Erectile dysfunction (ED), which is sometimes referred to as impotence, is the inability to achieve or maintain an erection. There are three types of erectile dysfunction: primary, secondary, and situational. Primary erectile dysfunction occurs when a person has never been able to obtain an erection during sexual activity; in other words, their struggle with ED has been a lifelong experience. Secondary erectile dysfunction is more common and occurs when a person has had the ability to obtain an erection and engage in sexual activity in the past but no longer can. Situational erectile dysfunction occurs when a person experiences erectile problems only on certain occasions (e.g., when they are engaging in sex with a new partner and experience “performance anxiety”). These three types of erectile dysfunction may affect self-confidence or cause undue stress in relationships. Having erectile difficulties can be a very troublesome and frustrating experience for many people. It is important to know that erectile dysfunction is very common and very treatable.

Causes and Symptoms

There are many factors that can interfere with a person’s ability to obtain or maintain an erection. The most common factor is age. The worldwide prevalence of erectile dysfunction has been predicted to reach 322 million cases by the year 2025.¹ ED has is now regarded as a major health problem for the increasingly healthy ageing population. Erectile dysfunction primarily affects people older than 40 years of age. With increasing age comes potentially increased physiological and psychological problems, which can be related to erectile difficulties. However, this does not mean that every person over the age of 55 experiences erectile disorders. In fact, some older people maintain erectile function well into their eighties.

One common cause of erectile problems is poor blood circulation in the body, particularly in the penis. The penis becomes erect when blood flows into the cavernous and spongy tissue that runs the length of the penis. Several circulatory problems can limit the speed at which blood can flow into the penis, and increased circulatory problems can create increased erectile problems. People with low blood pressure, blood clots, and/or heart problems are more likely than others to experience erectile difficulties. Furthermore, the use of cardiovascular medication has an impactful effect on erectile dysfunction, as they increase the risk of ED.² People who use alcohol, nicotine, cocaine, and other drugs that can impair sexual functioning are also at risk of erectile problems.

Stress and Anxiety

Stress and anxiety are major causes of erectile problems that are often overlooked. If a person is experiencing considerable pressure at work, facing relationship difficulties, or undergoing a myriad of other hardships, they may have difficulty obtaining an erection. This can be true for a variety of different reasons. In sexual situations, they may be distracted by pressing life issues rather than being fully immersed in the joys of sex and all the great ways to make it optimally exciting. These factors can prevent a person from experiencing the sexual stimulation required to produce a firm, long-lasting erection. High levels of stress can also affect a person by decreasing blood flow to the penis. A harmful domino effect can take place when erectile dysfunction is caused by stress; if a person is already stressed and has trouble obtaining or maintaining an erection with their partner or by themselves, feelings of frustration can lead to even more stress, thus creating a negative feedback loop. This new stress factor is called “performance anxiety.” Many sociologists have considered anxiety to be a contributing factor to the development of the various types of sexual dysfunctions in men and women. These sexual anxieties prevent an individual from experiencing sexual arousal and, in fact, inhibit autonomic nervous system functioning to such an extent that physiological arousal is impossible^3. Most people that have penises experience occasional erectile difficulties, and it is important to avoid feeling frustrated or stressed when issues do arise. By reducing the feelings of performance anxiety, a person is more likely to overcome the erectile issues they may be experiencing. It is important to breathe deeply, relax, and solve one problem at a time. If you are experiencing erectile difficulties, ask yourself the following questions:

1. Are there ways of reducing stress in your life?
2. Is your partner aware of your situation, and is there a way you can communicate with him or her to reduce performance anxiety?

In addition to stress, erectile dysfunction can also result from feelings of shame, guilt, fear, and/or other emotions that have been associated with sex during one’s life. If a person was raised in a strict religious family, they might have learned to believe that sex is a sin, and therefore may feel ashamed at the thought of engaging in any type of sexual activity, including masturbation. Perhaps their parents caught them masturbating one day and punished them for it. Or they had a negative sexual experience with a partner, leaving them feeling embarrassed or ashamed. Any negative experiences one may have had in the past could have made sex more stressful, thus causing erectile difficulties.

For some people, erectile dysfunction is actually caused by physiological problems rather than psychological ones. In these cases, those affected should see a doctor who can help diagnose the problem that is affecting their ability to obtain and maintain an erection. Drugs like Viagra have become a very popular remedy for erectile problems, but they should only be used if psychological difficulties have been ruled out by a doctor. If the aforementioned techniques yield no positive results, it can be very helpful to interview several doctors and clinical psychologists who know of advanced therapies that can help alleviate the condition. Please remember that erectile problems are very common and they can be treated successfully in most instances.

