Erectile dysfunction (ED)

Erectile dysfunction (ED) is the inability to get or keep the erection, enough for an intercourse.

Sometimes every man gets erection problems; this is considered to be normal. The erectile dysfunction is spectated in following cases:

  1. A man gets completely unable to get an erection
  2. A man gets a short-term erection, insufficient for an intercourse
  3. A man is unable to get an efficient erection
  4. An ED is considered being primary, when a man could never get or keep an erection.
  5. A secondary ED is obtained much later by the man, who was earlier able to get an erection.
  6. A secondary ED is much more widespread, then a primary one.

In the US, nearly 50% men from 40 to 70 years have different erection problems, and this pathology rate grows with aging. Nevertheless, ED isn’t considered as a normal aging feature, it can be resolved at any age.


To get penis erected, there is needed enough blood and its outcome must be slowed; its nerves must be functioning well, a testosterone level must be proper and a man must have a strong libido. Any of these violations can cause an ED.

The most erectile dysfunction cases are caused by the pathologies of penis nerves or blood vessels. Other possible reasons are hormonal imbalance, structural penis damage, usage of some drugs and also the psychological problems (frequent erectile dysfunction causes and characteristics). The following erectile dysfunction reasons are the most frequent:

  • Artery hardening (atherosclerosis), damaging the penis arteries;
  • diabetes;
  • post-operational complications after prostate surgery;

some drugs, just like the antihypertensives or prostate hyperplasia medicines, also the CNS-affecting drugs, e. g. the antidepressants or sedatives.

Did you know?

  • An episodic inability for erection is normal and evidences no ED at all.
  • Nearly half of men older than 65 and some older than 80 usually have an erection, sufficient enough to penetrate the woman genitals.
  • Testosterone level reduction causes the libido lowering, but ist not a direct cause for ED.
  • To correct the erectile dysfunction a combination of intrapenile injection drugs and pumping devices is used; it is highly efficient and has no side effects, often seen at the oral drugs usage.
  • The sexologist consultations can help even in the physically caused cases of ED.

There is often a number of ED factors at the same time. For example, a man with slight ED, caused by diabetes or peripheric vessel disease, can encounter a heavy ED after the starting of new drug usage or stress increasing.

Blood vessel diseases

Atherosclerosis can partially block the blood income to the legs (peripheric vessel disease). Usually, the penile blood-supplying arteries are also blocked, which reduces the blood income into the caverns and causes the erection problems. Diabetes, high cholesterol level, high blood pressure and smoking contribute the atherosclerosis development and following erectile dysfunction.

Sometimes, the blood leaves the penile veins too fast, which lowers the penile blood pressure, violating the erection duration and support (so-called venous occlusive dysfunction).

Neural pathologies

In the case of damaging the penial nerves, the erectile dysfunction can develop too. With diabetes, besides the atherosclerosis, the penial nerves can be damaged. As far as the penial nerves are close to prostate, the prostate surgery (cancerectomia, or hyperplasia removal) often causes an ED.

The pathologies, less often causing the ED are the spinal cord damage, multiple sclerosis and stroke. Besides this, the lasting suppression of genital and buttock nerves (so-called saddle-area) at long-distance bike riding, can cause the temporary ED.

Other disorders

Hormonal violations (e. g, pathological testosterone reduction) sometimes lower the libido and can cause the erection problems.

At Peironi disease, the scar tissue is formed inside the penis, which causes its deformation and often pains during erection. These disorders in complex also cause the ED.

What is Peironi disease?

During Peironi disease, the inflammation inside the penis causes the scar tissue formation. While this tissue doesn’t increase in size during an erection, the penis deforms, making the penetration difficult or impossible during the coitus. The scar tissue can grow at the caverns, which response for erection, and cause the erectile dysfunction.

Drugs, including alcohol and illegal drugs like cocaine and amphetamines, can also cause the ED or contribute to its appearance.

Sometimes, the psychic disorders (like the possible failure fear or depression) or the factors, lowering the man’s energy (diseases, high fatigue or stress), can cause the ED or help its appearance. The erectile dysfunction can be caused by momentary circumstances – time, place or partner.

A long and painful erection (priapism) can damage the penis tissues, responsive for the erection, which leads to the erection problems.


The episodic ED is frequent enough, but the men, who constantly can’t reach or support the erection, must visit their doctor, because the ED can be a sign of serious pathology, including atherosclerosis or neurological diseases. Most ED cases are curable. Here is an information, helping a man, whether to contact his doctor and which procedures can be held on examination.

Alerting signs of ED

The men with ED can encounter some alerting symptoms and changes:

  1. No erection at night or on awakening
  2. Buttocks (or near) and/or groin numbing (so-called saddle-area).
  3. Painful cramping of leg muscles during physical overloads, quickly relieved on the rest (intermittent claudication).

