For some time, erectile dysfunction (ED) was termed impotence. Throughout that time and now, it has prompted the same feelings in men. Sexual anxiety and frustration are common in these patients, even in transient ED.
Erectile dysfunction diagnosis is not always easy, but not because it is a multi-step or very complex process. It is because men are often hesitant and avoid the topic, even if they are anxious.
In this article, we’re reviewing the topic thoroughly. First, we’re covering the normal physiology of erections and how they work. After defining erectile dysfunction, we’re also discussing the signs, symptoms, and causes.
If you’re worried about ED, you will rest assured after reading about the diagnostic steps your doctor will likely take and the treatment options available to recover your erectile function.
How erections work
The first step to understanding erectile dysfunction is to know how erections work. It is essential to get a grasp of the penile structures that participate in erectile function.
Penile arteries and veins are essential here because what triggers an erection is blood accumulated in the penis. The most crucial artery in the penis is known as the common penile artery. It is a branch of a larger artery known as the internal pudendal artery.
The common penile artery has three branches: a dorsal branch, a bulbourethral branch, and a cavernous branch. The bulbourethral artery provides oxygen and nutrients to the corpus spongiosum and the bulb. But the dorsal artery and the cavernous artery are both crucial for erection. The dorsal artery increases the size of the glans. The cavernous artery fills the corpus cavernosum with blood. When this structure fills with blood, we get penile engorgement and a successful erection.
All of this is controlled by different nerves that work together to achieve an erection. The names of the nerves are similar. There’s a dorsal nerve of the penis, which comes from the pudendal nerve. It also branches into cavernosal nerves and others, bringing autonomic nerve fibers to the penis. These nerves reach the corpora cavernosa after traveling behind the prostate gland to each side.
Through an exchange of neurotransmitters and nerve impulses, these nerves regulate the blood flow in the penis. They are also responsible for providing a sensation to the penis and taking this information to the brain. Certain regions in the brain modulate erections. This includes the anterior hypothalamic nuclei, the paraventricular seat, and the medial preoptic center.
In a nutshell, to achieve an erection, we need several structures:
- Vascular structures: They will increase the blood flow and trap the blood in the corpus cavernosum.
- Nervous structures: Autonomic and sensitive nerves for sexual stimulation and blood flow regulation.
- Penile structures: Especially the corpus cavernosum, a pair of sponge-like regions that fill with blood during erections.
What is erectile dysfunction?
Erectile dysfunction is the inability to achieve a penile erection or maintain it. There are different types of erectile dysfunction, and each man with ED can have their own characteristics. In some cases, it will be temporary, while other patients are entirely unable to achieve an erection. In some patients, erection happens, but it is weak and penile engorgement is not enough for penetration. Still, others experience a relatively normal erection, but then it goes away and does not come back.
Each one of these cases should be evaluated separately. Some of these patients may have a psychogenic case of ED. Others may have vascular or nervous problems. Prostate surgery to take out prostate cancer can also trigger a case of ED. Sometimes, it will be a combination of different factors working together in one patient.
However, the effect is almost the same in these patients: it impacts self-esteem, the patient’s relationship with his partner, and his quality of life.
There are four main symptoms of erectile dysfunction.
Difficulty in achieving an erection
This is the classic presentation of erectile dysfunction. A man who cannot achieve an erection. This may happen most of the time or always, depending on the cause of erectile dysfunction.
Incomplete or weak erections
These men have an erection and proper sexual stimulation, but it is weak or insufficient to achieve penetration. This causes frustration and anxiety, worsening the problem still.
Difficulty to maintain an erection
Some men have a relatively normal erectile function, but it lasts for a very short time. After achieving penetration, they cannot keep the erection long enough for satisfactory sexual performance.
A reduction of sexual desire
Not having the motivation or a drop of libido is also a symptom of erectile dysfunction. In this case, hormonal problems and psychogenic causes should be ruled out.
Anyone can experience one of the symptoms above at least once in their lifetime. However, it is not always a real case of erectile dysfunction. According to the DSM-5 criteria, an erectile disorder should have these characteristics:
- The symptoms above are experienced in 75% of all sexual activity or more
- The problem is maintained for a long time, a minimum of 6 months
- Erectile issues are causing frustration or distress to the affected man or his partner
- There is no apparent reason (medication, relationship problem, stress, or medical conditions) causing these symptoms.
Still, if you experience erectile issues and they start making you feel frustrated or concerned, that is enough to look for medical help. Doctors may need to rule out several causes to evaluate the best way to solve the problem.
Before you go to the doctor, it is vital to evaluate your symptoms and gather some information. Ask yourself these questions:
- How often do I have this problem? Is it happening to me in 75% of all sexual encounters or more?
- When did I start experiencing ED? Is there any trigger I can trace?
- Is it an acquired problem or a lifelong condition since my first sexual experience?
- Is it more common with a partner or type of sexual encounter?
- Does a given situation or place make it more common?
- When I masturbate, do I have this problem?
- Do I wake up with an erection from time to time?
As noted above, erectile dysfunction has many causes, and there is often more than one at play in each patient. It is a multifactorial issue, meaning that different factors contribute to the problem.
