How Does Erectile Dysfunction Start?

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What is erectile dysfunction?

Erectile dysfunction also is known as impotence represents the inability to attain or maintain an erection of the penis adequate for the sexual satisfaction of both partners. Erectile dysfunction has a significant impact on the physical and psychological health of men worldwide and can also affect the quality of life of both the sufferers and their partners.

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Mechanism of penile erection

The penis physiological states of flaccidity or erection result from the contraction or relaxation, respectively, of smooth muscle cells in the corpus cavernosum.
Penile erection is a spinal reflex that is initiated by autonomic and somatic penile afferents and also by supraspinal influences from visual, olfactory, and imaginary stimuli. There are several central transmitters involved in the erectile control, some of them with a facilitatory role and others with an inhibitory role.
The central transmitters with a facilitatory role in the penile erection are:

  • dopamine,
  • acetylcholine,
  • nitric oxide (NO),
  • peptides, such as oxytocin and adrenocorticotropin/α-melanocyte-stimulating hormone.

The central transmitters that inhibit the penile erection are serotonin which may be either facilitatory or inhibitory, and enkephalins which are inhibitory.
The degree of contraction of the smooth muscle cells in the corpus cavernosa is determinate by the balance between contracting and relaxant factors. Noradrenaline contracts both smooth muscle of the corpus cavernosum and penile vessels via stimulation of α1-adrenoceptors, while nitric oxide is considered the most important factor for relaxation of penile vessels and corpus cavernosum.


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Which is the prevalence of erectile dysfunction around the world?

Sexual dysfunction and erectile dysfunction become more common as men age. The percentage of erectile dysfunction increases from 5% to 15% as age increases from 40 to 70 years. Growing older is not the end of your sex life. Erectile dysfunction can be treated at any age.
Erectile dysfunction may be more common in Hispanic men in those with a history of diabetes, obesity, smoking and hypertension.

Which are the risk factors of erectile dysfunction?

A normal erectile function can be affected by problems with blood flow, nerve supply or hormones. One of the diseases that cause blood flow problems is atherosclerosis. In patients with atherosclerosis, the arteries in the penis are narrowed and clogged, preventing the necessary blood flow to the penis to produce an erection.

The most common physical or organic causes of erectile dysfunction are:

  • heart disease and narrowing of blood vessels;
  • diabetes;
  • high blood pressure;
  • high cholesterol;
  • obesity and metabolic syndrome;
  • Parkinson’s disease;
  • multiple sclerosis;
  • hormonal disorders including thyroid conditions and testosterone deficiency;
  • structural or anatomical disorder of the penis, such as Peyronie disease;
  • smoking, alcoholism, and substance abuse, including cocaine use;
  • treatments for prostate disease;
  • surgical complications;
  • injuries in the pelvic area or spinal cord;
  • radiation therapy to the pelvic region.

Some drugs can also be involved in the occurrence of erectile dysfunction. Drugs that cause erectile dysfunction or other sexual problems as side effects are commonly prescribed for men without them knowing the risks.
These drugs include:

  • drugs to control high blood pressure,
  • heart medications (digoxin),
  • some diuretics,
  • drugs that act on the central nervous system, including some sleeping pills and amphetamines,
  • anxiety treatments,
  • antidepressants (monoamine oxidase inhibitors, selective serotonin reuptake inhibitors and tricyclic antidepressants,
  • opioid painkillers,
  • some cancer drugs, including chemotherapeutic agents,
  • prostate treatment drugs,
  • anticholinergics,
  • hormone drugs,
  • the peptic ulcer medication (cimetidine).

How is erectile dysfunction diagnosed?

It is very important for your health care professional to find the cause of your erectile dysfunction for choosing the best treatment for you. The following tests and procedures should be performed:

  • Medical history and concomitant medication: questions about your medical history will help your doctor find diseases that may lead to erectile dysfunction. Also, several drugs may be improved in the occurrence of erectile dysfunction. Changing the treatment, your erectile function can be improved.
  • Physical exam: your doctor will perform a physical exam to check overall health, including a check of your penis.
  • Blood and urine tests: a sample of your blood might be sent to a lab to check for signs of heart disease, diabetes, low testosterone levels and other health conditions.
  • Stress and emotional health: your doctor may ask you questions about your feelings such as depression or worry and about problems in your relationship.
  • Ultrasound. This test is usually performed by a specialist in an office. It involves using a wand-like device (transducer) held over the blood vessels that supply the penis. It creates a video image to let your doctor see if you have blood flow problems.


How does erectile dysfunction start? What are the signs?

