Men’s Health

Men’s Health

Erectile Dysfunction (ED)

Erectile Dysfunction (ED) — also known as impotence — is the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance.

It is a common yet often underdiagnosed condition that can significantly impact self-esteem, relationships, and quality of life, and may serve as an early indicator of underlying cardiovascular or metabolic disease. ED is not just a sexual health issue — it is a multifactorial medical disorder involving vascular, neurological, hormonal, and psychological components.

  • Globally, over 300 million men are estimated to be affected by some degree of ED.
  • Prevalence increases with age: About 40% of men at age 40 and 70% by age 70 experience ED.
  • The incidence is also rising among younger men due to lifestyle factors, stress, and metabolic syndrome.
  • ED is frequently associated with diabetes, hypertension, obesity, and dyslipidaemia, which impair vascular and endothelial health.

The burden of ED is not limited to sexual function — it also correlates strongly with depression, relationship problems, and reduced overall well-being.

Erectile dysfunction can result from organic, psychogenic, or mixed causes.

1. Organic Causes

  • Vascular (most common): Atherosclerosis, hypertension, hyperlipidemia → reduced penile blood flow.
  • Neurogenic: Diabetic neuropathy, spinal cord injury, multiple sclerosis, pelvic surgery (e.g., prostatectomy).
  • Endocrine: Hypogonadism (low testosterone), thyroid disorders, hyperprolactinemia.
  • Medication-induced: Antihypertensives (β-blockers), antidepressants (SSRIs), antipsychotics, or alcohol.

2. Psychogenic Causes

  • Anxiety, depression, performance stress, relationship conflicts, and chronic stress.

3. Lifestyle Factors

  • Smoking, alcohol overuse, obesity, sedentary behaviour, and poor diet all impair vascular function and hormonal balance.

Erection is a neurovascular event controlled by complex interactions between psychological stimuli, nerve signals, vascular responses, and hormonal influences.

  1. Sexual stimulation triggers parasympathetic nerve activation, releasing nitric oxide (NO) in the penile tissue.
  2. NO activates guanylyl cyclase, increasing cyclic guanosine monophosphate (cGMP), which causes relaxation of smooth muscle in the corpora cavernosa.
  3. This allows blood to fill the penile sinusoids, leading to erection.
  4. The venous outflow is compressed, maintaining rigidity. After ejaculation or cessation of stimulation, phosphodiesterase type 5 (PDE5) breaks down cGMP, leading to detumescence (return to flaccidity).

In ED, this delicate system is disrupted by:

  • Endothelial dysfunction: Decreased NO production or bioavailability.
  • Vascular insufficiency: Arterial stenosis or venous leak.
  • Nerve damage: Reduced signal transmission.
  • Hormonal imbalance: Low testosterone reduces libido and erectile capacity.
  • Psychogenic inhibition: Cortisol and anxiety inhibit parasympathetic activity

Typical features include:
  • Difficulty achieving or maintaining an erection firm enough for intercourse.
  • Reduced rigidity or duration of erection. Decreased sexual desire (libido).
  • Premature or delayed ejaculation (sometimes coexisting).
  • Morning erections may be absent or diminished in organic ED but preserved in psychogenic causes.
  • Symptoms may develop gradually (suggesting organic origin) or suddenly (suggesting psychogenic).

Diagnosis aims to identify the underlying cause and rule out systemic diseases.
1. Clinical Evaluation
  • Medical history: Onset, duration, severity, and pattern (situational vs consistent).
  • Medication and lifestyle review.
  • Sexual and psychosocial history.
2. Physical Examination
  • Blood pressure, BMI, secondary sexual characteristics, genital and vascular examination.
3. Laboratory Tests
  • Fasting blood glucose and HbA1c: To detect diabetes.
  • Lipid profile: Assess cardiovascular risk.
  • Serum testosterone: Morning sample to check for hypogonadism.
  • Prolactin and thyroid function tests: For hormonal imbalances.
4. Specialized Diagnostic Tests
  • Nocturnal penile tumescence testing: Differentiates organic from psychogenic ED.
  • Penile Doppler ultrasound: Evaluates arterial inflow and venous leak.
  • Intracavernosal injection test: Assesses penile vascular response.
  • Neurophysiological studies: When neurological causes are suspected

Effective management of ED requires addressing lifestyle, psychological, hormonal, and vascular components.

