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Diagnosis and Causes of Erectile Disorder

Lorraine Benuto, Ph.D., edited by C. E. Zupanick, Psy.D.

Erectile Disorder, or "ED" as it is commonly known, is defined as an inability to achieve and/or maintain a satisfactory erection necessary for the completion of sexual activity. Erectile disorder can impact men of all ages. With the natural process of aging, additional health problems may develop, which may increase the probability of ED. It is estimated that 35% of men, ages 40-70, suffer from moderate or severe ED, and an additional 25% of men in this age group have a mild ED (Ellsworth & Kirshenbaum, 2008).

upset older man A successful erection requires a healthy brain, a flexible circulatory system, completely functional nerves, and several hormones. When a man receives erotic stimulation, his nervous system responds by sending chemical messages to the pelvic region. This causes the smooth muscle in the penis to relax which allows the veins to dilate and blood to fill the corpus cavernosum (these are cave-like cavities located inside the shaft of the penis). When the corpus cavernosum expands, pressure is applied to the veins in the penis, keeping the blood trapped in the penis.

Clearly the process of achieving an erection is complicated. Many different systems are involved. Thus, ED can be caused a by a problem in any one of these systems. Erectile dysfunction is currently viewed as a symptom of an underlying disease that may affect nerves, arteries, or veins. Erectile dysfunction remains an under-diagnosed and under-treated condition that negatively affects the quality of life of both the man and his partner(s). Sexual health has been shown to be an important part of overall well-being. And, successful treatment of ED is associated with significant improvements in ratings of overall physical and emotional well-being (Ellsworth& Kirshenbaum, 2008). While there are a wide variety of treatment options available, many men do not seek out treatment.

While men who experience ED may feel embarrassed, frustrated, and worthless, their partners are also affected. Our society and culture places such a premium on the penis and the penis' ability to function at unrealistic standards. This may make it difficult for a man to discuss his concerns with his partner and doctor. Erectile dysfunction can become a vicious cycle. When a man is unable to perform sexually, the next time he finds himself in a sexual situation it is likely that he will be thinking about the time where he was not able to achieve an erection. This can create anxiety and while small quantities of anxiety can enhance sexual performance, excessive amounts of anxiety cause a surge of adrenaline, which is an erection's worst enemy. The partner of a man with erectile dysfunction may feel they are to blame for the lack of an erection. This in turn affects their own arousal and lead to feelings of hurt, frustration, and even anger. It is important to keep in mind that while relationship troubles can certainly impact sexual function, there are many causes of erectile disorder. Partners can find additional information in this section.

To be diagnosed with Erectile Disorder, at least one of the three following symptoms must be experienced on 75-100% of occasions of sexual activity for at least 6 months:

  • marked difficulty in obtaining an erection during sexual activity
  • marked difficulty in maintaining an erection until the completion of sexual activity
  • marked decrease in erectile rigidity

The symptoms must cause a great deal of stress in the person's life.

The symptoms must not be the result of a nonsexual mental health condition, happening because of severe stress, because of a medical condition, or due to a medication taken (prescription or drug of abuse).

The clinician should specify whether the condition is:

  • Lifelong - the problems have been present since the person became sexually active
  • Acquired - the problems began after a period of relatively normal sexual function

It should also be noted whether it is:

  • Generalized - not limited to certain types of stimulation, situations or partners
  • Situational - only happens with certain types of stimulation, situations or partners

Finally, the condition can be mild, moderate or severe depending on the level of stress over the symptoms that are happening.

Causes of Erectile Disorder

Oftentimes ED is not an illness of its own, but rather it is due to another medical condition. Erectile disorder may be caused by physical or psychological factors, or a combination of both. Sometimes the cause cannot be determined.

Physical factors that may cause erectile disorder include (but are not limited to):

  • hypertension
  • diabetes
  • problems with the prostate
  • heart problems
  • a side effect of certain medications
  • a deformity of the penis
  • lesions in the spine
  • substance use/abuse

However, the most common cause of erectile disorder is a condition called atherosclerosis. In our discussion of how an erection is achieved, we stressed that there are many factors that contribute to a healthy erection. Atherosclerosis is caused by damage to the cells that line blood vessels (endothelial cells). The damage to these cells causes a decrease in nitric oxide production. This is the key neurotransmitter (chemical messenger) in the brain during the normal erectile process. These cells are damaged by oxidative stress which can be caused lifestyle choices: a diet that includes excessive fats and sugars, smoking, and excessive consumption of alcohol.

A large number of men presenting with erectile disorder have an identifiable, physical cause. However, there are other less apparent, psychological causes for ED such as relationship difficulties (Ellsworth & Kirshenbaum, 2008). Depression, drug and alcohol abuse, anxiety, stress, performance anxiety, and relationship problems are often reported by men experiencing erectile dysfunction. Many men may believe that erectile disorder is "all in their head" when there are many physical and psychological factors that can be related to the condition. Another common myth often observed among patients is the idea that there is no cure or treatment. While a cure for erectile disorder may not be available, there are many effective treatment options.