Causes Of Erectile Dysfunction

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Erectile dysfunction (ED), which worldwide is likely to affect in excess of 300 million men by 2025, is often either untreated or insufficiently treated. It can be a prelude to other serious illnesses and may be a cause or consequence of depression in affected individuals.  ED is a multifactorial condition and one of the most studied sexual phenomena. Some authors report an overall prevalence of ED of 52%.

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Have ED symptoms been linked to certain situations?

Being the most common sexual dysfunction in men, some ED symptoms have been linked with specific situations involving certain types of stimulation or partners. Other patients suffering from ED reported that it occurred in a generalized manner with all situations, stimulations, and partners.  Therefore, ED can be distinguished as lifelong ED (i.e., when the dysfunction has been present since the individual first became sexually active) or acquired ED (i.e., when ED emerges after a period of a relatively normal sexual function.)
Physical and psychological conditions are taught to be favouring the onset of ED. Physical factors, which can result from a deteriorated condition and can affect all ages are between the most frequent causes.
These include:

  • obesity
  • heart disease
  • smoking
  • diabetes mellitus
  • atherosclerosis
  • hypertension
  • neurologic disorders
  • alcohol abuse
  • hormonal abnormalities
  • hyperlipidaemia (or elevated levels of one or more lipids and/or lipoproteins in the blood)
  • vascular insufficiencies
  • cardiovascular diseases
  • myocardial infarctions.

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Hyperglycaemia, which is a main determinant of vascular and microvascular diabetic complications, may participate in the pathogenetic mechanisms of sexual dysfunction in diabetes.
Also, it should not be overlooked the fact that the first symptoms of ED can mask an underlying, serious cardiovascular problem. The effort of the heart to increase the blood flow required for erection is comparable to that required by the heart for vigorous exercise.  Erectile dysfunction may thus be considered analogous to coronary heart disease (CHD), arising from the blockage of small vessels and reduced arterial compliance. The role of lipid levels is well-known in CHD; the association between hyperlipidaemia and ED is attributed to the impairment of endothelium-dependent relaxation in smooth muscle cells of the corpus cavernosum by hypercholesterolemia.
This was confirmed by a study of men with diabetes with ED problems compared with other groups of patients without erectile problems. The conclusion of the study was that ED was the most efficient predictor of coronary artery disease. There are many studies suggesting that ED is a significant predictor of cardiovascular risk factors and vice versa.
Psychological factors have demonstrated an increased role in ED onset.
These include:

  • unrealistic expectations
  • depression or anxiety
  • anger
  • long-term stress experienced by individuals with an extreme personality trait of dominance or submission
  • relationship distress (e.g., empathy deficits, unresolved conflicts).

Numerous studies have also shown that, in humans, men’s dominance and social status translate into mating and reproductive success.

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Are ED and depression related?

Young men experiencing ED might have difficulties with their partners as a consequence of chronic social stress, possibly leading to a depressive state, and gradually decreasing sexual activity.
Recently, the Journal of Sexual Medicine published a review of 42 studies including over 192.000 men in order to confirm a causal relationship between ED and depression. The results highlighted the fact that men with depression had a 39% increased risk for ED. And men with ED were almost three times more likely to have depression than men who had no trouble with erections.
It was necessary, in the opinion of the authors, that men with ED be screened for depression and men with depression be screened for ED. The links between the two conditions are thought to be both physical and psychological connections. For starters, there are many medications used to treat depression that have sexual side effects, which may include ED.
Some classes of drugs that can lead more frequent to ED as a side effect are:

  • serotonin reuptake inhibitors (SSRIs),
  • serotonin and norepinephrine reuptake inhibitors (SNRIs),
  • tricyclic and tetracyclic antidepressants,
  • some forms of monoamine oxidase inhibitors (MAOIs).
  • Bupropion, mirtazapine, vilazodone, and vortioxetine tend to have fewer sexual side effects.

If men suspect that medication is one of the causes of erectile dysfunction, they should see their doctor. Sometimes, changing the dosage or switching to a different medication helps, but these steps should always be taken under a doctor’s care.
Both ED and depression can be treated, and it’s important to seek help for both conditions. Men should have a full physical check-up to make sure that physical causes of erectile dysfunction, such as diabetes, low testosterone, or heart disease, are addressed if necessary. Psychotherapy and counselling can benefit both men and their partners.

