As a male in my 40s, I’m part of a group that faces some common physical and mental health challenges, such as receding hairlines, bicep tendon tears, and erectile dysfunction (ED). Though many guys seem to think ED is just an issue related to low testosterone, the causes of erectile dysfunction are many.
In this article, I’ve outlined the majority of ED causes and many of the most common treatments. Although most men face a situation now and then when it’s difficult to get it up or keep it up, this deserves your full attention if it’s an ongoing issue. Erectile dysfunction may be a sign of something severe.
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What is erectile dysfunction (ED)?
The definition of erectile dysfunction (ED), also known as impotence, is “the inability to achieve or maintain an erection that is sufficient for satisfactory sexual performance.”
Your nervous, muscular, and vascular systems must work in concert to form and maintain a firm erection. Stimulated by thought, touch, or REM sleep, nitric oxide (NO), acetylcholine, and other chemical messengers signal the penis’ smooth muscle to relax. As the muscles relax, your corpora cavernosa fills with blood. As it fills with blood, the veins leaving the penis get blocked, allowing it to fill with more blood until it’s full. As long as the veins remain blocked, you’ll maintain your erection.
Erections fall into two categories:
- Reflex erections: Controlled by peripheral nerves and the spinal cord and triggered by physical touch
- Psychogenic erection: Controlled by the limbic system of the brain and triggered by erotic or emotional stimuli (like seeing your naked wife)
The Massachusetts Male Ageing Study (MMAS) found that 52% of men ages 40-70 years displayed mild to moderate ED signs. Interestingly, another report showed that one in four men seeking medical guidance for ED are less than 40 years old.
Though erectile dysfunction is not itself a lethal condition, it may indicate a physical health problem that could be deadly. On the other hand, it could also be a sign of a less threatening physical condition or a mental health condition.
Causes of ED
Though many men jump to the conclusion that they have low testosterone, their hormones might not have anything to do with their lack of sexual function. Then again, testosterone could play a role.
If you have erectile dysfunction, consider the following 14 causes before jumping to the conclusion on the cause of yours.
The first four causes are the most common.
1. Cardiovascular Disease
Erectile dysfunction is one of the first signs of cardiovascular disease. Because the vessels of the penis are much smaller than those of the heart, vascular damage affects penile function before cardiac signs show up.
About one in three men with hypertension develop erectile dysfunction. High blood pressure alone doesn’t cause cardiovascular disease, though. Increased blood pressure may cause blood vessel damage, which is exacerbated by elevated and oxidized LDL cholesterol and high systemic inflammation levels.
The same factors that lead to heart disease, heart attacks, and strokes lead to erectile dysfunction. However, those warning signs show up in penile function long before they show up as symptoms in the heart.
ED may precede cardiovascular disease by a significant period that usually ranges from 2 to 5 years (3 years in average)Wang JM et al.
While ED may be a serious warning sign, the good news is, you may be able to stall or even reverse some of the cardiovascular damage before it causes heart disease.
2. Sleep problems
Inadequate sleep wreaks havoc on your mental and physical health. Though some hardass men cling to the adage, “Sleep when you die,” the reality is, without sufficient quality sleep, you’ll be dead a lot younger than you should be. Don’t buy into that nonsense.
Your first indicator of inadequate sleep’s impact on sexual function is a reduction in morning erections. If the last time you had a morning erection was while living with your parents in high school, that’s a serious problem. For many guys, after a couple of weeks of quality sleep, they wake up in the morning standing tall.
Studies show that shift work, obstructive sleep apnea, and other sleep disorders increase the risk of erectile dysfunction. Of all of the erectile dysfunction causes, inadequate sleep is the easiest to correct.
Also, with adequate sleep, many men (and women) find their excess weight falls off, their brains work better, and their moods lift from a cloud of despair and fatigue.
Medication causes erectile dysfunction in about 25% of cases. Eight of the twelve most prescribed medications in the United States list ED as a potential side effect. The medications list includes most antidepressants, diuretics, blood pressure medications, ACE inhibitors, and beta-blockers.
If you can change your lifestyle and diet in a way where you wouldn’t need the medication, suck it up and change your diet and lifestyle.
4. Depression, anxiety, or other mental health issues
According to one meta-analysis, the risk of ED increases by 39% when men have depression. On the flip side, having ED increases the risk of depression by 192%.
So, the physiology of depression may cause a slight increase in ED risk, but when someone who doesn’t have depression develops ED, it significantly increases the risk of depression.
That makes sense, though. After all, a man’s ability to get and maintain an erection instills confidence because it tells him he’s still reasonably vigorous. On the other hand, if a man wants to get it up and can’t, it will probably be a blow to his self-esteem.
