Erectile Dysfunction

Erectile dysfunction in Young Men: Causes and treatments

You would automatically associate erectile dysfunction (ED) with older adults. But what if you’re a young man and suddenly start experiencing erectile problems?

Is there any difference between ED in older adults and young men? What can you do to recover from this problem?

In this article, we’re reviewing a concerning problem for many young men. Erectile dysfunction is not as rare as you may think. Its causes are usually not the same in young men. But depending on your particular case, you might benefit from one treatment or another.

Prevalence of ED

Erectile dysfunction is a type of sexual dysfunction. According to US statistics (1), around 50% of men experience at least a very slight degree of erectile difficulty. This is also sexual dysfunction and counts as ED, but it is only complete if:

  • The patient cannot achieve or maintain an erection after sexual stimulation

  • The patient does not have any nocturnal erections

Only 10% of US males have this type of complete erectile dysfunction. Moderate dysfunction affects around 25% of patients. Mild cases were reported in 17% of patients. The incidence increases after 40 years, with 34% of moderate ED and 15% of complete ED. In other words, as we age, our risk of erectile difficulties becomes higher.

But what about young men?

In a study performed in younger men, around 10% of them reported an episode of difficulty to achieve or maintain an erection during the past year. In other words, 1 out of 10 young males reports at least one case of erectile dysfunction every year (2). 

Still, the problem is highly underestimated. Most young men do not report this problem, especially in mild cases of ED. Doctors do not usually question their patients about it. So, the prevalence may be higher than we think, even in young patients. If you had a recent episode and feel worried about it, you’re definitely not alone. ED in young men is more common than you think.

Symptoms

How do you know that you actually have erectile dysfunction problems? Is it only about not achieving an erection? Not exactly. The problem is more complex than you think because different factors are associated.

For example, you may not feel aroused at this particular moment. Without sexual arousal, erections may not be as hard, and sometimes there’s no erection at all.

An excellent way to identify if you really have ED problems is by considering this list of ED symptoms:

  • Not being able to achieve penetration: You may achieve a very weak erection every time you try. When it is not suitable for penetration, it is more likely ED.

  • Worsening erectile problems: It is also important to evaluate how ED is progressing. Sudden-onset ED could be a temporary problem. Worsening erection problems over a long period are usually more severe.

  • Recurrent sexual dysfunction: It is critical to assess for how long you’ve had this problem. Is it always happening to you? Or is it just a momentary event? More severe cases feature recurrent and prolonged problems achieving erections.

  • Short-lived erections: In some cases, patients with ED report achieving a relatively hard erection. But they are not able to maintain an erection through the climax. They may fail to achieve ejaculation or cannot experience an orgasm.

  • No morning or nocturnal erections: In complete erectile dysfunction, nocturnal and morning erections are gone. Throughout the night, we can have several erections. This is also known as nocturnal penile tumescence. You may not feel a morning erection but have a completely normal penile tumescence at night.

  • Ejaculation problems: Some patients with erectile dysfunction also have ejaculation problems. It can be premature ejaculation or pain during ejaculation. Thus, it is important to mention this symptom to your doctor for a more complete assessment.

  • Penile curvatures: There’s a medical condition known as Peyronie’s disease. This is a curvature in the penis caused by fibrous tissue. It is more evident during erections. Patients with Peyronie’s disease usually have associated erectile dysfunction problems.

  • Unsatisfactory sexual experience: Erectile dysfunction is associated with sexual dissatisfaction. This is both a consequence and sometimes a cause of ED. For example, not being able to satisfy your partner may lead to anxiety and erectile dysfunction. Having past unsatisfactory sexual experiences may lead to a decrease in sexual arousal and no erectile function.

  • Anxiety, depression, and major life events: Patients may experience erectile problems when they go through significant life events or stressful moments. Thus, it is important to assess depression, anxiety, and stress. They are particularly prevalent in cases of sudden-onset erectile dysfunction.

To evaluate your symptoms and gather objective data, your doctor may use a formal questionnaire. Each one of them has different items you should answer. In the end, you will be given an erectile dysfunction score. The most common questionnaires used in clinical settings include (3,4):

  • Sexual Encounter Profile

  • International Index of Erectile Function

  • Self-Esteem and Relationship Questionnaire

Causes of erectile dysfunction in young men

The cause of erectile dysfunction in men can be divided into two main branches. First, we have psychogenic causes such as performance anxiety and depression. The second type is organic causes, which usually include vascular disease or structural problems.

Psychogenic causes are easily identified because they have a sudden onset, and the quality of self-stimulated or spontaneous erections is acceptable. Organic causes have a more gradual onset, and libido can be low or average (5).

Psychogenic causes

  • Depression and anxiety: ED and depressive symptoms share a very close link. Men who look for ED treatment usually have a more severe problem if they also suffer from depression. This relation is a two-way street because ED is a predictor of depression, and depression can also be a predictor of ED. Erectile function and sexual behavior are influenced by self-confidence. Thus, patients with performance anxiety and depression may have it difficult. At the beginning of sexual life, performance anxiety can be very common in young men. This may adversely affect the erection and their sexual arousal. After failed sexual experiences, performance anxiety may increase, and the patient enters into a vicious cycle.