1. Lifestyle and Risk Factor Modification
  • Smoking cessation and alcohol moderation.
  • Regular physical activity (improves endothelial function and testosterone).
  • Weight reduction in obesity.
  • Glycemic and blood pressure control in diabetics.
  • Healthy diet rich in antioxidants, omega-3s, and L-arginine.
2. Psychological and Behavioral Therapy
  • Individual or couples counseling for anxiety, depression, or relationship issues.
  • Cognitive-behavioral therapy (CBT) for performance anxiety.
  • Sexual education to restore confidence and reduce stress.
3. Pharmacological Treatment
a. Phosphodiesterase Type 5 (PDE5) Inhibitors – First-Line Therapy
These agents enhance the effect of nitric oxide by inhibiting PDE5-mediated cGMP degradation, prolonging smooth muscle relaxation and erection.
Common agents include:
Common agents include:
  1. Sildenafil (Viagra®) – onset in 30–60 minutes, duration ~4 hours.
  2. Tadalafil (Cialis®) – longer duration up to 36 hours, suitable for daily use.
  3. Vardenafil (Levitra®) – similar efficacy to sildenafil.
  4. Avanafil – rapid onset and improved tolerability.
Important: PDE5 inhibitors require sexual stimulation to be effective and should not be used with nitrates (risk of severe hypotension).

b. Hormonal Therapy
Testosterone replacement therapy (TRT): For men with clinically confirmed hypogonadism.
Can be given as gels, injections, or transdermal patches.
Improves libido, mood, and erectile response when testosterone is low.

c. Intracavernosal or Intraurethral Therapies
  • Alprostadil (PGE₁): Direct vasodilator injected into the corpus cavernosum or inserted as a urethral suppository.
  • Combination injections: Papaverine + Phentolamine + Alprostadil (Trimix) for resistant cases.
d. Second-Line and Device-Based Therapies Vacuum erection devices (VED):
  • Create negative pressure to draw blood into the penis, maintained with a constriction ring.
  • Penile constriction rings: Used for venous leak prevention.

e. Surgical and Regenerative Approaches
1. Penile Prosthesis Implantation: For refractory cases, malleable or inflatable penile prostheses provide permanent mechanical rigidity with high satisfaction rates.
2. Vascular Reconstructive Surgery: For younger men with focal arterial injury (rarely indicated).

3. Regenerative / Endothelial-Protective Approaches (“Neurovascular Protective” Concept): Analogous to “chondroprotection” in osteoarthritis, current research focuses on protecting and regenerating neurovascular integrity through:

  • Low-intensity shockwave therapy (Li-ESWT): Stimulates angiogenesis and nerve regeneration.
  • Platelet-rich plasma (PRP) injections: Growth factors promote tissue repair and endothelial function.
  • Stem cell therapy: Experimental; aims to restore smooth muscle and endothelial cells.
  • Nutraceuticals: L-arginine, Pycnogenol®, ginseng, zinc, and vitamin E support nitric oxide production and vascular health.
This neurovascular-protective paradigm shifts ED management from symptomatic relief to restoring normal penile physiology.

  • Relationship and marital strain.
  • Depression, anxiety, and reduced self-confidence.
  • Infertility (due to inability to complete intercourse).
  • Cardiovascular events — ED often precedes coronary artery disease by 3–5 years, serving as a warning sign of endothelial dysfunction.

  • Maintain cardiovascular health through diet, exercise, and blood pressure control.
  • Stop smoking and limit alcohol.
  • Manage diabetes and cholesterol effectively.
  • Monitor testosterone and treat hormonal deficiencies.
  • Avoid misuse of anabolic steroids or recreational drugs.
  • Regular check-ups for men over 40, especially with risk factors

Consult a healthcare provider if you experience:

  • Persistent difficulty achieving or maintaining erections.
  • Decreased sexual desire or premature ejaculation.
  • Symptoms of low testosterone (fatigue, low mood, reduced muscle mass).
  • ED accompanied by chest pain, shortness of breath, or other cardiovascular symptoms.
  • ED developing after pelvic surgery or trauma.
  • Early assessment can restore sexual function, improve psychological well-being, and detect systemic disease early.

  • Sachs G, Shin JM. Mechanism of action of PPIs. Aliment Pharmacol Ther. 2001;15(2):15–22 Feldman HA, et al.
  • Massachusetts Male Aging Study: prevalence and incidence of ED. J Urol. 1994;151:54–61.
  • Ayta IA, et al. Global prevalence of ED: systematic review. BJU Int. 1999;84:48–56.
  • Burnett AL, Nehra A, et al. AUA Guideline on the Management of ED.
  • Malavige LS, Levy JC. ED in diabetes. J Sex Med. 2009;6:1232–1247.