When to contact the doctor?

Even if ED can worthen man’s life, it’s not a dangerous disorder by itself. Nevertheless, the ED can be a symptom of serious disease. As far as the groin or leg numbing can be an evidence of spinal cord damage, the men with such disease must immediately contact the doctor. The men with other suspicious changes need to call a doctor and ask him about the urgency of examination.

What does the doctor do?

First, the doctor asks a man about his symptoms and anamnesis. Afterwards, a physical examination is held. During that, a possible ED reason is often detected, which can possibly lead to additional examinations (frequent reasons and characteristics of erectile dysfunction).

The doctor investigates the following:

  1. Drugs and alcohol consuming.
  2. Smoking status information.
  3. Diabetes.
  4. Blood pressure increasing.
  5. Atherosclerosis.
  6. Post-operational data (prostate cancer/hyperplasia surgery, rectum cancer or blood vessel diseases).
  7. Information about survived physical damage (pelvic bones breaking or spinal damage).
  8. Blood vessel pathology symptoms (calf muscle pain at going, temperature dropping, feet numbing or cyanosis).
  9. Neural disease symptoms (e. g. numbing, tingling, weakness, incontinence or falling).
  10. Hormonal disorder symptoms (libido loss, breast growth, testicles reduction, body hair loss, tremor, BMI or appetite changes, difficulties at surviving the high or low environment temperature).
  11. Psychic disorder symptoms, especially depression.
  12. Sexual satisfaction.
  13. Sexual dysfunction (e. g, vaginitis or depression), had by man’s partner.

Sometimes, the men scruple to talk to a doctor about this, but the information is very important in the definition of erectile dysfunction.

The physical examination is concentrated on external genitals and prostate; besides that, the doctor looks for hormonal, neural or vascular pathologies and examines the rectum.

Sometimes the reason becomes obvious after the anamnesis studying. The ED can develop soon after the prostate surgery or after the start of new drug treatment. One of the important characteristics is the absence of erection at night or on awakening. If the erection is evident, the somatic reason is less probable, than the psychologic, while the somatic reasons prevent the erection in any day time. Other factors for psychologic reason are the ED sudden development in young and healthy man, the symptoms are situative and remove without any medication. Intermittent claudication, reduced temperature or toe/feet cyanosis can evidence the peripheric blood vessel pathologies or vascular disease, caused by diabetes.

Frequent ED reasons and characteristics

Vascular diseases

Artery passability disorder (peripheric vessel disease)

Intermittent claudication (a feeling of acute or nagging pain, muscle cramps or regular, predictable leg muscle fatigue on physical activities, which relief quickly on a rest)

Widespread risk factors (high blood pressure, diabetes or abnormal cholesterol and lipid level in blood)

Comparison on simultaneous BP measuring on ankle and arm (ankle-brachial index)

Checking the risk factors (increased sugar and lipid level in blood)

Ultrasound measuring of blood circulation in penile arteries


Unwanted blood outcome off the veins (a penis is unable to hold the blood in caverns during the erection, as usual)

Erection occurs, but is unsupported

Penile arteries ultrasound investigation

Neural violations

Diabetic neural damage (neuropathy)


Sometimes, the numbing, burning or other foot aches are spectated

Dysuria (rarely)


Medical examination

There are also possible the EMG and neural impulse speed testing


Multiple sclerosis

Weakness or numbing feeling in different body parts, which is periodical and appears in different moments


Lumbal punction and liquor analyses can be held

Nerves damaging during

the pelvic surgery or radiation therapy

known surgical operations (e. g, radical prostatectomia) or radiation therapy

Medical examination only

Spinal cord damage, caused by trauma or tumor

Numbing between penis and anus

Usually, there are additional symptoms of spinal cord damage (leg weakness or numbing and dysuria)


Long-time nerve suppression in buttocks or genital area (“saddle area”), during bike or horse riding

Is usually spectated among the competing sportsmen, who pass the long distances on a bicycle. The symptoms appear soon after the ride


Medical examination only

Prostatitis (prostate inflammation)

Pelvic or groin aches and disturbing symptoms appearance in the urogenital system (aches, burning, haematuria, frequent urinations or urination difficulties)

Medical examination only


Survived stroke in the past

Medical examination only

Hormonal disorders

Hypogonadism (testosterone deficit)

Libido loss, sleep disorders, also depression and sudden mood changes. Timed muscle and testicle reduction, bone durability and body hair loss. Fat volume increasing and breast growth


Testosterone blood level changes

Cushing syndrome

“Moon face”, trunk fat increasing, purple strings on belly, high blood pressure and mood changes

Blood cortisol measurement Blood analysis

Heavy hyperthyreose (excess of thyreoid hormone)