In different parts of this article, we mentioned the importance of psychological factors. We also discussed hormones and how different structures need to remain intact for an erection to take place. With that in mind, let’s examine the causes of ED more closely and one by one:
Chronic health conditions
A variety of chronic health diseases can trigger erectile dysfunction. We can take diabetes, for example. In these patients, a high blood sugar level slowly interferes with blood vessels and nerves. The small arteries fail in their attempt to deliver enough blood flow. Some nerves become very weak or disconnected from their target areas. Thus, not having intact blood vessels or having a nerve problem interrupts and impairs the erection function. Other chronic diseases can also impair erectile function. For example, hypertension, depression, sleep problems, and chronic obstructive pulmonary disease. Rheumatoid arthritis and painful conditions may indirectly affect a man’s libido and interest in sex.
Vascular problems trigger the majority of organic ED cases. It accounts for around 50% of all ED in men over 50 years. The most common vascular problem is atherosclerosis, which reduces the blood flow to the penis and other organs. Arterial hypertension and similar health problems can cause vascular damage and impair erectile function. Similarly, receiving radiation therapy in the pelvis (cancer treatment) can potentially damage these blood vessels.
It is the cause of erectile dysfunction in many young bicycle riders. They have a compression of the perineum for hours, and some bicycle seats cause nerve injury and vascular damage. In these patients, changing the bicycle seat could protect them from having ED.
Sex and sex hormones have a very close relationship. Low testosterone levels can reduce libido and impact erectile function. Hypogonadism and a very low testosterone level are usually associated with ED. Another endocrine problem that causes ED is hypothyroidism. It is somewhat rare because thyroid problems are not as common in males as in women.
Structural problems in the penis can also interfere with erections. One of the most common is Peyronie disease. In this case, there is scar tissue in the penis or fibrosis. It causes a visible and abnormal curvature of the penis. In severe cases, scar tissue is also found in the corpora cavernosa. It causes blood flow problems and erectile problems.
Psychological causes are critical, especially in patients with ED. Sexual anxiety is a common cause of ED and affects men and their partners. Depression is another common cause of ED, and it feeds off ED in an endless loop. Posttraumatic stress disorders can also lead to sexual dysfunction, including ED.
As noted in the anatomy and physiology section of the article, the cavernous nerves run along the prostate before entering the penis. Many patients have irreversible ED after prostate surgery. New surgical methods are designed to spare nerves from damage in young patients. However, even in these cases, temporary erectile problems are still common. This happens because the nerves are spared but suffer a temporary stretch and need to recover. Penile rehabilitation is available for these patients to regain their erectile function.
Certain medications can trigger or worsen erectile problems. Certain antihypertensive and psychotropic drugs are on the list. Extended treatment with finasteride, dutasteride, or alpha-blockers can also lead to posttreatment ED in some people.
The most common lifestyle causes of ED are obesity and smoking. Obesity may reduce our circulating testosterone levels and is associated with diabetes and other health conditions that trigger ED. Smoking causes severe inflammation and vascular problems that contribute to ED.
Many patients are hesitant to talk about erections with the doctor because they picture uncomfortable testing and studies. However, in most cases, the diagnosis is solely based on the clinical findings. In other words, your doctor will not likely need any uncomfortable test to diagnose erectile dysfunction.
Depending on the cause, you may need laboratory tests or an imaging study if you had pelvic trauma or previous surgery. Another exam to assess erectile function is the nocturnal penile tumescence testing, which can be completed at home using an electronic device. It is not routinely done, though, and only required when the diagnosis is uncertain.
Thus, there is no reason to fear. The most likely scenario is a conversation with your doctor, an accurate description of your symptoms, and following recommendations or different treatment options to solve the problem.
No matter how bad is your erectile problem, it has a solution. There is a multi-step treatment protocol in which doctors use less invasive methods first. If they do not work, they use other methods after considering the options with their patient.
The treatment ladder goes like this:
It is imperative in patients with ED. They can enjoy sexual intercourse without penetration, and sexual counseling is meant to find alternatives and solutions to the psychological causes of ED. Depending on the case, it can be personal or couple therapy.
Certain modifications in our lifestyle and habits may also impact our sexual life. Quit smoking, exercising, practicing with Kegel exercises to strengthen your pelvic floor, and adjusting your expectations around sex can be helpful to improve ED.
This is appropriate when the cause of ED is related to hormones, usually testosterone.
They are perhaps the most common treatments for erectile problems. It is usually phosphodiesterase type 5 (PDE5) inhibitors such as sildenafil (Viagra) and others.
When oral medication is insufficient, it is possible to use penile injections for faster and stronger erections. It sounds terrible and painful, but the needle is very thin and designed for that.
External vacuum devices
They pump blood mechanically into the cavernous bodies.
It is invasive therapy and only recommended when no other option effectively solves the problem. It includes revascularization surgery, which improves the blood flow to the penis or a penile implant (penile prosthesis).
Erectile dysfunction is a multifactorial problem, and different risk factors are often at play in the same patient. Cardiovascular disease and surgery for prostate cancer or benign prostatic hyperplasia can result in penile erection problems. Thus, when diagnosing erectile dysfunction, prostate surgery (radical prostatectomy) should be considered one of the causes.
However, it is possible to regain our sexual function with ED treatment. Different types of treatment are available for different kinds of patients. It all depends on the diagnosis of erectile dysfunction and the identification of the leading cause.
In most cases, the erectile dysfunction diagnosis is straightforward and does not require any imaging test or invasive procedure. You may need a lab exam or two, and only tricky cases require more advanced diagnostic methods.