Causes of Erectile Dysfunction

What can cause Erectile Dysfunction?

Erectile Dysfunction (ED) happens due to various reasons, but its main causes are fall in 4 major conditions:

  1. Unable to pump the required blood within the penis as a result of arterial disease. This is said to be one of the main causes of erectile dysfunction and about 40% of those who have the condition have it for this reason.
  2. A neurologic condition that doesn’t let the penile nerves from normally secreting the neurotransmitters that deal with the penile arteries and decrease the penile nerves sensation. As a result, the erectile process activation is disrupted.
  3. Blood leakage coming from the abnormal penile veins when there’s an erection, which prevents the blood from getting into the penis for an adequate period. The leakage can be due to the bad vascular sinuses relaxation, pathology of tunica, or fibrosis in the muscle at the corpora.
  4. Due to a medical condition that disrupts the arteriogenic system and could lead to the inability to expand and be filled with a good amount of blood.

There are several other medical conditions that could lead to erectile dysfunction. In fact, one study showed the following symptoms in men:

  • 90% have depression (psychological impotence is a common cause of erectile dysfunction for persons in the 20s or 30s)
  • 86% are suffering from peripheral vascular disease
  • 64% suffer from diabetes
  • 61% have ischemic heart disease
  • 55% have urinary tract symptoms
  • 52% are suffering from hypertension

Erectile Dysfunction common with age

It’s a well-accepted idea that the prevalence of ED and its severity is a result of aging, which is usually aggravated by various conditions, such as diabetes, cardiovascular disease, hypertension, low testosterone, high cholesterol, lower urinary tract infections, chronic neurologic conditions like Alzheimer’s, Parkinson’s, and stroke, as well as psychological conditions, such as anxiety and depression. Any of the conditions mentioned above, along with the use of medications to treat them, can all contribute to Erectile Dysfunction. Furthermore, almost 48% of men that are over 50 years old suffer from Erectile Dysfunction resulting from physical and relational factors. However, this does not necessarily mean that this sexual dysfunction is unavoidable if you’re aging.

Men over 50

In most men over the age of 50, sexual desire and interest still remain strong. One of the major risk factors for ED in men over the age of 50 is atherosclerosis of the cavernosal and pudendal arteries. This condition is a result of the development of plaques within the arterial walls, which gradually obstruct the lumen or that open space where blood is supposed to flow. Atherosclerosis is usually a result of hypertension, hypercholesterolemia, diabetes, and sometimes, smoking. It could possibly trigger pathological changes that includes the degeneration of the penile smooth muscle that could affect the ability of corpora cavernosa to expand, and eventually leads to venous leakage. 

erectile dysfunction elderly

Prostate problem is another common risk factor in aging and several studies have confirmed the link between Erectile Dysfunction, painful ejaculation, hypoactive sexual desire, and ejaculatory incompetence, to BPH, which is usually common in men that are over the age of 50.Sometimes, symptoms of ED and other sexual dysfunctions may be treated with alpha-blockers, Cialis, or Viagra. Some of the most common symptoms of the prostate are a pain in the suprapubic area, pelvis, scrotum, inguinal area, perineum, back, and lower abdomen. Other symptoms associated with BPH are frequency and urgency of urination, burning feeling duration urination, as well as an extremely slow flow of urine. Some other age-related physiological changes that are normally associated with aging are sometimes falsely interpreted as symptoms of sexual dysfunction when they simply require full understanding by the patient and his partner as well as readjusting their sexual techniques.

Erection Problems in 20s and 30s

Sudden erection problems in the 20s or 30s are often linked to psychologial reasons such as anxiety and depression. These problems can often be cured by a temporary use of potency enhancers such as Cenforce (Sildenafil) or Eli (Tadalafil). Once the self-confidence has been regained the patient can stop using the medication and have a normal sex live again.

Cardiovascular Causes

Severe hardening, narrowing, and clogging of the aorta, tributaries, iliac vessels, or the penile arteries, as well as sinuses, can also lead to sexual dysfunction. One of the most common natural causes of Erectile Dysfunction in 30s is vascular disease, which is said to be 40% of all factors. Almost 17% of men that have Erectile Dysfunction are suffering from atherosclerosis, a condition where the arteries are clogged with yellowish plaques that contain fatty materials cholesterol, and lipophages or those cells that are absorbing fats. This condition can partially or totally obstruct the blood vessels. Atherosclerosis is usually a result of smoking and hyperlipidemia or an elevated concentration of all or any lipids in the blood including triglycerides and cholesterol. This condition may also be due to diabetes and obesity. The weakened blood flow at the penile region is what prevents the tumescence and engorgement of the penis. This can also lead to the leakage of venous due to the poor compression of venules against tunica, which is a result of contracted vascular sinuses.

causes of erectile dysfunction in 20s

Link between ED and CVD

In addition, it was found that there’s a direct link between ED and CVD. Erectile Dysfunction could be among the first signs that the patient has a hidden or occult cardiac condition, like ischemic heart disease and may have antedated the manifestations for several months and even years. It is for this reason why the penis is sometimes known as the barometer of the body in terms of vascular integrity. The direct link between Erectile Dysfunction and vascular pathology is what prompted some physicians to advise any man suffering from ED to undergo a cardiovascular workup. This is especially true if he is showing some symptoms that could be a risk factor for ED, such as hypertension, diabetes, smoking, hyperlipidemia, and obesity. Patients that have a single vessel ischemic heart disease may achieve better erection compared to those who have multiple vessel obstruction.