Unfortunately, antidepressants cause sexual dysfunction in 26-80% of patients, depending on the medication. Although antidepressants may be necessary and help some people feel better, if they’re depressed and have ED, they may only help resolve the depression, not the ED.
Relationship problems, performance anxiety, and other mental stress may affect erectile function and sexual arousal.
A firm erection requires healthy muscle function. In this case, the corporal smooth muscle must remain relaxed to allow blood to flow in and the venous return to remain blocked. If the corporal muscle stops relaxing, you lose your erection.
With just a 15% reduction in corporal smooth muscle function, it’s almost impossible to maintain an erection.
Not surprisingly, then, as men age and lose general muscle function, they also lose some function in this muscle, leading to an increased rate of erectile dysfunction.
Also, older men tend to have more cardiovascular disease, have lower testosterone, and take multiple medications, which can all compromise sexual function.
It is well established that men who engage in sexual activity are happier, live longer, are less depressed and definitely do experience a better quality of life.Ferrini MG et al.
6. Type II Diabetes and/or Metabolic Syndrome
People with type II diabetes have triple the risk, and those with metabolic syndrome are 2.6 times more likely than those without it, to develop ED.
Chronically elevated blood sugar creates free radicals, which lead to blood vessel and nerve damage. Elevated blood glucose also causes muscle tissue dysfunction and impairs nitric oxide availability, sabotaging multiple parts of the erection process.
About four out of five people with type II diabetes are also overweight or obese, which further increases ED risk.
The most common injuries that lead to erectile dysfunction include:
- treatment for prostate disease
- trauma to the area from sports, activities, or accidents
- spinal cord injury
Some research indicates that cycling long distances over time can lead to ED, although other research refutes the findings.
Anything that compromises the nervous or muscular function in the area can lead to ED.
8. Kidney disease
About 70% of men with chronic kidney disease (CKD) develop erectile dysfunction. However, kidney disease itself may not always cause ED. Like many with ED, those with CKD tend to be obese, smokers, diabetic, hypertensive, and/or have cardiovascular disease.
It may be that those risk factors cause both chronic kidney disease and erectile dysfunction, rather than CKD causing ED.
9. Low Thyroid
When it comes to hormones and ED, most people think of testosterone. However, thyroid hormone also plays a critical role.
Low thyroid (hypothyroidism) triggers an increase of thyroid stimulating hormone (TSH). This reduces luteinizing hormone and gonadotropin-releasing hormone, which are necessary for normal sexual activity.
Unfortunately, few doctors check thyroid levels in their male patients. Yet, thyroid function also plays a significant role in maintaining healthy cholesterol levels, brain function, and body composition, too.
10. Low testosterone
Total testosterone levels may not play as significant a role in erectile function as free testosterone levels do.
Free testosterone is available to act on target tissues, whereas the rest of the total testosterone is bound and unavailable. Under stress or because of genetics, sex hormone-binding globulin (SHBG) can remain elevated. SHBG binds testosterone, keeping it from being available to do its job.
A man with lower total testosterone and lower SHBG may have higher free testosterone levels than men with high total testosterone levels. Personally, my total testosterone hovers around 1000-1200 mg/dL, but my SHBG is always on the high end as well. As a result, I have a harder time putting on muscle than some of my friends who have lower total testosterone, but higher free testosterone.
All that to say that the erectile dysfunction—testosterone connection isn’t as straightforward as many men believe it is.
Low testosterone, if it leads to lower free testosterone, or elevated estradiol (a measure of estrogen levels), or both, can cause erectile dysfunction. Anti-androgen supplements lead to such a testosterone/estradiol imbalance.
Interestingly, even in men that don’t have a testosterone problem, testosterone therapy reduces the occurrence of erectile dysfunction.
Testosterone affects the penis tissue’s ability to form an erection and impacts the mental aspect of gaining arousal. It helps maintain veno-occlusive function. Said a different way, testosterone helps reduce venous leakage from the penis.
Hormone replacement therapy (HRT) can be an effective treatment for ED. However, HRT may pose other health risks, so it isn’t necessarily a good choice.
11. Overweight and Obesity
Not surprisingly, overweight and obesity increase the risk of erectile dysfunction. Carrying the extra body fat might lead to emotional changes and cause depression, which is one factor in ED. Of course, excess body fat can increase inflammation, raise blood pressure, contribute to blood sugar and cholesterol problems, and increase estrogen and decrease testosterone levels.
Each of the above factors individually can contribute to ED. Combining them increases the risk.
