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Erectile dysfunction is a problem for many older men but it’s also not uncommon among younger guys. ED medications have a 20-year success record of helping millions of men to get better and firmer erections.

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Written by Dr Kimberly Langdon, MD

Information last reviewed 06/21/19

About

It takes more than a penis and a willing partner to make an erection. Erectile dysfunction, or the inability to get an erection or sustain one, can be the result of multiple underlying conditions that affect your brain, nerves, heart, hormones, penis, prostate, testicles, and how they interact and depend on each other. That takes a lot of coordination, physically, hormonally, and mentally.

The heart, brain, penis, and hormones must all get along

Overall, there are four body systems needed to get and maintain an erection:

  • Cardiovascular - heart and blood vessels
  • Neurologic - brain, nerves, limbic system
  • Urogenital - testicles, prostate, penis
  • Endocrine - hormones (testosterone) must be coordinated between the hypothalamus, pituitary, and testicles.

Besides the psychological function of the brain, which is dependent on neurotransmitters or ‘happy hormones’ such as serotonin, norepinephrine, dopamine, and GABA, the electrical or conduction system known as the nervous system must be fully operational for an erection to occur.

So, it is TRUE that the brain is the largest sexual organ or erogenous zone and directly impacts sexual function - both desire and performance. Now that we have one basis for understanding the brain’s role in an erection, the rest of the organs must cooperate as well. It is a complex interplay of timing, reactions, responses, and feedback that result in a fully erect penis.

Erections 101

Let’s start with the normal erectile process, which starts with visual, olfactory (smell), and touching sensations that cause the release of neurotransmitters (hormones)  and chemicals that cause relaxation of the blood vessels of the penis. Relaxed or dilated blood vessels fill with blood and expand the penile tissue until it is rigid.

The reason the penis stays filled with blood is due to the vessels being compressed to prevent outflow or more inflow. The amount of blood is key and being well-hydrated maximizes blood volume.

Causes

The mechanism that underlies ED is blood vessel dysfunction and/or nerve dysfunction.

One serious disorder that can cause ED is diabetes due to the poorly controlled glucose levels in the blood. Glucose is inflammatory to both nerve and blood vessels making the tiny vessels of the penis even more susceptible to damage that may be irreversible.

Healthy nerves are needed to interact with the vessels so damage to both magnifies the effect.  High cholesterol, high blood pressure, and smoking can all lead to similar damage to the delicate blood vessels of the penis. Damaged blood vessels mean that they cannot expand and fill with enough blood to create an erection.

Symptoms

  • Incomplete erections
  • Flaccid erections
  • Semen secretion followed by weak erections
  • No early morning erections
  • Hard erections in the morning with flaccid erections before sex indicate a psychological problem
  • Urination problems
  • Pain or bruising from excessive masturbation

Diagnosis

Before getting into specific details of an erection, a diagnosis of ED must be based upon the following medical criteria (DSM-5):

  1. In over 75% of sexual acts, a man must experience one of the following symptoms:
    1. Difficulty obtaining an erection
    2. Difficulty keeping an erection to complete the act, or
    3. Low erectile rigidity
  2. The ED symptoms have lasted 6 months or more
  3. The ED symptoms cause psychological distress
  4. No other mental disorders, medical conditions, drug use, life stressors, or relationship issues are identified.

Related Conditions

Medical conditions that can cause erectile dysfunction

Treatment

In general, our doctors can suggest one of the common ED medications, such as:

These safe and effective oral medications may be all that you need to rid yourself of ED for good. They are called PDE5 inhibitors and were discovered accidentally to treat ED due to the vasodilating [TN5] side effects noted when used to treat another condition known as pulmonary hypertension, a condition that causes the lung blood vessels to constrict.

Our doctors will assess which PDE5 best suits your lifestyle. According to the Princeton Consensus Panel, men with ED should be categorized as having cardiac or vascular disease until shown otherwise and placed in low, intermediate, or high-risk categories.

However, this does not mean that they must avoid PDE5 inhibitors. Men who make the modifications in their lifestyles can safely use medications to treat ED and improve their sex life. Even patients with significant symptoms such as exercise-induced chest pain can be placed on PDE5 inhibitors since several studies show no adverse events. Consultation with a cardiologist is suggested in symptomatic men.

Despite its complexity, erectile dysfunction (ED) is readily corrected with medications to treat the underlying cause because ED serves as a gauge of overall health and fitness. Recurring ED may be a sign of underlying diseases such as diabetes, high cholesterol, high blood pressure, or depression. These systemic diseases impact the ability of blood vessels to dilate in every organ in the body, including the penis.

Q&A

Disclaimer: This is not medical advice. You and your physician will determine if and how you should take any medication prescribed to you following a medical consultation.

  1. [Guideline] Rosen RC, Jackson G, Kostis JB. Erectile dysfunction and cardiac disease: recommendations of the Second Princeton Conference. Curr Urol Rep. 2006 Nov. 7(6):490-6. 
  2. Gupta BP, Murad MH, Clifton MM, et al. The Effect of Lifestyle Modification and Cardiovascular Risk Factor Reduction on Erectile Dysfunction: A Systematic Review and Meta-analysis. Arch Intern Med. 2011 Sep 12. 
  3. Cheitlin MD, Hutter AM Jr, Brindis RG, Ganz P, Kaul S, Russell RO Jr, et al. ACC/AHA expert consensus document. Use of sildenafil (Viagra) in patients with cardiovascular disease. American College of Cardiology/American Heart Association. J Am Coll Cardiol. 1999 Jan. 33(1):273-82. 
  4. Jackson G, Kloner RA, Costigan TM, Warner MR, Emmick JT. Update on clinical trials of tadalafil demonstrates no increased risk of cardiovascular adverse events. J Sex Med. 2004 Sep. 1(2):161-7. 
  5. Nehra A, Jackson G, Miner M, Billups KL, Burnett AL, Buvat J, et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc. 2012 Aug. 87(8):766-78. 

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