Treatments

Psychological Treatments

There is a growing understanding that assessments of ED treatment should include behavioral, psychological, and relationship factors that may be of significant concern to those affected by ED and their partners. Again, people may have had negative experiences with sex in the past, and this can lead to negative associations with sex.⁴ The way to combat these negative associations with sex is to change them to positive ones. Realize that masturbation is perfectly healthy and normal and is actually a great way to learn more about yourself and your sexuality. Recondition yourself by thinking about positive thoughts while masturbating. Learn more about the beauty of sex and how wonderful it can be in the context of a loving and honest relationship. Oftentimes, the best cure for a sexual difficulty is to openly communicate with one’s partner about what one is experiencing so that both people can solve the problem together. Try practicing the technique of sensate focus with your partner. Sensate focus is a therapy technique that is commonly used to treat sexual problems such as female anorgasmia, erectile difficulty, and low sexual desire. In time, you will be able to override the negative thoughts that could be causing ED and become more confident and happy during your sexual experiences.

Pharmacological Treatments

Sildenafil, also known as Viagra, has been the latest trend in the treatment of erectile dysfunction. This drug increases levels of nitric oxide by suppressing the body’s breakdown of cGMP (cyclic guanosine monophosphate), which regulates blood flow in the penis. Some side effects of Sildenafil include lightheadedness, dizziness, facial flushing, nasal congestion, indigestion, and (very rarely) a bluish tint in one’s vision. There are serious side effects when sildenafil is combined with certain drugs, such as nitroglycerin, and other nitrates that are taken to treat heart disease. Taking Viagra might also reduce romantic spontaneity because it has to be taken several hours before sexual intercourse for it to be effective. However, Sildenafil is a well-tolerated oral treatment for ED; its efficacy, excellent safety profile, lack of significant adverse events, convenient oral administration, and low rates of discontinuation from treatment suggest that Sildenafil may be a valuable agent for the management of patients with ED.⁵

Along with Viagra, two other FDA-approved drugs on the market to help people with erectile difficulties are Levitra, and Cialis. All three are scientifically proven to deal with erectile problems. In 1998, Viagra was the first erectile drug to come onto the market with FDA approval. In 2003, Levitra was introduced into the market with FDA approval. Cialis was approved in 2003 for alleviating erectile problems. There are also herbal substances available that supposedly help with erectile difficulties, but they have not received government approval.

Timing

Viagra and Levitra are effective for four hours, but require sexual excitation and genital stimulation, so a person who engages in any type of continued sexual activity is likely to achieve a firm erection and experience sexual climax. Cialis is effective for 36 hours, which gives couples a much longer “window of opportunity” to engage in sex.

External Vacuum Constriction Devices

There are numerous external mechanical aids that are FDA approved to aid in erectile dysfunction. Most of the devices require a prescription, so an evaluation by a doctor is necessary. The basic principle of vacuum constriction devices (sometimes referred to as “penis pumps”) is that a vacuum chamber is placed over the penis; a pump provides suction in the chamber, inducing an erection, while a rubber band is placed at the base of the penis to trap the blood in the penis. Vacuum constriction devices include the ErecAid system (distributed by Osbon Medical Systems Ltd.) and the Vacuum Erection Device (distributed by Mission Pharmacal Co.). People who use these need to understand that vacuum pumps may be difficult for some people to use and may cause penile trauma if used improperly.⁶ Users of vacuum constriction devices may experience painful ejaculation due to the constriction of the rubber band. Users also should be patient while relying on these devices, since they can diminish spontaneity of sexual intercourse. To help counteract this, males can integrate the device into foreplay and include their partner in the pumping action. People who use the device regularly usually find they can achieve an erection more quickly as they gain experience with the procedure.

Internal Devices

In cases of complete erectile dysfunction, in which tissue damage or other physiological problems prevent other solutions (such as Viagra) from being effective, penile implants may be the method of choice. The surgery needed to insert these implants is usually performed on people between the ages of 40 and 70 years because they will be rendered impotent and suffer irreversible tissue damage as a result of the surgery. This tissue damage will reduce the use of other treatments, such as any oral medication or external vacuum constricting devices. There are two types of implants: inflatable and non-inflatable implants. One possible complication of this procedure is infection, which can cause penile erosion and reduced penile sensation.

Intracavernosal Injection

Intracavernosal injection, or ICI, is best used when the cause of erectile dysfunction is neurological (result of brain damage). Vasoactive drugs are injected into the penis, which help facilitate erection by relaxing the smooth muscle tissues in the penis. Three common drugs used for this technique are Papaverine, Alprostadil, and Phentolamine. It should be noted that the majority of patients who discontinue intracavernosal injection remain sexually active yet do not progress to more invasive or effective therapies.⁷ However, there is a high success rate with this form of treatment for patients who cannot take oral medication and for people with diabetes, a spinal cord injury, or radical prostatectomy. Some people find this treatment unnerving because it involves inserting a hypodermic needle into the corpora cavernosa of the penis. Side effects include penile pain, priapism (a continuous, usually nonsexual erection), and fibrosis (the development of excess fibrous connective tissues in an organ).