Signs and symptoms of erectile dysfunction may differ from person to person. Some men may be able to sustain an erection for a short period of time, while other men might exhibit a complete inability to achieve an erection.
The key to the treatment of erectile dysfunction is to recognize the early warnings signs and symptoms. These signs and symptoms include:

  • Difficulty achieving an erection

The inability to achieve an adequate erection represents the primary symptom of erectile dysfunction. Erectile dysfunction may be a short-term or long-term problem for you. If your erectile dysfunction persists, it will interfere with your relationship. An intermittent problem with getting an erection may be considered a normal part of life. If your ability to achieve an erection becomes unpredictable, meaning it is not possible to get one during the times when you want to have sex, you may be looking at a symptom of erectile dysfunction.

  • Inability to sustain an erection

If you can get an erection, but it does not last long enough to complete sex, you may suffer from erectile dysfunction.

  • Inability to have an erection

Some men may have trouble getting an erection at all, which may lead to feelings of distress, guilt, embarrassment, shame, or other difficult emotions.
You may also feel like your inability to have sex impacts your relationship with your partner and reduces your overall sense of health and well-being.

  • Other symptoms of erectile dysfunction

Other symptoms that may be related to erectile dysfunction include:

  • Premature ejaculation;
  • Delayed ejaculation;
  • Inability to ejaculate;
  • Reduced libido or sex drive;
  • A dysfunction in the muscles of the pelvic floor;
  • Trauma to the pelvis, such as pelvic fractures;
  • Failure to become aroused after sufficient stimulation, which is a condition known as anorgasmia;
  • Low levels of the hormone testosterone.

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What treatments are available for erectile dysfunction?

Depending on the cause and severity of your erectile dysfunction and any underlying health conditions, you might have various treatment options. Your doctor can explain the risks and benefits of each treatment and will consider your preferences. Your partner’s preferences also might play a role in your treatment choices.

Oral medication

Oral medications are a successful erectile dysfunction treatment for many men. They include:

All four medications belong to the class of drugs called phosphodiesterase type 5 inhibitors and act by enhancing the effects of nitric oxide, a natural chemical produced by your body that relaxes muscles in the penis. Releasing of the nitric oxide will increase the blood flow into your penis and allows you to get an erection. These drugs do not automatically produce an erection without sexual stimulation. Oral erectile dysfunction drugs are not aphrodisiacs.
Possible side effects that may occur when taking phosphodiesterase type 5 inhibitors include flushing, nasal congestion, headache, visual changes, backache and stomach upset

Other medications

Other medications for erectile dysfunction include:

  • Alprostadil self-injection: with this method, you use a fine needle to inject alprostadil (Caverject Impulse, Edex) into the base or side of your penis. Side effects can include mild bleeding from the injection, prolonged erection (priapism) and, rarely, a formation of fibrous tissue at the injection site.
  • Alprostadil urethral suppository: alprostadil intraurethral (Muse) therapy involves placing a tiny alprostadil suppository inside your penis in the penile urethra. You use a special applicator to insert the suppository into your penile urethra.
    The erection usually starts within 10 minutes and, when effective, lasts between 30 and 60 minutes. Side effects can include pain, minor bleeding in the urethra and formation of fibrous tissue inside your penis.
  • Testosterone replacement: in some men, erectile dysfunction might be complicated by the low levels of the hormone testosterone. In this case, testosterone replacement therapy might be recommended as the first step or given in combination with other therapies.

Penis pumps, surgery and implants

If medications are not effective or appropriate in your case, your doctor might recommend a different treatment. Other treatments include:

  • Penis pumps: a penis pump (vacuum erection device) is a hollow tube with a hand-powered or battery-powered pump. The tube is placed over your penis, and then the pump is used to suck out the air inside the tube. This creates a vacuum that pulls blood into your penis.
  • Penile implants: This treatment involves surgically placing devices into both sides of the penis. These implants consist of either inflatable or malleable (bendable) rods. Inflatable devices allow you to control when and how long you have an erection. The malleable rods keep your penis firm but bendable.
    Penile implants are usually not recommended until other methods have been tried first.


Recent studies have shown that exercise, especially moderate to vigorous aerobic activity, can improve erectile dysfunction. However, benefits might be less in some men, including those with established heart disease or other significant medical conditions.

Psychological counselling

If your erectile dysfunction is caused by stress, anxiety or depression, or the condition is creating stress and relationship tension, your doctor might suggest that you, or you and your partner, visit a psychologist or counselor.

Alternative medicine

Before using any supplement, check with your doctor to make sure it’s safe for you, especially if you have chronic health conditions. Some alternative products that claim to work for erectile dysfunction can be dangerous.
Some of the food supplements can interact with prescription drugs and cause dangerously low blood pressure. These products are especially dangerous for men who take nitrates.


