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Erectile dysfunctionAlso known as ED, Impotence
Erectile dysfunction (ED), as the name suggests, is a medical condition that causes an inability to achieve or maintain an erection for satisfactory sexual performance. The condition mainly affects men older than 40 years and the prevalence of ED increases with age. Some of the common causes of the condition include excessive medication, chronic illness, poor blood flow to the pelvic region, and unhealthy habits such as drinking too much alcohol or excessive smoking.
Most of the time, this condition is temporary and is triggered by stress, performance anxiety, or certain medications. Sometimes it can be due to underlying medical conditions like diabetes, heart problems, depression, and high cholesterol levels. In these cases, it requires intervention by a specialist. Since most men find it embarrassing to discuss the problem with their doctor, they resort to self-medication that can worsen the problem in the long run and harm their overall health.
- Individuals above 40 years of age
- Loss of libido
- Physical examination.
- Penile doppler
- Serum testosterone level
- Urine assessment (urinalysis)
- Overnight erection test
- Oral medications: Tadalafil & Vardenafil
- Intracavernosal injections (ICIs)
- Intraurethral suppositories
- Vacuum-assisted erection devices (VED)
- Penile implants (or prosthesis)
- Sexual health expert
Symptoms Of Erectile Dysfunction
The inability to sustain an erection is one of the main presentations of erectile dysfunction.
However, based on the cause of the impotence (organic / non-organic or psychogenic) the other symptoms that a person can also experience include:
Symptoms of psychogenic ED
- Sudden onset of errection issues
- Intermittent dysfunction (variability and situational)
- Loss of sustaining capability
- Nocturnal erection
- Excellent response to phosphodiesterase type 5 (PDE-5) inhibitors
Symptoms of organic ED
- Gradual onset
- Often progressive
- Consistently poor response to phosphodiesterase type 5 (PDE-5)inhibitors
- Poor nocturnal erection
- Symptoms improve on standing than lying down (in cases of venous leak)
Causes Of Erectile Dysfunction
In order to understand the causes of ED, you need to first know the mechanism of an erection. Here is what happens during an erection.
The penis remains in its flaccid state when the blood vessels in penis are not fully dilated. This allows only a small amount of arterial blood flow in penis that is basically required for nutritional purposes. When you are sexually stimulated, there is a release of neurotransmitters namely nitric oxide (NO) from the nerve terminals in the penis. This causes relaxation of the smooth muscles of blood vessels and results in increased blood flow into the cavernosa of the penile region. This causes the penis to become erect and rigid.
Erection ends when the ejaculation occurs and sexual arousal ends, that allows the accumulated cavernosa blood to flow out through the penile veins back into the circulation.
Sometimes a combination of various physical and psychological factors can cause a disturbance in the mechanism of erection. These factors are explained in detail in the next section.
Types Of Erectile Dysfunction
Broadly, ED is categorized into two main types namely organic impotence and non-organic impotence.
Organic impotence: It refers to the inability to obtain an erection firm enough for vaginal penetration, or the inability to sustain the erection until completion of intercourse.the reason can be vascular, neurogenic, secondary to chronic disease & iatrogenic, or hormonal.
Non-organic or psychogenic impotence: In this, impotence or loss of erection is caused by anxiety, guilt, depression, or conflict around various sexual issues. In simple terms, caused due to an underlying psychological problem.
Here’s a quick sneak peak at the common types and causes of ED:
1. Psychogenic erectile dysfunctionPsychogenic erection is a result of audiovisual stimuli or fantasy. Impulses from the brain modulate the spinal erection centers to activate the erectile process. This type of ED is may be due to :
- Physical and mental health problems
- Psychological trauma
- Relationship problems/partner dissatisfaction
- Family/social pressures
- Stress, anxiety, and depression
2. Neurogenic erectile dysfunction
It is caused due to a dysfunction in the nerve signaling to the corpora cavernosa, a structure present in the penile region to store blood and hence erection. Common causes of this type of ED include problems with the:
- Central nervous system: Spinal cord injury, multiple sclerosis, stroke, Parkinson disease, etc.
