The Call-On-Doc Guide to Erectile Dysfunction

The causes of erectile dysfunction range from person to person, with each typically being categorized as physical, psychological, or lifestyle. It can be due to a chronic condition, lifestyle choices, a physical ailment, mental health and wellness related, or a cause that combines all of these factors. (2) The most common of each cause includes:

Physical causes

• Cardiovascular diseases and conditions: Erectile dysfunction and heart disease share a common connection through atherosclerosis, the buildup of plaque in the arteries. Atherosclerosis can occur in the blood vessels of the heart, leading to coronary artery disease, and it can also affect the blood vessels that supply the penis. The narrowing and hardening of these blood vessels can restrict blood flow, reducing the ability to achieve and maintain an erection. Therefore, ED can serve as a potential warning sign of underlying cardiovascular disease, making it important for men with ED to consider a comprehensive evaluation for their heart health. (3)
• Diabetes: Erectile dysfunction and diabetes are interconnected due to the damaging effects of diabetes on blood vessels and nerves. Diabetes can lead to nerve damage (neuropathy) and impaired blood flow, affecting the ability to achieve and sustain erections. High blood sugar levels can also disrupt hormonal balance and decrease libido, further contributing to ED. Additionally, the longer a person has diabetes and the poorer their blood sugar control, the higher the risk of developing ED. (4)
• Hormonal imbalances: Hormone imbalances can contribute to erectile dysfunction by disrupting the delicate hormonal interplay necessary for optimal sexual function. Testosterone, the primary male sex hormone, plays a crucial role in libido and erectile function. Insufficient testosterone levels can lead to reduced sexual desire and impaired ability to achieve and maintain erections. Conversely, imbalances in other hormones, such as thyroid hormones or cortisol, can also affect sexual function indirectly by causing fatigue, mood disturbances, or systemic health issues that contribute to ED. (5)
• Neurological disorders: Neurological disorders and erectile dysfunction are connected through the intricate relationship between nerve function and sexual response. Neurological conditions such as multiple sclerosis, Parkinson's disease, and spinal cord injuries can disrupt the transmission of nerve signals necessary for achieving and maintaining an erection. Nerve damage or dysfunction can impair the brain's ability to send appropriate signals to the penile nerves, affecting blood flow and erectile function. (6)
• Obesity: Obesity and erectile dysfunction are connected through multiple mechanisms. Excess weight can lead to cardiovascular problems, including atherosclerosis, which restricts blood flow to the penis and impairs erectile function. Obesity is also associated with hormonal imbalances, such as lower testosterone levels, which can contribute to ED. Additionally, obesity can lead to psychological factors like low self-esteem, body image issues, and reduced sexual confidence, which may further contribute to ED. (7)
• Certain medications: Certain medications and erectile dysfunction can be connected as some drugs may have side effects that affect sexual function. Medications used to treat conditions like high blood pressure, antidepressants, antipsychotics, and prostate conditions can potentially cause or worsen ED. These medications may interfere with nerve signals, blood flow, or hormone levels involved in achieving and maintaining erections. It's important to discuss any concerns about medication-related ED with a healthcare provider who can explore alternative medications or adjust dosages to minimize this side effect.
• Peyronie's disease: Peyronie's disease is a condition characterized by the development of fibrous scar tissue, or plaques, in the penis. These plaques can cause penile curvature, pain, and erectile dysfunction. The curvature resulting from Peyronie's disease can make sexual intercourse challenging or uncomfortable. Additionally, the presence of the plaques can disrupt normal blood flow within the penis, affecting the ability to achieve or maintain an erection. 
• Sleep disorders: Sleep disorders and erectile dysfunction are connected through various physiological and psychological factors. Sleep disorders, such as sleep apnea or insomnia, can disrupt hormone production, including testosterone, which is crucial for sexual function. Sleep deprivation can lead to fatigue, decreased libido, and reduced sexual performance. Additionally, psychological effects such as increased stress, anxiety, or mood disturbances caused by sleep disorders can contribute to ED. (8)
• Chronic kidney disease: Kidney disease and erectile dysfunction can be connected due to the impact of kidney disease on multiple bodily systems. Kidney disease can lead to hormonal imbalances, including decreased testosterone production, which can contribute to ED. Reduced kidney function can also result in the accumulation of waste products and toxins in the body, leading to damage to blood vessels and nerves involved in penile function. Additionally, certain medications used to manage kidney disease or associated conditions may have side effects that affect sexual function.
• Chronic liver disease: Liver disease can cause hormonal imbalances, such as reduced testosterone levels, which can contribute to ED. Liver dysfunction can also impact the metabolism and clearance of medications, potentially affecting their effectiveness or causing side effects that affect sexual function. Additionally, liver disease can lead to the accumulation of toxins in the body, which can damage blood vessels and nerves involved in achieving and maintaining an erection. 

