What Causes Erectile Dysfunction

It is not an exaggeration to say that the quality of erections is one of the best health indicators for men. This does not mean that if you have good natural erections everything is fine but it rather means that if you are suffering from ED then it is very likely that this an important health warning that no man should ignore. This is not surprising since for many men their ED has the same underlying causes with very serious health issues such as Cardiovascular Disease, Metabolic Syndrome and Diabetes. It is a well-established fact that in such cases ED can predate a cardiovascular episode by 3-5 years.

Endothelium & Smooth Muscle Dysfunction

By far the most common cause of erectile dysfunction is endothelium dysfunction, which is also often abbreviated as ED. In brief, so as not to overcomplicate things, the endothelium is a layer of cells that is found throughout the erection mechanism (the corpora cavernosa) and these need to be healthy in order for the erection bodies to expand adequately so as to trap the blood flowing in the penis (the expanding erection bodies trap the blood by effectively becoming engorged and blocking the veins that take away the blood from the penis).

If the endothelium cells (and the accompanying smooth muscle tissue) are not healthy this means that the expanding erection bodies have lost some of their elasticity and although enough blood flows in the penis, the erection bodies do not expand adequately to trap it so as to get an erection.

So what causes Endothelium Dysfunction?

Everything that is bad for your cardiovascular and heart health since endothelium dysfunction is the first stage of cardiovascular disease (the endothelium cells are lining all the arteries in our bodies and cardiovascular disease starts when the endothelium becomes damaged). You might have come across the list of things that are bad for the endothelium, which include:

·       Bad diet and obesity (and all the associated health issues such as fatty liver disease, metabolic syndrome and diabetes)

·       Lack of exercise

·       Low Vitamin D

·       Smoking

·       Stress

·       Lack of or bad quality sleep

In reality, together with aging and smoking, the most important (controllable – since genetics also play an important role) cause of endothelium dysfunction is bad diet and a condition caused (usually) by bad diet called insulin resistance, which in turn can lead to fatty liver disease, metabolic syndrome and type 2 diabetes. This does not mean that the rest are not important and all men with erection issues should check themselves for things like Vitamin D deficiency (usually caused by insufficient sun exposure) or sleep apnoea. Having said that, from the list above it becomes obvious that your lifestyle will usually be the underlying cause of your erections issues due to the impaired endothelium function. The good news is that drastically improving your lifestyle will not only improve your overall health but can also improve your erections or at least prevent your ED from becoming worse. Even more encouraging is the fact that there are a number of treatments available such as shockwave therapy and daily intake of PDE-5 inhibitors that can help heal your damaged erection mechanism.

In terms of diagnosis, endothelium dysfunction in your penis can be checked through a Penis Doppler ultrasound examination (see next Section for more information) as well as some specialised blood tests (ADMA).

Atherosclerosis

A small number of men may have such advanced endothelium issues and damaged arteries that the main arteries to the penis become very narrow (due to plaque formation, a process called atherosclerosis), thus restricting the blood inflow (in addition to endothelium dysfunction) and resulting to severe erection issues. This is also diagnosed through a Penis Doppler Ultrasound.  If blood inflow issues due to atherosclerosis are detected, then this will usually mean that the patient has advanced cardiovascular disease and immediate evaluation by a cardiologist is required.

Diabetes & Metabolic Syndrome

Diabetic patients have a much higher prevalence of ED (around 50%) and usually the more severe kind. This is not surprising since the same issues that lead to endothelium dysfunction (bad diet in particular) are also responsible for Type 2 diabetes. Beyond that though, diabetes itself can independently harm the erection mechanism by exacerbating the endothelium damage as well as damaging the nerves involved in the erection. The unfortunate thing is that many men (and women) have undiagnosed diabetes or pre-diabetes (often called Metabolic Syndrome) so it is very important that if you have ED to also check your blood sugar, insulin and lipids levels, if these were not recently checked. 

Low Testosterone and Other Hormonal Issues

Testosterone is the male hormone and is produced by the testicles. It is an essential hormone that affects all our organs but the erection mechanism is particularly vulnerable to low testosterone levels. In fact, the most telling sign that your testosterone levels might be low is reduced libido and ED. Testosterone levels drop as we age but they can also be low because of a number of issues including problems with the testicles, problems in the brain (which signals testosterone production) or (again!) due to obesity/bad diet. Another hormone that is important for the erection mechanism is prolactin, which would also need to be checked since it might be the result of a benign brain tumour called prolactinoma.                    

Radical Prostatectomy and Pelvic Trauma

Men who have had a radical prostatectomy (removal of the prostate gland) surgery because of prostate cancer will almost certainly face ED issues, which in many cases will be severe.  This happens because the nerves and the arteries involved in the erection mechanism get severely damaged when the prostate is removed. This in turn means that for some time following the surgery there will be complete absence of erections, which might also result in fibrosis in the erection mechanism due to inadequate highly oxygenated blood flowing in the corpora cavernosa. So following radical prostatectomy, it is very important to immediately address the lack of erections in order to prevent further damage. In addition to radical prostatectomy any trauma or surgery in the pelvic area may also damage the local nerves and arteries and result to ED. 

Peyronie’s Disease and other Anatomical Issues

Peyronie’s is a disease that affects the erection bodies of the penis. Although we do not know the exact causes of Peyronie’s, it affects 3-9% of adult men and it results to a fibrotic (scar tissue)  plaque forming on the corpora cavernosa (usually there is only one localised plaque but there can also be multiple). Although the plaque itself is benign, it anatomically affects the penis. Common sign of Peyronie’s disease is pain and mild or severe penile curvature during erections, a palpable lump on the penis shaft and unfortunately erectile dysfunction. When it comes to ED, it is unclear whether the plaque leads to ED or whether ED and Peyronie’s have common risk factors. Irrespective, it is important to rule out Peyronie’s disease (through a penile ultrasound examination) or any signs of corporal fibrosis when first diagnosed with ED.

Beyond Peyronie’s, there are various anatomical issues of the penis that might affect erections including a tight frenulum or foreskin and congenital (i.e. from birth) penile curvature. These can all be evaluated during a physical examination by your doctor through an artificial erection test (see next section for more details) and review of your medical and sexual history. 

Drug Interactions 

Drugs used to treat male baldness, statins, anti-depressives, high blood pressure and others can affect your erections for a number of reasons. If your doctor suspects that any medication that you are currently taking, contribute to your ED issues, then he might recommend stopping them or switching to alternatives.

Venous Leak

In very rare cases, there might be an abnormal vein in your penis that does not get blocked by the expanding erection mechanism. As a result, although there is enough blood inflow and the erection mechanism works well, this leaky vein drains the blood thus preventing the formation of an erection. Most men who suffer from venous leak, usually do so from a very young age and are unresponsive to ED medication.  Another sign of venous leak might be that your ability to maintain an erection might depend on the position during sexual intercourse. If your doctor suspects venous leak, then he might request a more specialised test called CT Cavernosography so as to confirm the presence of the leaky vein(s). Initial treatment involves either cutting or embolizing (clogging) the leaky vein. If that is unsuccessful then a penile implant surgery would need to be considered.