- Peripheral nervous system: Diabetic neuropathy, lumbar disc disease, radical pelvic surgery, etc.
3. Vasculogenic erectile dysfunction
The reduced blood inflow and arterial insufficiency caused due to vascular disease and endothelial dysfunction can lead to erectile dysfunction. Diseases that can lead to vasculogenic ED include:
- Arterial insufficiency/peripheral arterial disease
- Veno-occlusive disease
4. Secondary erectile dysfunction
As the name suggests, an underlying medical disorder that can increase the risk of erectile dysfunction.
- Hepatic insufficiency
- Dyslipidemia (abnormal cholesterol levels)
- Renal insufficiency
- Chronic obstructive pulmonary disease
- Sleep apnea
- Benign prostatic hypertrophy
- Lower urinary tract infection symptoms
5. Latrogenic erectile dysfunction
The most common iatrogenic cause of erectile dysfunction is radical pelvic surgery. Generally, the damage that occurs during these procedures is primarily neurogenic in nature. This is because of the close relationship between the cavernous nerves and the pelvic organs, surgery/radiation, etc. on these organs is a frequent cause of impotence. It includes conditions such as:
- Cavernous fibrosis
- Peyronie's disease
- Penile fracture
- Drug-induced (antihypertensives, antidepressants, antiandrogens, etc.)
- After a surgery
- After radiation therapy (cancer, etc)
6. Hormonal erectile dysfunction
Androgens are considered the major hormonal regulator of penile development and physiology. Androgens influence the growth and development of the male reproductive tract and secondary sex characteristics. Their effects on libido and sexual behavior are well established. This could happen due to:
- Diabetes mellitus
- Thyroid disorder
As erectile dysfunction can be caused by one or several of these factors, it is important to talk to your doctor to know the exact cause and treat these underlying health problems.
Risk Factors For Erectile Dysfunction
The factors that can cause or increase the risk of erectile dysfunction include:
- Sedentary life
- Unhealthy diet
- Certain medications including some antihypertensives and antidepressants
- Alcohol consumption
- Heart disease
- Pelvic surgery
- Penile injuries
- Cancer surgery
Diagnosis Of Erectile Dysfunction
The tests recommended for patients seeking medical care for erectile dysfunction include an evaluation of:
- An accurate medical and sexual history
- A careful general and focused genitourinary examination
- Radiological test like penile doppler
- Routine lab tests
1. Radiological tests
Radiological tests like penile doppler are important for the diagnosis of ED. It is an advanced imaging technique used to measure the blood flow through the blood vessels in the penis. Blood flow is very important for a man’s erections.
2. Routine lab tests
The routine lab tests include hormonal and biochemical tests such as:
- Total and free testosterone
- Sex hormone-binding globulin
- Thyroid hormone
- Total and high-density lipoprotein cholesterol
- Fasting glucose and glycosylated hemoglobin
- Prostate/testis/penis abnormalities
- Serum estrogen
- Dehydroepiandrosterone sulfate (DHEAS)
- Sex hormone binding globulin
Prevention Of Erectile Dysfunction
Some of the common ways that can help you to prevent ED include:
- Keep a close tab on disorders, particularly diabetes or heart problems, as these can increase your risk of ED.
- Limit tobacco consumption as it can impact your sex life as well as your ability to get an erection.
- Overweight/obesity is a common risk factor for ED, so make sure you lose weight to improve your physical as well as sexual health.
- If you are on drugs such as antidepressants and antihistamines, talk to your doctor to change the medications or ways you can minimize the effect of these drugs on your sexual activity.
Specialist To Visit
If you experience any signs associated with erectile dysfunction such as difficulty getting an erection, difficulty to maintain an erection enough for intercourse, or diminished sexual desire, you must consult an expert.