Psychological causes

• Stress and anxiety: Stress and anxiety can contribute to erectile dysfunction by affecting the release of hormones, increasing muscle tension, and reducing blood flow to the penis, making it more difficult to achieve or maintain an erection. Additionally, the psychological impact of stress and anxiety can further exacerbate ED by causing performance anxiety and reducing sexual desire.
• Depression: Depression can contribute to erectile dysfunction by affecting neurotransmitters in the brain that are involved in sexual arousal and function, leading to reduced libido and difficulties in achieving or sustaining erections. Additionally, the emotional and psychological toll of depression, such as feelings of sadness, hopelessness, or low self-esteem, can further impact sexual desire and performance.
• Relationship problems or conflicts: Erectile dysfunction can be caused by relationship problems or conflicts due to the emotional stress, anxiety, and reduced intimacy that can result from such issues. Negative emotions, lack of communication, and unresolved conflicts can contribute to performance anxiety, decreased sexual desire, and difficulties in achieving or maintaining erections.
• Performance anxiety: Erectile dysfunction can be caused by performance anxiety, as the fear or pressure to perform sexually can trigger stress and anxiety, leading to difficulties in achieving or sustaining an erection. Performance anxiety creates a cycle of worry and self-doubt that can interfere with the natural physiological responses needed for successful sexual function.
• Low self-esteem: Low self-esteem can lead to erectile dysfunction by contributing to feelings of inadequacy, anxiety, and self-doubt, which can create psychological barriers to sexual arousal and performance. Negative self-perception can interfere with confidence, intimacy, and overall sexual satisfaction, impacting the ability to achieve and maintain erections.

Lifestyle factors

• Sedentary lifestyle and lack of exercise: A sedentary lifestyle and lack of exercise can contribute to erectile dysfunction by promoting obesity, reducing cardiovascular health, and impairing blood flow to the penis. 
• Poor diet and nutrition: Poor diet and nutrition can lead to erectile dysfunction by contributing to obesity, cardiovascular problems, and impaired blood flow, which are all essential factors for healthy erectile function. A diet high in processed foods, saturated fats, and refined sugars can negatively impact overall vascular health, hormone levels, and the body's ability to respond to sexual stimuli, affecting the quality of erections.
• Substance abuse: Substance abuse can lead to erectile dysfunction by affecting the nervous system, blood flow, and hormone levels in the body. Substance abuse, such as illicit drug use, can damage blood vessels, impair nerve function, and disrupt hormonal balance, all of which can contribute to difficulties in achieving or maintaining erections.
• Excessive alcohol consumption: Excessive alcohol abuse can lead to erectile dysfunction by inhibiting the production of nitric oxide, a chemical necessary for the relaxation of blood vessels in the penis, resulting in reduced blood flow and difficulties in achieving or sustaining an erection. Additionally, chronic alcohol abuse can disrupt hormone levels, including testosterone, further contributing to erectile dysfunction.
• Smoking: Smoking can lead to erectile dysfunction by causing damage to blood vessels and reducing blood flow to the penis, making it more difficult to achieve and maintain an erection.
   

While the prevalence of ED tends to increase with age, it is not solely attributed to aging itself. Rather, age-related factors such as underlying health conditions, medication use, lifestyle choices, and hormonal changes can contribute to the development of ED. The aging process can impact various physiological aspects involved in achieving and maintaining an erection, such as reduced blood flow, nerve sensitivity, and hormonal fluctuations. However, many older individuals maintain satisfactory sexual function throughout their lives. 