Cavernous Arterial Insufficiency

In addition, men suffering from cavernous arterial insufficiency are often at high risk of suffering from CAD or Coronary Arterial Disease. Some other factors associated with atherosclerosis, such as the reduced endothelial Nitric Oxide Synthase (NOS), a type of enzyme that converts the oxygen and L-arginine to produce the nitric oxide, as well as an increased level of free radicals, along with a high level of homocysteine at the vascular plaques. All these could contribute to Erectile Dysfunction. Recent strong evidence suggests that the depletion of NOS from the nitrergic nerves can also lead to sexual dysfunction. Other Cardiovascular Diseases, such as aortic aneurysm and congestive heart failure may also be linked to Erectile Dysfunction. In a recent study, which analyzes the extragenital vascular disease on 457 patients suffering from Erectile Dysfunction, the researchers have discovered an insufficiency of an isolated penile artery in about 25 percent of the patients, along with lower extremity, carotid, and penile atherosclerosis, which has been found in 75% of those who were affected. This again demonstrates a close link between penile arteries and vascular changes in the body. Meanwhile, in another recent study done in Italy, age, diabetes, and coronary arteries have been found to be independent factors of Erectile Dysfunction. Instead, the sexual condition was found to be associated with Coronary Arterial Disease. Furthermore, Erectile Dysfunction has been found in patients suffering from acute coronary syndromes and may be considered as a symptom of diffused or coronary atherosclerosis.


In another study that was conducted, it was found that the most common risk factor in the development of Erectile Dysfunction is smoking, and followed by hypertension and obesity. Men who have Erectile Dysfunction has been found to have arterial insufficiency and poor blood flow and were also suffering from Coronary Arterial Disease, which is around 40% of the group. Meanwhile, 23.3% of these men have diabetes. Furthermore, the venous occlusive disease was also observed on patients with hypertensive, which makes up 36.5% of the group. The possibility of having unusual blood flow parameters has also increased along with the number of risk factors associated with vascular diseases.

Diabetes Mellitus

It was found that around 30 – 75 percent of men suffering from diabetes have complained of Erectile Dysfunction. Conversely, studies show that around 1 in 4 men with Erectile Dysfunction have diabetes. In one of the studies, it was found that Erectile Dysfunction could be among the first symptoms of diabetes. Also, it was established that about half of men with diabetes have developed Erectile Dysfunction within only 10 years of being diagnosed with the condition. Sexual dysfunction on patients suffering from diabetes has also been found to be dependent on the patient’s age where ED affects about 15% of men within the age of 30 to 34 and 55% of those whoa re 60 years old and above.   Meanwhile, type 2 diabetes, which is usually common on older people and is associated with insulin resistance, has been linked to a higher occurrence of Erectile Dysfunction compared to those with type 1 diabetes. A recent study done on 401 men suffering from Erectile Dysfunction and were observed for 9 years to 15 years and have not been treated, has revealed some unexpected and interesting results. Although about 33% of those that have moderate or minimal symptoms of ED has exhibited progression, about 32% of those with minimal, 14% of those with moderate, and 31% of those with complete ED were able to fully recover from the sexual condition. Weight loss and quitting smoking, as well as overall improvement of health, are among the most important factors that were credited for the remission of ED as well as the delay of its progression.

Metabolic Syndrome and causes of Erectile Dysfunction

As defined by the National Institute of Health Expert in 2001, metabolic syndrome is characterized by these clinical findings:

  • Triglycerides that’s more than 150 mg per deciliter
  • Those with a systolic blood pressure of more than 130 mm of mercury (mmHg) and diastolic is more than 85 mmHg or those that are taking antihypertensive medications.
  • Those that have an HDL cholesterol level that’s less than 40 mg per deciliter or are taking medications that are lipid-lowering.
  • Those having a waist circumference of more than 100 cm or 40 inches.
  • Self-reported diabetes

Medical experts believe that metabolic syndrome is a precursor of CVD or cardiovascular diseases. Furthermore, it was found that about 43% of them are suffering from erectile dysfunction, compared to only 24% of those with increased insulin resistance. Early detection of metabolic syndrome on younger men suffering from ED but has no other clinical symptoms can help to lower their risk of endothelial dysfunction as well as CVD in the future.