Motor anxiety, highered pulse and BP, tremor, body mass loss and inability to survive the heat

Blood thyreoid hormone measurement

Heavy hypothyreose (lack of thyreoid hormone)

Weakness, lowered pulse and BP, skin tightening, appetite loss, body mass growth and inability to survive the cold

Blood thyreoid hormone measurement

Structural defects

Peironi disease (scar tissuing in penial caverns, responsive for erection)

Scar tissuing in penial caverns, frequent strong penis deformations during erection

A pain is often felt during the intercourse

Medical examination only

Penis USI to detect the scar tissue

Hypospadias (inborn defect)

Urethra hole is opened on a lower penis surface

Medical examination only

Microfallia (inborn defect)

Extremely small penis size

Medical examination only

Psychic disorders


Anxiety, helplessness and hopelessness feeling, loss of appetite and sleep disorders

Medical examination only

Fear of possible failure or stress

Full erection during sleeping or masturbation. Concerns about an intercourse quality. The ED  can sometimes appear due to some partners or situations

Medical examination only


Medicine (Some of the frequently used drugs, able to cause the ED)

Past usage of medicine, able to cause the erection problems

Medical examination only

Hypoxemia (chronic oxygen deficit in blood)

There is usually a chronic lung disease (e. g, chronical lung obstruction)

Pulse oxymetry (oxygen blood level measurement)

*the signs include the symptoms and results of examination. The given signs are typical, but aren’t always appearing.

†The testosterone level is usually measured. If it is low, the doctor measures other hormone levels.

ED — erectile dysfunction; MRI — magnetic resonance imaging.

Some of the most frequently used drugs, causing the erectile dysfunction:



Antihypertensive drugs

Beta-adrenoblocators (atenolol, carvedilol, metoprolol and propranolol)


Diuretics (such as furosemide, hydrochlorthiaside and chlortalidone)



Drugs for medication of prostate hyperplasia

Alpha-adrenoblocators (terazosin, doxazosin, tamsulosin and silodosin)

5-alphareductase inhibitors (finasteride and dutasteride)

Prostate cancer drugs

Hormonal drugs (leuprolide, triptorelin and gosereline)




CNS-affecting drugs


Benzodiazepines (alprazolam, chlordiazepoxide, diazepam and lorazepam)

Cocaine or amphetamines during the long-term consumption

MAO inhibitors (phenelzine, selegiline and tranilcipromine)

Opiates (codeine, heroin, hydromorphone, methadone, morphine or oxycodone) during the long-term consumption

Selective inhibitors of serotonin reuptake (citalopram, escitalopram, fluoxetine and sertraline)

tricyclic antidepressants (amitriptyline, dezipramine, imipramine and nortriptyline)


Androgen antagonists (megestrol)

Anti-tumor drugs (majority of anti-tumor drugs)


ACE-drugs (many antihistamines and some antidepressants).



It’s usually needed to make an examination. Lab analyses include the blood testosterone measurement. If it is reduced, a doctor measures other hormone levels. Depending on the study of survived diseases, procedures and medication methodics and also depending on the examination results, there can be held the analyses of blood to define the diabetes, thyreoid pathologies and lipid exchange disorders. Usually they give the doctors enough information to plan the medication.

Sometimes, a doctor injects the drug into the penis to stimulate erection, and afterwards evaluates the blood circulation in its veins and arteries. Rarely, the doctor can recommend a special device for domestic erection monitoring during the sleep.

  • Healing the main reasons
  • Teaching and consulting
  • Oral PDE inhibitors

Sometimes other drugs, mechanical devices or surgical operation

The treatment is held for a disease, caused the disorder; sometimes the doctor cancels the drugs, causing the erection problems, or alters the prescribed drug. But before stopping the usage of any drug, a man needs to discuss this move with his doctor.

Body overweight is a risk factor for many ED-causing disorders, so the body mass reduction can improve the erection. Smoking is the factor of atherosclerosis development risk, so the smoking quitting can also improve the erection. Besides that, stopping the alcohol consumption can also be very useful.

Even if the erective dysfunction is caused by a somatic disorder, the psychological component is often spectated, that’s why the doctors offer the psychotherapeutic consulting and tuition (including the tuition of man’s sex partner, if possible). Family consulting with qualified sexologist can help improving the interaction between partners, weaken the pressure on intercourse quality and can also help to resolve the interpersonal conflicts, reasoned the erection problems.

Healing with the drugs, refilling the testosterone can help to renew the erection for men with the low level of that hormone. The testosterone drugs can be taken daily as plasters or gels. Sometimes the nasal drugs and subcutaneous implants are recommended. The men with very low testosterone level may need the testosterone injections twice a month.