Which are the complications of erectile dysfunctions?

Complications of erectile dysfunction include:

  • Relationship troubles and lack of intimacy;
  • Difficulty getting your partner pregnant;
  • Increased stress;
  • Depression;
  • Anxiety;
  • Low self-esteem or low self-worth;
  • Feeling discouraged by an unsatisfying sex life.

When should you see a doctor?

You may not need to see your doctor if the inability to get and maintain an erection happens to you once or twice. Your sex ability may be affected by many lifestyle factors such as stress, smoking and drinking too much alcohol. If you notice the problem is happening on a routine basis and it is impacting your ability to have a satisfying sex life, then it is time to consider seeing a doctor.
For some men, it is not always comfortable to discuss with their healthcare provider about their erectile dysfunction. However, the primary reason for seeking out the advice of a qualified health care professional is because there are a variety of options to treat erectile dysfunction. Why you suffer in silence when your doctor can help you to find which treatment options in the best choice for you?
Also, seeing a doctor is very important to diagnose the erectile dysfunction and to find out the causes of erectile dysfunction. If your doctor knows the origin of your problem, this may significantly reduce or eliminate incidences of erectile dysfunction and enhance your sex life.
Your doctor may ask you the following questions:

  • What effect is this problem has on your enjoyment of sex?
  • What effect is this problem having on your relationship if you are in one?
  • How long have you had these symptoms? Did they start slowly or all at once?
  • Do you wake up with an erection? How about the evening?
  • If you do have erections, how firm are they? Is penetration difficult?
  • Do you have problems with sex drive, arousal, ejaculation, or orgasm (climax)?
  • How is your relationship with your partner? Has anything changed lately?
  • How satisfied are you with your sex life? Has anything changed lately?
  • Are you under a lot of stress most of the time? Or has anything especially upsetting happened to you?
  • Do you have any mental illnesses or depression?
  • Are you taking any medications for depression or anxiety?

Can erectile dysfunction be prevented? Steps you should take to prevent erectile dysfunction

The following things can be done to prevent erectile dysfunction:

  • Stop smoking: smoking is linked to heart diseases and blood vessel diseases, which may lead to the occurrence of erectile dysfunction.
  • Follow a healthy eating plan: recent studies show that erectile dysfunction is relatively uncommon among men who eat a traditional Mediterranean diet, which includes fruits, vegetables, whole grains, heart-healthy fats including nuts and olive oil, fish, and wine, particularly red. Food high in fat, especially saturated fat and sodium, should be avoided.
  • Maintain a healthy weight to prevent diabetes mellitus and arterial hypertension. Also, losing weight may help reduce inflammation, increase testosterone levels, and increase self-esteem, all of which may help prevent erectile dysfunction.
  • Manage your cholesterol through diet and medication, if needed.
  • Avoid drinking too much alcohol. Mild or moderate alcohol consumption is not bad for erectile function. Chronic consumption of alcohol can cause liver damage, nerve damage, and other conditions such as interfering with the normal balance of male sex hormone levels that can lead to the occurrence of erectile dysfunction.
  • Be physically active: physical exercises increase the blood flow through the body, including the penis. If you are a beginner, you should start slow, with easier activities such as walking at a normal pace or gardening. You can gradually work up to harder activities, such as walking briskly or swimming. Do at least 30 minutes of physical exercises per day.
  • Avoid using illegal drugs: illegal drugs may prevent you from getting or keeping an erection. Using illegal drugs may mask other psychological, emotional, or physical factors that may be causing your erectile dysfunction.
  • Avoid anabolic steroids: These drugs can shrink the testicles and block their ability to make testosterone.
  • Avoid risky sex: some cases of erectile dysfunction are caused by penile injuries that occur during sex.
  • Do not neglect your mental health. Mental and emotional stress are other important risk factors of erectile dysfunction. In some cases, they may even be the underlying causes of erectile dysfunction. Depression and anxiety can interfere with your ability to get and maintain an erection. Talk to your doctor if you are experiencing symptoms of depression or anxiety that interfere with your day-to-day activities, including your sex life.


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  1. K. Hatzimouratidis (Chair), F. Giuliano, I. Moncada, A. Muneer, A. Salonia (Vice-chair), P. Verze EAU Guidelines on Erectile Dysfunction, Premature Ejaculation, Penile Curvature and Priapism
  2. Bella A, Lee J, Carrier S, Bénard F, Brock G. 2015 CUA Practice guidelines for erectile dysfunction. Canadian Urological Association Journal. 2015;9(1-2)
  6. Urology Care Foundation. Diagnosing erectile dysfunction. What you should know.

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