Erectile dysfunction

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Erectile dysfunctionis a sexual dysfunction characterized by the inability to develop or maintain an erection of the penis. There are various underlying causes, such as cardiovascular leakage and diabetes, many of which are medically treatable. The causes of erectile dysfunction may be physiological or psychological. Physiologically, erection is a hydraulic mechanism based upon blood entering and being retained in the penis, and there are various ways in which this can be impeded, most of which are amenable to treatment. Psychological impotence is where erection or penetration fails due to thoughts or feelings (psychological reasons) rather than physical impossibility; this can often be helped. Notably in psychological impotence there is a very strong placebo effect. Erectile dysfunction, tied closely as it is to cultural notions of potency, success and masculinity, can have devastating psychological consequences including feelings of shame, loss or inadequacy; often unnecessary since in most cases the matter can be helped. There is a strong conspiracy of silence (expression)|culture of silence and inability to discuss the matter. In fact around 1 in 10 men will experience recurring impotence problems at some point in their lives.^[1] Folk remedies have long been advocated, with some being advertised widely since the 1930s. The introduction of the first pharmacologically approved remedy for impotence, sildenafil (trade name Viagra), in the 1990s caused a wave of public attention, propelled in part by heavy advertising. The Latin term impotentia coeundi describes simple inability to insert the penis into the vagina. It is now mostly replaced by more precise terms. The study of erectile dysfunction within medicine is covered by andrology, a sub-field within urology.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Dr. John R. Brinkley initiated a boom in male impotence cures in the US in the 1920s and 1930s. His radio programs recommended expensive goat gland implants and “mercurochrome” injections as the path to restored male virility, including operations by surgeon Serge Voronoff. After the Kansas State Medical Board revoked his medical license and the Federal Radio Commission refused to renew his radio license (both in 1930), Brinkley moved his operations just over the Texas border to Mexico where he opened a medical clinic and broadcast advertisements into the US from a border blaster radio station.

Surgeons began providing patients with inflatable penile implants in the 1970s.

Modern drug therapy for ED made a significant advance in 1983 when British physiologist Giles Brindley, Ph.D. dropped his trousers and demonstrated to a shocked American Urological Association audience his phentolamine-induced erection. The drug Brindley injected into his penis was a non-specific vasodilator, an alpha-blocking agent, and the mechanism of action was clearly corporal smooth muscle relaxation. The effect that Brindley discovered established the fundamentals for the later development of specific, safe, orally-effective drug therapies.^[1]

Reference: Helgason ÁR, Adolfsson J, Dickman P, Arver S, Fredrikson M, Göthberg M, Steineck G. Sexual desire, erection, orgasm and ejaculatory functions and their importance to elderly Swedish men: A population-based study. Age and Ageing. 1996:25:285-291.[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Penile erection is managed by two different mechanisms. The first one is the reflex erection, which is achieved by directly touching the penile shaft. The second is the psychogenic erection, which is achieved by erotic or emotional stimuli. The former uses the peripheral nerves and the lower parts of the spinal cord, whereas the latter uses the limbic system of the brain. In both conditions an intact neural system is required for a successful and complete erection. Stimulation of penile shaft by the nervous system leads to the secretion of nitric oxide (NO), which causes the relaxation of smooth muscles of corpora cavernosa (the main erectile tissue of penis), and subsequently penile erection. Additionally, adequate levels of testosterone (produced by the testes) and an intact pituitary gland are required for the development of a healthy male erectile system. As can be understood from the mechanisms of a normal erection, impotence may develop due to hormonal deficiency, disorders of the neural system, lack of adequate penile blood supply or psychological problems. Restriction of blood flow can arise from impaired endothelial function due to the usual causes associated with coronary artery disease, but can also include causation by prolonged exposure to bright light or chronic exposure to high noise levels.

A few causes of impotence may be iatrogenic (medically caused). Various antihypertensives (medications intended to control high blood pressure) and some drugs that modify central nervous system response may inhibit erection by denying blood supply or by altering nerve activity.