Opioid analgesics. Is there any risk to develop ED?

Opioid analgesics are efficient medications widely used to relieve chronic pain conditions.
Ina recent study published by The Journal of Sexual Medicine opioid use was associated with a 96% increase in ED risk.
Methadone, an opioid analgesic and some other opioid medications (such as buprenorphine and fentanyl) have been reported to cause ED in men. This study included 8829 men and it was the first meta-analysis performed to describe the relationship between opioid use and ED risk based on all available epidemiologic studies.

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Low testosterone levels?

Low testosterone, also called hypogonadism is definitely a direct indicator for low sex drive and erectile dysfunction.
Testosterone, an important hormone for men is produced by the testes, providing many masculine characteristics, like facial hair and a deeper voice. It also contributes to strength, bones, and muscle mass.
Hypogonadism can happen if there is a problem with the hypothalamus or pituitary gland (two areas of the brain that help trigger the production of testosterone) or with the testes themselves. For example, men who have both testes removed during treatment for testicular cancer would no longer produce enough testosterone.
To recover the sex drive and improve the general mood it is recommended therapy with testosterone. However, it may not be helpful for erectile function if there are underlying causes of erectile dysfunction, such as diabetes or heart disease.
Regular monitoring done by the physician is important for men on testosterone therapy. It is recommended to have the testosterone levels checked every 3-4 months during the first year. This can be done with a simple blood test.
Testosterone therapy has been shown to improve the sexual function, according to a published study. The New England Journal of Medicine supported the idea that in older men, with low testosterone levels and therapeutic failure to drugs like Viagra, Cialis or Levitra, the testosterone replacement therapy was beneficial and increased their sexual activity. The study was not large enough to evaluate the safety aspects of the replacement therapy but men who have low testosterone and erectile dysfunction are encouraged to discuss their treatment options with their treating physician.


It is very important to understand the ED causes and to treat it. Untreated or inadequately treated ED can also be a sign of poor communication between health professionals and service users of all ages. Patient education and communication can lead to an improved treatment of ED that could cost-effectively prevent premature deaths and avoidable morbidity, as ED can be a robust early-stage indicator of vascular diseases and type-2 diabetes.


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  1. Braun, M., Wassmer, G., Klotz, T., Reifenrath, B., Mathers, M., & Engelmann, U. (2000). Epidemiology of erectile dysfunction: Results of the ‘Cologne Male Survey’. International Journal of Impotence Research, 12, 305–311. doi:10.1038/sj.ijir.3900622
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author
  3. Azadzoi, K. M., & De Tejada, I. S. (1991). Hypercholesterolemia impairs endothelium-dependent relaxation of rabbit corpus cavernosum smooth muscle. The Journal of Urology, 146, 238–240. doi:10.1016/ S0022-5347(17)37759-5
  4. Gazzaruso, C., Giordanetti, S., De Amici, E., Bertone, G., Falcone, C., Geroldi, D., Garzaniti, A. (2004). Relationship between erectile dysfunction and silent myocardial ischemia in apparently uncomplicated type 2 diabetic patients. Circulation, 110, 22–26. doi:10.1161/ 01.CIR.0000133278.81226.C9
  5. Nicolini Y, Tramacere A, Parmigiani S, Dadomo H. Back to Stir It Up: Erectile Dysfunction in an Evolutionary, Developmental, and Clinical Perspective. J Sex Res. 2018 Jun 22:1-13. doi: 10.1080/00224499.2018.1480743. [Epub ahead of print] PubMed PMID: 29932774
  6. Qian Liu, MPH, et al.“Erectile Dysfunction and Depression: A Systematic Review and Meta-Analysis”(Full-text. Published online: June 27, 2018)
  8. Zhao S, Deng T, Luo L, Wang J, Li E, Liu L, Li F, Luo J, Zhao Z. Association Between Opioid Use and Risk of Erectile Dysfunction: A Systematic Review and Meta-Analysis. J Sex Med. 2017 Oct;14(10):1209-1219. doi:10.1016/j.jsxm.2017.08.010. Epub 2017 Sep 8. Review. PubMed PMID: 28923307.

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