you were asleep, there are devices that can measure and record them.

Psychology —There are always psychological factors associated with sexual functioning, whether they are the cause or just a result. You, and possibly your partner, may be given a questionnaire to help determine what emotional and psychological factors may be contributing to your condition.

Treatments for Erectile Dysfunction

The treatment and management of erectile dysfunction may involve medicine, psychological counseling, lifestyle changes, surgery, and attention to other medical conditions that may be causing sexual dysfunction.  The goal of treatment is to restore normal sexual function whenever possible and to discover alternatives to maintain or enhance the richness of your relationship.

Treatment may involve the following:

  • Lifestyle changes
  • Medications
  • Surgery
  • Other treatments

Medical treatments available for erectile dysfunction may include oral pills such as Viagra, Levitra, Cialis, urethral inserts, and injections.

Surgery is an option when all other efforts to restore or bypass your erectile dysfunction have failed. In fact, there are several possible alternatives that will permit you to have satisfactory sexual intercourse such as the penile implant.

Another treatment modality for erectile dysfunction is a vacuum constriction device, which involves a pump attached to an air-tight chamber that fits over your penis. This treatment, which can be used daily, is optimal for men who do not want or are not suitable for drug treatment. The blood is held there by a rubber-retaining ring around the base of your penis. The success rate is between 70%-94%.