Surgical intervention for a number of different conditions may remove anatomical structures necessary to erection, damage nerves, or impair blood supply.Complete removal of the prostate gland or external beam radiotherapy of the gland are common causes of impotence; both are treatments for advanced prostate cancer. Some studies have shown that male circumcision may result in an increased risk of impotence,^[1][2] while others have found no such effect,^[3][4][5] and another found the opposite.^[6]

Excessive alcohol use has long been recognised as one cause of impotence, leading to the euphemism “brewer’s droop,” or “whiskey dick;” Shakespeare made light of this phenomenon in Macbeth.

A study in 2002 found that ED can also be associated with bicycling. The number of hours on a bike and/or the pressure on the penis from the saddle of an upright bicycle is directly related to erectile dysfunction.^[7]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Psychogenic
• Genitourinary trauma
• Anxiety
• Depression
• Drug-induced
• Vascular disease
• Neurologic disease

• Acromegaly
• Addison’s Disease
• Adiposogenital dystrophy
• Advanced age
• After sexual abuse
• After testicle injury or infection
• Aging
• Angitis obliterans
• Apoplexy
• Arteriosclerosis
• Autoantibodies against sperm
• Azoospermia
• Balanitis
• Cachexia
• Castration
• Chemotherapy
• Chronic hepatopathy
• Chronic Renal Failure
• Circulatory disorders
• Cirrhosis
• Conus Medullaris Syndrome
• Cryptorchidism
• Depression
• Diabetes Mellitus
• Drugs, toxins
• Epididymitis
• Epispadia
• Exhaustion
• Exogenous testosterone substitution
• Gonadal agenesis
• Heart failure
• Histrelin
• Hormone secreting adrenocortical tumors
• Hydrocele
• Hyperadrenocorticalism
• Hyperprolactinemia
• Hypertension
• Hyperthyroidism
• Hypogonadism
• Hypopituitarism
• Hypospadia
• Hypothyroidism
• Idiopathic
• Incomplete descent of one or both testes
• Insecurity
• Klinefelter’s Syndrome
• Leriche’s Syndrome
• Lipid metabolism disorders
• Lymphoma
• Male menopause
• Male pseudohermaphroditism
• Multiple Sclerosis
• Mumps
• Nafarelin
• Necrospermia
• Noonan’s Syndrome
• Oligospermia
• Orchitis
• Paraplegia
• Paroxetine
• Pelvic ring fracture
• Phimosis
• Pituitary adenoma
• Polyneuropathy
• Priapism
• Prolapsed disk
• Prostatitis
• Pyelitis
• Radiation therapy
• Reifenstein’s Syndrome
• Relationship conflict
• Renal anomaly
• Repressed homoeroticism
• Schizophrenia
• Sertoli-cell-only syndrome
• Severe systemic diseases
• Sorafenib
• Spermatocytosis
• Stress
• Surgery
• Tabes Dorsalis
• Testicular hypoplasia
• Testicular torsion
• Testicular trauma
• Testosterone deficiency
• Triptorelin pamoate
• Tuberculosis
• Tuberous Sclerosis
• Tumor of the genital organs
• Urethritis
• Varicocele
• Vilazodone

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Erectile dysfunction must be differentiated from other diseases such as non sexual mental disorders, normal erectile function, substance use and medication use.^[1]

• Nonsexual mental disorders

• Major depressive disorder

• Normal erectile function
• Substance/medication use
• Another medical condition

• Diabetes mellitus
• Psychological events

• Other sexual dysfunctions

• Male hypoactive sexual desire disorder
• Premature (early) ejaculation^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

The prevalence of lifelong versus acquired erectile disorder is unknown^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Risk factors for erectile dysfunction includes age, smoking tobacco, lack of physical exercise, and diabetes.^[1]

• Alexithymia
• Age
• Diabetes
• Decreased desire
• Depression
• Lack of physical exercise
• Neurotic personality traits
• Post traumatic stress disorder
• Submissive personality traits
• Smoking tobacco^[1]

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