Although general physician is what most people tend to go to when it comes to problems with sex life, you can even consult specialists such as:
Treatment Of Erectile Dysfunction
There are multiple non-invasive treatments for ED that include lifestyle changes, oral medications (phosphodiesterase type 5 inhibitors), vacuum-assisted devices, and intraurethral suppositories. While lifestyle changes and oral medications are typically first-line treatments for ED, more-invasive treatments including intracavernosal injections and surgically implanted prosthetic devices may be required for the management of complex cases.
1. Oral medications
These medications inhibit the enzyme phosphodiesterase type 5 (PDE5), which keeps the level of cGMP (cyclic guanosine monophosphate) high and promotes erections. The most well-known of these PDE5 inhibitors is sildenafil, while other commonly used medications include:
2. Intracavernosal injections (ICIs)
These are an alternative to oral medications and are injected directly into the penile corpora (at the lateral base of the penis). The most commonly injected medication is prostaglandin E1 (PGE1), which stimulates cyclic adenosine monophosphate (cAMP) to induce smooth muscle relaxation and promote erections. It may be preferred in certain patients in whom oral medications may be contraindicated or nerves that stimulate erections are damaged.
3. Intraurethral suppositories
These medications are preferred by patients who wish to avoid oral or injectable medications. While intraurethral suppositories improve erectile function, they are known to be less effective than ICIs.
4. Vacuum-assisted erection devices (VED)
It is a device that is placed over the penis and pumped to create a vacuum, which pulls blood into the penis to cause engorgement and erection. The device may be challenging to use for patients with a large amount of lower abdominal fat and buried penis.
5. Penile implants (or prosthesis)
It is a surgically implanted device that comes in an inflatable form (with two- or three-piece devices) and malleable form (with two rigid cylinders that are implanted within the penile corpora). This device remains rigid and may be simply positioned to allow for intercourse. These are usually recommended for people who fail to respond to less-invasive ED treatments, but in some cases are also considered to be the first line therapy.
It is also a recommended treatment approach for men with psychogenic ED. The reason being, most patients have symptoms of depression and anxiety related to sexual performance. This increases a man’s focus on the firmness of his erection, leading to self-consciousness and cognitive distractions that interfere with arousal and contribute to poor performance. In such a case, getting help from a psychiatrist or a sex counsellor can be of great help.
Do not think twice before getting professional help to treat ED. Get consultation from the best of the experts with a single click.
Home-care For Erectile Dysfunction
Here are a few lifestyle changes that can help you deal with erectile dysfunction and improve your sexual life.
1. Exercise regularly
It is essential to stay physically active. It helps to maintain regulated blood flow to the pelvic regions. Erectile dysfunction has been found to be more commonly reported in men who are not physically active2. Try different forms of physical workout such as running, swimming, or brisk walking. Regular workout helps to keep lifestyle problems such as cardiovascular diseases, obesity, high cholesterol, and stress away which also decreases the risk for erectile dysfunction.
2. Foods to eat and avoid
A healthy, balanced diet plays a very integral role in maintaining the flow of blood to the sexual organs such as the pelvis and penis. Nutritious and healthy eating habits reduce an individual’s risk for lifestyle problems such as obesity, vascular diseases, and diabetes. Include fruits, vegetables, and whole grains in your daily diet. Reduce or avoid the intake of foods such as red meat and refined grains as it may increase the risk for erectile dysfunction.
3. Limit intake of medications
Intake of several forms of antidepressants, sedatives, and antihistamines have been found to affect the male’s sexual response. The vascular network that produces an erection is often controlled by the nervous system. These medications have been found to interfere with the critical nerve signals and therefore impair the sexual response.
4. Get enough sleep
Fatigue and stress have been found to severely affect sexual health. Psychological stress leads to increased adrenaline which further causes the contraction of the blood vessels. The contraction in the blood vessels inhibits the supply of blood to the pelvic region and helps adversely affect sexual health.