Regardless of one’s feelings, the fact is, being overweight or obese increases your risk of health problems. That runs contrary to the “healthy at any weight” dogma popularized in media today, but that dogma isn’t based in reality.
12. Parkinson’s disease or multiple sclerosis
Neurological damage can cause erectile dysfunction. For men younger than 40 years of age, multiple sclerosis more than doubles the risk of ED. Epilepsy, parkinson’s disease, and many other neurological disorders increase the risk of erectile dysfunction.
Chances are, though, erectile function is low on the priority list when dealing with these conditions. Once the disease or condition is under control, you may consider some natural or medical therapies to restore sexual function.
13. Peyronie’s Disease
According to the Mayo Clinic, “Peyronie’s (pay-roe-NEEZ) disease is a noncancerous condition resulting from fibrous scar tissue that develops on the penis and causes curved, painful erections. Penises vary in shape and size, and having a curved erection isn’t necessarily a cause for concern. But Peyronie’s disease causes a significant bend or pain in some men.”
The pain prevents many men from forming and maintaining an erection. In the chronic phase of the condition, medical therapy may be required to return normal function. Treatment includes injection treatments, traction therapy, and surgery.
14. Vitamin B12 deficiency or toxicity
Of all the causes of erectile dysfunction, vitamin B12 imbalance is the most recently discovered and is least known by doctors. For healthy erectile function, you need a “Goldilocks” amount of vitamin B12…not too much, not too little.
Vitamin B12 deficiency can contribute to nerve problems, which could lead to ED. On the flip side, excessive vitamin B12, like the amounts used in B12 injections, can also lead to erectile dysfunction.
Acupuncture & Massage
According to a recent systematic review and meta-analysis, acupuncture did not consistently improve symptoms of erectile dysfunction. It certainly won’t make it worse, though.
Massage involves treating the area around the penis to increase blood flow. While it may work, research doesn’t show a compelling benefit from massage either.
Many nutritional supplements show a small level of success in supporting erectile function. Most directly or indirectly affect nitric oxide levels. The increased nitric oxide helps relax the smooth muscle and increases blood vessel size, improving blood flow.
The most scientifically supported supplements include rhodiola rosea, panax ginseng, yohimbine, and L-arginine. Consuming more nitrates may also improve nitric oxide levels.
Dehydroepiandrosterone (DHEA) is a weak androgenic hormone. Research shows that lower DHEA levels associate with a higher incidence of erectile dysfunction. But that association may exist only because DHEA levels fall with age. Low DHEA likely doesn’t cause ED. Thus far, taking supplemental DHEA does not seem to improve ED symptoms.
Diet & Lifestyle
To support healthy erectile function, eat a higher-protein diet and plenty of leafy, green vegetables.
High-protein diets improve body composition, stabilize blood sugar, support healthier triglyceride and blood pressure levels, and may improve mood. Leafy, green vegetables provide a dense source of nitrates, which enhance nitric oxide levels.
You might wonder what impact alcohol has on erectile function. Many guys have experienced what happens when you drink so much alcohol in an evening of afternoon that by the time you’re under the covers with your significant other, you can’t get it to work.
Excess alcohol in a single evening kills an erection. But that’s not erectile dysfunction. It’s alcohol intoxication.
Interestingly, a moderate alcohol intake, similar to its effects on cardiovascular disease, lowers the risk of erectile dysfunction. Excessive, chronic alcohol consumption increases risk.
As already mentioned, sleep is critical for erectile function as well as many other aspects of health. Get at least seven hours of sleep every night. And, of course, stop smoking.
Strength training not only builds muscle and improves body composition, but it also enhances testosterone production. For the investment of your time, nothing beats a well-designed strength training program for improving overall health and wellbeing.
When natural alternatives aren’t enough, many medical treatments exist to treat erectile dysfunction. Some carry side effects. All work better when used in addition to good nutrition and lifestyle choices.
Oral medications include phosphodiesterase type 5 (PDE5) inhibitors such as sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®), and avanafil (Stendra®). Tadalafil can be taken daily, whereas the others are only intended for use prior to intercourse.
As an alternative to oral medication, a doctor may recommend intracavernosal injections, where medication is injected into the base of the penis. Though that might cause your stomach to squirm, a doctor may recommend injections when oral medication is contraindicated, such as for those on heart attack-related medication. Intraurethral suppositories provide an alternative to injections, though I’m not sure that sounds any less painful.
Additional therapies include penile shockwave therapy, vacuum pumps, and penile prostheses.
While these may be necessary choices for those with extreme cases, the reality is this: Most men can significantly improve their erectile function by making consistently better lifestyle, diet, supplement, and exercise choices.
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