Firstly, the non-invasive methods are prescribed (mechanical devices or drugs). Sometimes the men need to try the medication method for some times, before the doctor concludes, whether it is efficient or not. Usually, the oral drugs are used first. The intrapenial drugs are also effective before the intercourse: they must be used secondarily. Although, the majority of men prefer to use the drugs for erective dysfunction treatment more, than other methods, the mechanical devices are another highly efficient method of ED medication: they are very effective and as far as they have no adverse effects, typical for the drugs, their usage is very safe. The method, applied at last, when any other way is useless, is falloprothesing, when the refillable implants are installed into a penis; this method is the most efficient for proper intercourse supporting.

Mechanical devices

The men, able to get the erection, but unable to support it, can use the erectional ring. Just as they have their erection, the elastic ring is installed near the penis root and it prevents the blood from leaving the penis and supports its hardness. When a man can’t reach the erection, the handpump can be used: it is taken on the penis and creates the negative pressure around it. Such a device routes the blood into the penis thanks to the slight vacuum effect; afterwards the erection ring is put on the penis root. The disadvantages of this method are following: the bruises on a penis, penis point temperature lowering and no spontaneity of intercourse. Sometimes, in order to advance the ring and pump, the drugs are used.


The main drugs to medicate the erectile dysfunction are oral phosphodyestrase inhibitors. There are also prostaglandynes to use as intrapenile or intraurethral injections. The PDE inhibitors are used more often, than the other drugs, due to their convenient usage and support in terms of intercourse spontaneity. To treat the ED, there are also the OTC drugs in the stores, but they are usually ineffective or (and) contain the PDE-5 inhibitors in a covert dose. The drug usage with a covert PDE-5 inhibitor contain can lead the man to the possible adverse effects.

Oral PDE-5 inhibitors (sildenafil, vardenafil, avanafil and tadalafil) increase the penial blood income. These drugs have the same action mechanism, but differ in duration, adverse effects and food interaction. Tadalafil has longer effect in comparison with other drugs (near 36 hours), which is liked by some men.

The majority of PDE-5 inhibitors are most effective when taken fasting, nearly an hour before the sex. The men, taking the nitrates (nitroglycerin is the most frequent one, but there also are the poppers (amylnitrate recreation drugs), are prohibited to use these drugs, because this combination can lead to a collapse of blood pressure. The other PDE-5 temporary side effects are the face and corps heating, vision disorders (including daltonism) and headaches. Rarely, the priapism (durable erection), which needs emergency medical assistance. Rarely, the men become deaf or blind after the usage of PDE-5 inhibitors, but it’s not clear enough, whether the drugs are the reason for these violations.

Alprostadil (PGE1 prostaglandine) without other drugs or combined with papaverine/phentolamin can be directly injected into a penis side part using the very thin needle, which helps the erection to appear in majority of men. The alprostadil suppositories can be applied into the urethra, using the straw-like applicator. These treatment methods can cause the priapism and penis aches. Usually, the doctor tutors the men about the independent application of the drug during the hospital visit. Afterwards, the men can independently apply those drugs at home. The men, for whom the oral drugs are ineffective, can combine the alprostadil suppository with an oral PDE-5 inhibitor.

Surgical intervention

For some men the medicamental therapy is considered to be inefficient or unacceptable. Those men can be prescribed with surgical intervention with falloprosthetics. The prostheses are the hard silicone rods or hydraulic systems, which can fill and empty. During their installation, the risks of improper narcosis usage, infection or bad prosthesis functioning can be encountered.

The main thing to know for the elderly men

Although, the ED is amplifying with aging, it mustn’t be considered a normal aging feature. The main thing is, that the elderly men have higher ED risks because of vascular diseases. Many elder couples practice the satisfactory contacts without erection and intercourse; those pairs sometimes decide not to ask for a special treatment. Nevertheless, the ED treatment can be good for the elder men.

Key moments:

  • The ED is often caused by psychologic, neural and blood vessel disorders, traumas, drug adverse effects or surgical interventions.
  • By reasoning, the doctor evaluates the psychologic factors and interpersonal relationships.
  • The testosterone drug medication can help with refreshing the erection for men with lowered testosterone level in a serum, but please consider, that the reduced testosterone level is usually not a cause for an ED
  • The PDE-5 inhibitors (sildenafil, vardenafil, avanafil or tadalafil) help the majority of men with an ED.
  • The majority of men, who do not react on the treatment with oral PDE-5 inhibitors, can reach the erection, using the alprostadil injections, used separately or combined with an oral usage of PDE-5 inhibitor.
  • The efficient medicines for heavy erective dysfunction are the vacuum erection devices and falloprosthetics.

Authors: Irvin H. Hirsch, MD, Clinical Professor, Department of Urology, Sidney Kimmel Medical College of Thomas Jefferson University.

Erectile Dysfunction