5. Get rid of your vices
Drink in moderation. Excess of alcohol has been found to be detrimental to the overall health. Chronic heavy drinking has been found to affect organ systems, causing fluctuations in the sex hormones. Irregular fluctuations in the sex hormones have been found to affect the sexual health and are considered to be major triggers for conditions such as erectile dysfunction.
If you smoke, quit smoking. Nicotine narrows the blood vessels and hampers the flow of blood to the pelvic region (including the penis).
Complications Of Erectile Dysfunction
If left untreated, ED can lead to various health complications that can impact your sexual as well as mental well being. Some of the common complications that can result from ED include:
- An unsatisfactory sex life
- Being stressed or depressed
- Embarrassment or low self-esteem
- Problems in the relationship with your partner
- Inability to get your partner pregnant
ED And Comorbidities
ED is common in men with both type 1 and type 2 diabetes. Studies show that diabetics are three times more likely to develop ED. Moreover, the risk of ED in men with diabetes increases with age and there is a high chance of getting ED around 10-15 years earlier than non-diabetics.
This can be attributed to factors such as longer duration of diabetes, old age, poor glycemic control, and neuropathy. Moreover, the condition is more severe and less responsive to medicines in diabetics. ED can cause an increase in mental stress, lead to disordered interpersonal relationships and interfere in their sexual life, thus affecting the overall quality of life in diabetics.
Diabetics, especially those with poor glycemic control, obesity, and those who are aged, are at a high risk of developing ED. Hence, keeping your blood glucose levels under control can play a key role in lowering your risk of ED.
Sexual dysfunction is a common symptom associated with depression. The chemical imbalances that occur when depressed can reduce a person’s ability to experience pleasure, both physical and emotional, which affects the sex drive and erection. Also a person suffering from depression experiences symptoms such as low self-esteem, anxiety, and guilt, which can cause ED.
As every patient with depression has a different sexual problem, it is wise to not depend on random search results but consult a psychiatrist, who is trained to diagnose clinical depression and also treat ED. Remember, both depression and ED are treatable conditions, so do not wait until the symptoms worsen. Instead, seek help as soon as possible to lead a healthy and happy life.
As obesity affects a person both physically and mentally, these issues can, in turn, affect sexual well being. It can lead to difficulties with orgasm, decline in sexual frequency, lower sexual desire, and lack of satisfaction in men. Obesity can lead to hormonal imbalance, endothelial dysfunction, insulin resistance, psychological factors, and physical inactivity, which can lead to erectile dysfunction. This risk of erectile dysfunction increases with increasing body mass index (BMI).
Obesity is one of the most rapidly increasing and most common public health concerns in the world. Yet, it is also one of the most neglected health issues. So keep a close eye on your weight by eating a healthy diet, exercising regularly, staying away from stress, and avoiding any vices which can make you gain weight.
How healthy are YOU? Is your BMI normal? Here’s a quick way to know if you have normal BMI or are overweight/obese.
4. Performance anxiety
Sexual performance anxiety, simply put as anxiety during/before sexual activity, is one of the most common sexual problems across the world that affects both men and women. It is responsible for premature ejaculation and erectile dysfunction in men. This is also commonly seen in men during the first night after marriage but is seen to improve with time.
Although there have been many cases of sexual performance anxiety, there is yet no diagnosis available for the condition. Also, there is no cause for concern, as it can be effectively treated with proper counseling or behavioral therapy. Consult a doctor who can help you improve your sexual performance and have a healthy sexual relationship.
Alternative Therapies For Erectile Dysfunction
Acupuncture for ED
Studies suggest that acupuncture has been found to successfully reverse erectile dysfunction. It helps in improving the ability to maintain an erection, sustainable hardness during erection, and improved sexual satisfaction.
Ayurvedic medicine for ED
1. Ginseng: Ginseng root has been used as an important constituent in Chinese medicine . It is used for many beneficial properties and has been known to act as an effective remedy for ED. However, certain precautions need to be exercised since it can cause side effects like insomnia and few medicine interactions. The recommended dosage is 600 mg-1000 mg a day. It is available in powdered and capsule form.