Yohimbine

This natural substance is found in the bark of the West African Yohimbe tree. The drug that is derived from the chemicals in the Yohimbine tree increases penile firmness enough to help with milder forms of erectile dysfunction. It increases blood flow to the penis by indirectly increasing parasympathetic activity in the autonomic nervous system. The FDA has approved this drug, and it is available by prescription under such names as Yocon, Erex, and Yohimex. There are over-the-counter products containing Yohimbine, but a study conducted by the FDA concluded that the concentration of Yohimbine in these products is negligible and has little or no effect. Some side effects of this drug are anxiety and insomnia.

Intraurethral Therapy

The prescription drug Alprostadil and/or other prostaglandin drugs can also be inserted into the penis in pellet form through the urethral opening. This method is often called MUSE, which stands for medicated urethral system for erection; It is easy, fast, and produces erections after about 15 minutes by dilating blood vessels in the penis. Some side effects include hypotension (decreased or lowered blood pressure), priapism, urethral burning, syncope (a brief loss of consciousness associated with an inadequate flow of oxygenated blood to the brain), and penile pain. Males with partners who are (or may be) pregnant should not use this method, since it can travel through the placenta and impact fetal development.

Testosterone Therapy

Low testosterone is the cause of erectile dysfunction for a small fraction of males.  The National Institutes of Health consensus development panel on impotence stated that endocrine assessment of morning serum testosterone is generally indicated as part of the evaluation of erectile dysfunction.⁸ Treatment may involve injecting testosterone into the body or wearing testosterone patches on the skin.

Future Methods

There are new and exciting cures already in the works for treating erectile dysfunction. Although Viagra has become quite popular, it has a reputation for reducing spontaneity and has potentially serious side effects for people with heart problems. A new drug called Uprima claims to preserve spontaneity. This drug is placed under the tongue and takes effect in approximately twenty minutes. Another new and exciting treatment currently in development is called “gene therapy.” Still in its preliminary testing, gene therapy offers a treatment for erectile dysfunction that is quick, convenient, and has few side effects. Researchers are hoping to have the treatment administered via injection only once or twice a year. Others hope to effectively create a cream that will produce the same results without the use of hypodermic needles. Some gene therapy methods in development directly target smooth muscle tissue in the penis, while others are designed to increase the production of nitric oxide, which open blood vessels and causes vasocongestion.

Helpful Tips

The following are general guidelines that one can take to help prevent erectile dysfunction:

• Avoid smoking cigarettes (smoking constricts blood vessels and thus may inhibit blood flow to the penis)
• Exercise daily to maintain good blood flow
• Eat a well-balanced diet, which is necessary to achieve strong and lasting erections
• Drink alcohol in moderation or abstain from it completely; alcohol may inhibit sexual response and increase one’s anxiety about achieving an erection
• Create a relaxed environment before and during sexual activity to avoid stress or anxiety
• Maintain open communication with your partner to reduce stress and anxiety about sexual intercourse⁹

References

1. Shamloul, Rany, and Hussein Ghanem. “Erectile Dysfunction.” The Lancet, vol. 381, no. 9861, 2013, pp. 153–165., doi:10.1016/s0140-6736(12)60520-0
2. Shiri, R, et al. “Cardiovascular Drug Use and the Incidence of Erectile Dysfunction.” International Journal of Impotence Research, vol. 19, no. 2, 2006, pp. 208–212., doi:10.1038/sj.ijir.3901516.
3. Barlow, David H. “Causes of Sexual Dysfunction: The Role of Anxiety and Cognitive Interference.” Journal of Consulting and Clinical Psychology, vol. 54, no. 2, Apr. 1986, pp. 140–148., doi:10.1037/0022-006x.54.2.140.
4. Swindle, Ralph W., et al. “The Psychological and Interpersonal Relationship Scales: Assessing Psychological and Relationship Outcomes Associated with Erectile Dysfunction and Its
5. Wagner, G. “Clinical Safety of Oral Sildenafil Citrate (VIAGRATM) in the Treatment of Erectile Dysfunction—by Morales Et Al.” International Journal of Impotence Research, vol. 10, no. 2, 1998, pp. 74–74., doi:10.1038/sj.ijir.3900335.
6. Padma-Nathan, Harin. “Transurethral Drug Therapy for Erectile Dysfunction.” Penile Disorders, 2 Jan. 1997, pp. 159–162., doi:10.1007/978-3-642-60548-2_11
7. Sexton, Wade J., et al. “Comparison Of Long-Term Outcomes Of Penile Prostheses And Intracavernosal Injection Therapy.” The Journal of Urology, 1 Mar. 1998, pp. 811–815., doi:10.1097/00005392-199803000-00051.
8. Jain, Pankaj, et al. “Testosterone Supplementation For Erectile Dysfunction: Results Of A Meta-Analysis.” Journal of Urology, vol. 164, no. 2, 1 Aug. 2000, pp. 371–375., doi:10.1016/s0022-5347(05)67363-6.
9. LeVay, Simon, Janice I. Baldwin, and John D. Baldwin. Discovering Human Sexuality. Sunderland, MA: Sinauer Associates, 2012. Print​

Last Updated: 07 February 2019.