Recognizing erectile dysfunction involves observing certain signs and symptoms related to your sexual health. Here are some indicators that may suggest the presence of ED:

• Difficulty achieving or maintaining an erection: If you consistently struggle to achieve or sustain an erection sufficient for sexual intercourse. This struggle may involve an inability to achieve an erection altogether even with stimulation or the inability to sustain it long enough for satisfactory sexual intercourse.
• Reduced sexual desire or libido: A noticeable decrease in your interest or desire for sexual activity even in an environment where it is possible.
• Inconsistent or unsatisfactory erections: If your erections are inconsistent, unpredictable, or not firm enough to engage in satisfying sexual activity. 
• Emotional or psychological distress: ED can cause feelings of frustration, embarrassment, or anxiety surrounding sexual performance.

• Medical history: A doctor reviews a patient's medical history to gain insight into potential underlying causes and contributing factors that may lead to the development of ED. The doctor will then inquire about any existing medical conditions, such as diabetes, heart disease, high blood pressure, or hormonal imbalances. They will also ask about any previous surgeries or treatments that could affect blood flow or nerve function. Medication history is crucial, as certain medications, including antidepressants, antihypertensives, or prostate medications, can contribute to ED as a side effect. Additionally, the doctor will explore the patient's psychological well-being, including any stress, anxiety, or relationship issues that may be influencing sexual function. (9)
• Physical examination: The doctor may examine the genitals, specifically the penis and testicles, to check for any abnormalities or signs of underlying conditions. They may also assess the blood flow in the penis using a handheld Doppler ultrasound device to evaluate the integrity of the blood vessels. The physical exam may also include an evaluation of the patient's cardiovascular health, such as checking blood pressure and listening to the heart, as cardiovascular conditions can often be associated with ED. (10)
• Blood tests: These blood tests involve analyzing hormone levels, particularly testosterone, as low testosterone levels can affect sexual function. Low T levels are the number one contributor to ED, so if you have struggled with erectile dysfunction for a longer period of time, checking your testosterone levels might be a good starting point for long term resolution. The doctor may also check for markers of underlying medical conditions such as diabetes, high cholesterol, or cardiovascular disease, which can impact erectile function. Additionally, the blood tests may help identify any abnormalities in liver or kidney function that could be associated with ED. (10)
• Psychological assessment: The doctor may ask questions about the patient's overall mental and emotional well-being, including any stress, anxiety, depression, or relationship issues. They may explore the patient's sexual history and experiences, as well as their attitudes and beliefs surrounding sexuality. This assessment helps the doctor identify any psychological factors that could be influencing the development or maintenance of ED, such as performance anxiety, body image concerns, or intimacy issues. (11)

In some cases, additional tests may be recommended to further evaluate the specific cause of ED. These may include:

• Injection test: Helps with erectile dysfunction by inducing an erection to evaluate the response. It allows the doctor to assess the vascular and nerve function involved in achieving and maintaining an erection, helping to determine if the cause of erectile dysfunction is primarily due to physiological factors or if there is an underlying psychological component. (13)
• Nocturnal penile tumescence test: Helps with erectile dysfunction by assessing the frequency, quality, and duration of nighttime erections. It provides valuable information about the physiological aspect of erectile function and can help determine if the cause of erectile dysfunction is primarily physical or psychological in nature. (13)
• Ultrasound: An ultrasound can help with erectile dysfunction by evaluating the blood flow to the penis and identifying any structural or vascular issues that may be contributing to the condition. It provides a visual assessment of the blood vessels and can help determine if there are any abnormalities or blockages that may affect the ability to achieve or maintain an erection. (12)
• Urinalysis: A urinalysis may be part of a general health assessment, helping to identify any underlying medical conditions, such as diabetes or kidney disease, which can contribute to ED. (12)

A persistent inability to achieve or maintain an erection that is adequate for sexual activity persisting for at least half a year or six months. Throughout the six month minimum, at least 75% of all erections must fit the criteria of having too little rigidity in environments where sex is possible, being incapable of maintaining an erection throughout sexual activities, or being incapable of achieving an erection in general. The current iteration of the DSM (DSM-5) further describes biological and psychological factors that contribute to erectile dysfunction, how the condition is assessed and then treated. (14)

Lifestyle changes: With how they promote normalizing blood flow and circulation, making the following lifestyle changes are known to benefit those with erectile dysfunction: 
Regular exercise: Engaging in regular physical activity, such as aerobic exercises, can improve blood circulation, promote cardiovascular health, and enhance overall sexual function.