2. Tribulus herb: This plant (tribulus terestris), also known as puncture vine, has been used in traditional Chinese medicine and Ayurveda since ancient times. It is known to increase the sexual drive in men and women. It is also considered as a cure for ED in men. The extracts of the roots and flowers are used in the tablets available.
3. Maca root: This root is known to improve hormonal balance, especially of the thyroid gland. It helps in improving stamina, energy, and overall sexual performance.
4. Horny goat weed: Chinese medicine has traditionally used horny goat weed for treating ED. It has shown positive results on rats but has not been tested on humans yet. Experts recommend Horny Goat weed more for boosting overall energy and hence increasing performance. Extracts from the plant can be taken in the form of capsules or tablets.
5. Yohimbe: The bark of the African Yohimbe tree contains yohimbine which has shown positive results in treating ED in humans. However, it may indicate serious side effects like lowered blood pressure, anxiety, and irregular heartbeat. Never take Yohimbe without a doctor’s supervision. It is available in the form of capsules, containing the bark extract.
Home remedies for ED
Some of the common herbal remedies that are known to boost sexual function and health include:
1. Garlic: Garlic acts as an aphrodisiac and serves as a tonic for those suffering from loss of libido or those who are unable to maintain an erection. Crush two or three cloves of garlic and eat them every morning.
2. Onion: Onion, known to have several health benefits, has been known to strengthen reproductive organs and also benefits those suffering from erectile dysfunction. Usually, white onions are recommended for such conditions.
3. Dark chocolate: More often known as a herb, it contains close to 70% cocoa, which helps to increase dopamine levels in the brain. It helps to uplift the mood, relaxes the body, and improves the body’s response to stimulation. Have it more often, without giving yourself an occasion to.
4. Lady finger : As per the Ayurvedic literature, lady finger helps to regain sexual vigour. It helps to treat sexual disorders and overall improves health. Grind the ladyfinger and add it to a glass of milk. Add sugar according to taste. Drink this everyday for significant results.
5. Drumstick (Sahjan): According to Ayurveda, this spindly vegetable may help relieve symptoms of functional sterility in both males and females. The dried bark of the tree has been found to be beneficial for conditions such as impotence, premature ejaculation, and lack of motility of sperm. Grind the bark, add the powder to the milk. Now, boil the mix and your healthy mix is ready, drink it every day.
Frequently Asked Questions
- Sooriyamoorthy T, Leslie SW. Erectile Dysfunction. [Updated 2021 Apr 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan.
- Ende J. Organic Impotence. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 187
- Pastuszak AW. Current Diagnosis and Management of Erectile Dysfunction. Curr Sex Health Rep. 2014;6(3):164-176.
- Maiorino MI, Bellastella G, Esposito K. Lifestyle modifications and erectile dysfunction: what can be expected?. Asian J Androl. 2015;17(1):5-10.
- Mutha AS, Kulkarni VR, Bhagat SB, Beldar AS, Patel SB. An Observational Study to Evaluate the Prevalence of Erectile Dysfunction (ED) and Prescribing Pattern of Drugs in Patients with ED Visiting an Andrology Specialty Clinic, Mumbai: 2012-14. J Clin Diagn Res. 2015;9(7):PC08-PC11.
- Patel CK, Bennett N. Advances in the treatment of erectile dysfunction: what's new and upcoming?. F1000Res. 2016;5:F1000 Faculty Rev-369.
- Krzastek SC, Bopp J, Smith RP, Kovac JR. Recent advances in the understanding and management of erectile dysfunction. F1000Res. 2019;8:F1000 Faculty Rev-102.
- Yafi FA, Jenkins L, Albersen M, et al. Erectile dysfunction. Nat Rev Dis Primers. 2016;2:16003.
- Lee JK, Tan RB, Chung E. Erectile dysfunction treatment and traditional medicine-can East and West medicine coexist?. Transl Androl Urol. 2017;6(1):91-100.