  • Relational problems: Erectile dysfunction can be associated with a deterioration of a couple’s relationship. Conflicts with your sexual partner may lead to mild, moderate, or severe erectile issues. It could be emotional problems or sexual dissatisfaction. It could be associated with pain during sexual intercourse. In very young men, the problem may not be a deterioration of the relationship. Instead, it can be related to lack of experience, concerns for pregnancy, limited privacy, or feeling fear of emotional involvement. Either way, relational problems may lead to recurrent failures in sexual life. This affects the relationship even more and leads to another vicious cycle.

Organic causes

  • Neurologic problems: The parasympathetic system plays a significant role in erections. Thus, neurologic problems can also affect erectile function in many ways. For example, it is common to see erectile dysfunction in patients with epilepsy or multiple sclerosis. After a lumbar spine procedure, patients can also start experiencing ED. There’s nerve disfunction in multiple sclerosis, stress related to the disease, and endothelial dysfunction caused by inflammation. In patients with epilepsy, there’s a complex mix of endocrine, psychiatric, and psychosocial factors. After a spine procedure such as lumbar spine decompression, around 35% of patients have nerve damage. They may develop a persistent type of sexual dysfunction (6).

  • Structural conditions: In young men, the most common structural problems include occlusive problems in the arteries, endothelial dysfunction, and Peyronie’s disease. Perineal trauma can change the way arteries work to supply the penis. Thus, some bicycle riders have had erectile dysfunction problems due to subclinical trauma. Subclinical endothelial dysfunction is probably due to inflammation. High cholesterol and triglyceride levels, high blood pressure, and elevated C-reactive protein are all risk factors. These patients do not develop cardiovascular problems but are predisposed to them as well. Peyronie’s disease is apparently caused by recurrent trauma to the tunica albuginea of the penis. This leads to fibrous tissue formation that causes penile curvature. 21% of young patients with Peyronie’s disease have erectile dysfunction (7).

How does age affect ED?

In contrast to young males, aging men usually have different causes of ED. In most cases, it is associated with endocrine dysfunction. More specifically, with a low testosterone problem.

The risk of hypogonadism and low testosterone increases as we age. Up to 40% of men have low testosterone levels after 45 years of age. They experience low testosterone symptoms in different degrees, depending on various factors. This hormone is critical to maintaining bone health, vitality, cognition, and erectile function in males. It also contributes to ejaculations, libido, and overall sexual behavior (8).

Low testosterone triggers a series of processes, all of them leading to erectile dysfunction. For example, testosterone turns into a more active substance called DHT or dihydrotestosterone. Through this substance, it stimulates many cells to create new substances. One of these cells is the endothelium, where DHT is postulated to boost nitric oxide production. This substance is a powerful vasodilator. It facilitates blood flow and contributes to powerful erections. It is also associated with intracavernosal pressure.

Not having enough testosterone leads to low DHT levels and low stimulation of nitric oxide production. This causes endothelial dysfunction, which affects different organs, including the penile tissue. In the penis, intracavernosal pressure is reduced. This space usually fills with blood, and pressure is fundamental to maintain an erection. Thus, a significant reduction would be translated into failed or weak erections.

Another aspect of erectile dysfunction as we age is medication use. Several medications increase the risk of ED, and we take them more often as we age. For example, finasteride, antidepressants, neuroleptics, and some non-steroidal anti-inflammatory drugs.

Even so, antidepressants may improve the patient’s mood and bring back erectile function. Thus, instead of pointing to a drug as the cause of erectile dysfunction, your best choice is to talk to your doctor. Communicate your concerns about your medications and ask his opinion and suggestions before deciding on discontinuing your treatment.

Complications

The most common consequences of erectile dysfunction include:

  • Relational problems: This is the most common complication of erectile dysfunction. Patients usually do not talk about this openly to their sexual partners. Thus, this gives rise to misunderstandings and a progressive worsening of the relationship. Many couples need to go through therapy to understand what is happening and what each one can do.

  • Depression: Depressive symptoms can be both a consequence or a trigger of ED. Every failed attempt feeds a sense of guilt and self-devaluation that may lead to sadness or depression. In depressed patients, ED is more severe. Thus, this is a never-ending vicious cycle that we should identify and treat promptly.

  • Performance anxiety: It is particularly common in young men who are starting their sexual life. They feel not sure about themselves and how to please their partner. Failed attempts and past ED problems feed this insecurity and lead to increased performance anxiety. They may start feeling insecure about their physical appearance and sexual traits, and this also contributes to feeling anxious. Adrenaline released in anxious episodes can be an erection killer, even in a healthy young man.

  • Premature ejaculation: This is a common problem associated with ED. It is not always clear how they work together, but it is likely due to anxiety and psychogenic factors. 

  • Male hypoactive sexual disorder: Patients with ED usually report a lack of sexual interest. It can be due to relational problems with their partner or with sex in general. It is important to evaluate patients with male hypoactive sexual disorder and ED to know which condition led to the other.