• Healthy diet: Adopting a balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats can support overall well-being and vascular health, which is essential for erectile function.
• Weight management: Maintaining a healthy weight or achieving weight loss, if necessary, can positively impact ED, as obesity is associated with an increased risk of vascular and hormonal issues that can contribute to erectile difficulties.
• Stress management: Chronic stress can contribute to ED. Implementing stress-reduction techniques such as relaxation exercises, meditation, talk-therapy, and engaging in hobbies that bring joy can help alleviate stress and improve sexual performance.
• Limiting alcohol and tobacco use: Excessive alcohol consumption and smoking can have detrimental effects on erectile function. Reducing alcohol intake and quitting smoking can improve overall vascular health and sexual function.

Oral medications: Most erectile dysfunction prescriptions are PDE5 (phosphodiesterase type 5) inhibitors because PDE5 is an enzyme that plays a crucial role in regulating blood flow to the penis. By inhibiting the action of PDE5, these medications promote the relaxation of blood vessels and increase blood flow to the penis, thereby helping to achieve and maintain an erection. The following oral medications in this category have proven to be effective. 

• Cialis
• Vardenafil
• Viagra

Penile injections or suppositories: Penile injections are a treatment option for erectile dysfunction (ED) that involves injecting medications directly into the base or side of the penis. The most commonly used medication for these injections is alprostadil, a vasodilator that helps relax the smooth muscles and increase blood flow to the penis, leading to an erection. 

Psychotherapy: specifically cognitive-behavioral therapy (CBT) or sex therapy, can be an effective treatment approach for erectile dysfunction, particularly when psychological factors are contributing to the condition. Psychotherapy aims to address underlying emotional and psychological issues that may be causing or exacerbating ED. It helps individuals identify and modify negative thoughts, beliefs, or behaviors related to their sexual performance, reduces performance anxiety, enhances communication and intimacy in relationships, and provides strategies to manage stress or relationship conflicts that may impact sexual function.

Surgical interventions: In severe cases or when other treatments are ineffective, surgical options like penile implants or vascular surgery to improve blood flow may be considered.

Testosterone replacement therapy: TRT can help improve ED symptoms by increasing testosterone levels in the body. By optimizing hormone levels, TRT can enhance sexual desire, increase the frequency and quality of erections, and improve overall sexual satisfaction. However, it's important to note that TRT is not suitable for all individuals with ED, and its use should be carefully evaluated by a healthcare professional to ensure appropriate dosing, monitoring of hormone levels, and consideration of potential risks or side effects.

Vacuum erection devices: Non-invasive devices used to treat erectile dysfunction (ED). They typically consist of a plastic cylinder that is placed over the penis, creating a vacuum seal. By manually or mechanically removing air from the cylinder, blood is drawn into the penis, causing an erection. Once the erection is achieved, a tension ring is placed at the base of the penis to maintain the erection and allow for sexual activity.

The potential for reversing erectile dysfunction depends on the underlying cause and individual circumstances. Causes can typically be split into short-term and long-term ED, which can be summed up as temporary causes having to do with things like psych, stress, medication, and more versus constant causes like chronic conditions and low testosterone. In both cases, ED can be successfully treated or managed, allowing for improved sexual function. Lifestyle changes such as maintaining a healthy weight, engaging in regular exercise, adopting a nutritious diet, managing stress, and avoiding or minimizing alcohol and tobacco use can positively impact ED. Additionally, treatment options such as oral medications, vacuum erection devices, penile injections, testosterone replacement therapy, psychotherapy, or a combination of these approaches may be recommended by healthcare professionals to address the specific causes of ED.

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