Erectile Dysfunction

Erectile dysfunction is a problem for men in many stages of life. Unfortunately, many men struggle with this condition and do not reach out for help. Less than half of men who anonymously report problems getting or maintaining an erection seek out medical care for their condition.  

The Journal of Sexual Health reports that 18% of 18-24-year-olds, 13% of 25-44-year-olds, 25% of 45-54-year-olds, 34% of 55-64-year-olds, and about 50% of men over the age of 64 struggle with erectile dysfunction.  

Related: Men’s Health: Erectile Dysfunction 

Normal physiology 

An erection happens when arteries in the penis dilate to allow more blood to flow in, while veins constrict to keep blood from flowing out. In healthy individuals, an erection is a response to some kind of sexual stimulation. Men are considered “healthy” and normal when their erections match their desire, and they feel satisfied by the frequency and duration of the erection.  

Because sexual health is based on personal preferences and beliefs, perceived sexual health is the most important consideration when determining whether someone has a problem or not. 

Types of erection 

• Nocturnal penile tumescence (nocturnal type). These are normal occurrences and happen during REM sleep. Most people do not realize they are experiencing an erection during this time.  

• Reflexogenic erection. Reflexogenic erections are a result of direct stimulation of the genitals or other parts of the body. These are controlled by a reflex arc involving the sacral spinal cord.  

• Central or psychogenic type erection. Central erections are a result of thoughts or fantasies rather than physical stimulation. They are most often accompanied by feelings of sexual desire. 

Pathophysiology 

There are many different reasons someone may experience erectile dysfunction. It is important to get a thorough patient history to determine the root cause of the problem.  

Types of erectile dysfunction include:  

• Vascular erectile dysfunction: Reduced blood flow to the penis. Often co-occurs with heart disease and hypertension. 

• Psychological erectile dysfunction: Often referred to as “performance anxiety,” this can also be caused by mental health disorders such as anxiety or depression.  

• Neurological erectile dysfunction: Nerve damage in the central or peripheral nervous system.  

• Hormonal erectile dysfunction: Low levels of hormones such as testosterone. 

• Peyronie’s Disease: Development of scar tissue inside the penis that blocks normal blood flow or cause pain during an erection.  

Risk factors for erectile dysfunction 

Clinical assessment of erectile dysfunction is heavily dependent on patient history and self-reporting symptoms. While some information such as weight-to-waist ratio, blood cholesterol levels, and vital signs can indicate a higher risk for erectile dysfunction, it is up to the patient to describe their symptoms.  

International Index of Erectile Function 

Erectile function and its severity are often diagnosed using the International Index of Erectile Function. The 15 questions on the scale include:  

1. How often were you able to get an erection during sexual activity? 

2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration? 

3. When you attempted intercourse, how often were you able to penetrate (enter) your partner? 

4. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? 

5. During sexual intercourse, how difficult was it to maintain your erection until the completion of intercourse? 

6. How many times have you attempted sexual intercourse? 

7. When you attempted sexual intercourse, how often was it satisfactory for you? 

8. How much have you enjoyed sexual intercourse? 

9. When you had sexual stimulation or intercourse, how often did you ejaculate? 

10. When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax? 

11. How often have you felt sexual desire? 

12. How would you rate your level of sexual desire? 

13. How satisfied have you been with your overall sex life? 

14. How satisfied have you been with your sexual relationship with your partner? 

15. How do you rate your confidence that you could get and keep an erection? 

These questions may be difficult for patients to answer, and they may feel uncomfortable or even embarrassed to answer them. Allowing them to write their answers down or answer digitally may encourage patients to be more open and honest in their responses.  

Clinical management 

The management of erectile dysfunction focuses on correcting the cause of the problem.  

For patients with vascular erectile dysfunction, vasodilators such as sildenafil are paired with lifestyle changes to improve blood flow to the penis. Vascular erectile dysfunction is often considered a harbinger of cardiovascular disease, and many of the treatments are the same.  

Patients with neurological erectile dysfunction tend to be the most difficult to manage. However, many with severe neurological impairments choose to use implantable devices such as vacuum erection devices or penile implants.  

Hormonal erectile dysfunction can be managed using testosterone or other hormonal medications. These types of treatments require frequent follow-up and monitoring and may result in undesirable side effects.  

While medication and healthy lifestyles are the most commonly recommended tools to treat erectile dysfunction, the European Society of Sexual Medicine recommends that psychological treatment can be just as important.  

Men who combine physical and psychological treatments to resolve their erectile dysfunction tend to have better outcomes than those who focus only on one or the other. Including a romantic partner in the process can also help increase compliance and confidence in a treatment plan.