Besides these complications, other morbidities are also associated with erectile dysfunction.

According to some authors, men with ED have an increase in cardiovascular risk and all-cause mortality. Their chance of developing cardiovascular problems is significantly higher. The risk increase is similar to that of smoking and familiar history of heart problems. This risk has been evaluated by many studies and meta-analyses of more than 90,000 patients.

According to this data, they had a 44% higher chance of cardiovascular events, a 64% higher chance of myocardial infarction, and a 39% higher chance of stroke (9).

Treatments

Your doctor will only prescribe treatment after evaluating your case and figuring out the causes of erectile dysfunction. It may also be important to include your partner in the discussion.

An essential part of the treatment will be convincing you that sex is much more than erections. You can enjoy sex in many different ways, even if you don’t achieve an erection every now and then.

There are many options available for different patients. However, most young men will be fine with one of these or a combination (10):

  • Sexual counseling: This is the most common treatment. It is vital to learn how to enjoy sex, even when erections are not achieved. Your doctor may give you recommendations to relieve performance anxiety and similar issues.

  • Psychologic therapy: When no organic cause is encountered, it is considered psychogenic ED. The treatment may not require any drugs at all. In severe cases with no organic reason, you might need psychological therapy. It is helpful to relieve anxiety and treat depression.

  • Couple therapy: This step is fundamental if you’re experiencing couple-related problems. It is also essential to communicate with your couple about erectile dysfunction and find alternative ways to enjoy sex in these circumstances.

  • Oral medications: In many cases, oral drugs (PDE5 inhibitors) are recommended at the therapy’s starting phase. But in young patients, ED medications are usually discontinued after a while.

More medical therapy is available, especially for organic causes of impotence. They include external vacuum devices and invasive treatment. An external vacuum device uses negative pressure to inflate the penis with blood. Invasive therapy includes revascularization surgery and penile implant placement. They are only considered as a last resource for erectile dysfunction.

Penile injections are considered as an alternative in cases of severe ED. Testosterone replacement therapy is considered in cases of hypogonadism. Careful control of the underlying disease is vital in cases of diabetes, metabolic syndrome, and other chronic diseases. In a patient with prostate cancer who had a radical prostatectomy, ED rehabilitation is prescribed to recover their sexual function. 

Conclusion

Sexual activity is a fundamental part of a young man. However, erectile dysfunction problems are more common than we think. In young males, they are usually due to psychogenic causes such as performance anxiety and depression. Only a few cases can be triggered by organic causes such as vascular problems and Peyronie’s disease.

Treatment for these patients usually includes psychologic counseling, sexual counseling, and sometimes oral therapy. Only a few cases will require more complex treatment, such as testosterone replacement, penile injections, or surgical options.

Sources

  1. Mulligan, T., Frick, M. F., Zuraw, Q. C., Stemhagen, A., & McWhirter, C. (2006). Prevalence of hypogonadism in males aged at least 45 years: the HIM study. International journal of clinical practice, 60(7), 762-769.
  2. Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States: prevalence and predictors. Jama, 281(6), 537-544.
  3. Althof, S. E., Corty, E. W., Levine, S. B., Levine, F., Burnett, A. L., McVary, K., … & Seftel, A. D. (1999). EDITS: development of questionnaires for evaluating satisfaction with treatments for erectile dysfunction. Urology, 53(4), 793-799.
  4. Derby, C. A., Araujo, A. B., Johannes, C. B., Feldman, H. A., & McKinlay, J. B. (2000). Measurement of erectile dysfunction in population-based studies: the use of a single question self-assessment in the Massachusetts Male Aging Study. International journal of impotence research, 12(4), 197-204.
  5. Nguyen, H. M. T., Gabrielson, A. T., & Hellstrom, W. J. (2017). Erectile dysfunction in young men—a review of the prevalence and risk factors. Sexual medicine reviews, 5(4), 508-520.
  6. Siddiqui, M. A., Peng, B., Shanmugam, N., Yeo, W., Fook-Chong, S., Tat, J. C. L., … & Yue, W. M. (2012). Erectile dysfunction in young surgically treated patients with lumbar spine disease: a prospective follow-up study. Spine, 37(9), 797-801.
  7. Ludwig, W., & Phillips, M. (2014). Organic causes of erectile dysfunction in men under 40. Urologia internationalis, 92(1), 1-6.
  8. Mulligan, T., Frick, M. F., Zuraw, Q. C., Stemhagen, A., & McWhirter, C. (2006). Prevalence of hypogonadism in males aged at least 45 years: the HIM study. International journal of clinical practice, 60(7), 762-769.
  9. Vlachopoulos, C., Aznaouridis, K., & Stefanadis, C. (2010). Prediction of cardiovascular events and all-cause mortality with arterial stiffness: a systematic review and meta-analysis. Journal of the American College of Cardiology, 55(13), 1318-1327.

McMahon, C. G. (2019). Current diagnosis and management of erectile dysfunction. Medical Journal of Australia, 210(10), 469-476.

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