Recent studies

In fact, a recent study has confirmed these findings and has shown that erectile dysfunction is predictive of the manifestation of metabolic syndrome among men having a BMI of less than 25. This important finding just shows that ED can show early warning signs, which provides an opportunity for early therapeutic intervention, especially for aging men suffering from ED, because of their low body mass index, and may have a higher risk of getting metabolic syndrome and subsequent cardiovascular diseases.

Neurogenic Factors

Neurologic conditions were found to be the main causes of Erectile Dysfunction in about 10% to 20% of the cases . Several disorders and conditions could affect the sex centers of the brain as well as the other parts of the nervous system including the spinal cord, pituitary gland, hypothalamus, and peripheral nerves. All these supply the penis with blood and play a part in sexual function and development. For instance, brain lesions could disrupt the secretion of important neurotransmitters, such as oxytocin and dopamine and might inhibit the transmission of the neural impulses coming from the sex centers going to the penile nerves through the spinal cord. Some of the most common causes of these lesions include Alzheimer’s disease, stroke, epilepsy, tumor, Parkinson’s Multiple Sclerosis, infection, and trauma. Lesions on the spinal cord resulting from tumors, injury, diabetic neuropathy, infections, herniated disc, Multiple Sclerosis, and neurosyphilis can all be linked to loss of psychogenic add reflexogenic erections. This may also result in a lack of sexual pleasure and the absence of ejaculation and orgasm. These issues can all disrupt the process of sensory impulses transmission, coming from the penis towards the brain, as well as motor stimuli from the brain going to the penis.

neurogenic factors

Sacral Sex Center

The condition’s severity will mainly depend on the extent and level of the lesion, most especially related to the sacral spine’s secondary sex center. Any pathology that involves the sacral sex center can result in both the absence of psychogenic and reflexogenic erections. Trauma caused to the penile nerves or pelvic, which is a result of the disruption of the passage of neural impulses in and out of the penis may also result in the loss of sensation that could eventually lead to Erectile Dysfunction. As for spinal cord injury cases, it’s been found that 70% of quadriplegics and paraplegics are sexually active and around 70% of them are using an alternative form of sexual expressions such as genital stimulation and oral stimulation. Another study has found that reflexogenic erections have been found in almost 95% of those men that suffer from spinal injuries right above the sacral vertebrae. Furthermore, psychogenic erections have been maintained by around 25% of men suffering from partial sacral injuries. Even though the erectile ability is still maintained by patients that suffer from incomplete lesions, these erections are usually brief and unpredictable and often result in poor ejaculation, which impedes the overall sexual functioning.

Causes hypertension erectile dysfunction?

Some of the recent epidemiologic studies have confirmed the link between causes of erectile dysfunction and hypertension. Before, it’s estimated that about 8% – 10% of patients that have untreated hypertension are suffering from Erectile Dysfunction when they were first diagnosed with high blood pressure. However, in the more recent studies, there has been much higher prevalence that was reported, which ranges from 26% to 41%. Hypertension could potentially damage the vascular endothelium of the arteries in the penile region modify the overall composition of the tissues at the corpora cavernosa, which eventually increases the proliferation and size of the smooth muscles. This has also led to an increase in the inelastic fibrosis and collagen, as well as the hyperactivation of the nervous system. Furthermore, the condition could possibly impair the penile vessels’ ability to dilate and relax in order to allow the flow of blood, which is needed for an erection.

hypertension cause of erectile dysfunction

In addition, some young males who were suffering from hypertension have been found to have a low level of serum testosterone, which could possibly affect the secretion of NO within the penile tissue and impair the tissue’s responsiveness towards its action and can possibly contribute to the patient’s sexual dysfunction as a result of fear and anxiety. Unfortunately, some of the medications used for treating hypertension could possibly aggravate the patient’s sexual dysfunction. Some examples of these medicines are beta-blockers, which have the tendency to lower the libido and trigger sexual problems like ED. This usually happens if the drug will trigger constriction on the penile arteries. Some drugs also have an anti-androgenic effect that could affect the patient’s sexual desire and lessen their ability to achieve firm erections.

Hormone Factors Cause of Erectile Dysfunction

As previously stated, testosterone could have some influences on the development of the reproductive system of males, as well as their secondary sexual characteristics. Testosterone, is necessary, especially in its bioavailable serum form, by most men to help them achieve sexual arousal and to help in the proper functioning of their sexual organs. Furthermore, testosterone may help to regulate the neurotransmitter secretions within the spinal cord and the brain. However, the involvement of testosterone in Erectile Dysfunction is still a widely debated subject. Clinical and experimental data shows that having an appropriate amount of testosterone in men could play an important role in maintaining normal sexual functioning. Furthermore, in a recent clinical study that measures the overall testosterone level of men, it shows that around 5% of those who are suffering from Erectile Dysfunction may have low hormonal levels and about 18% have a low level of free testosterone.

testosterone and impotence

Even though testosterone is said to help facilitate erection by dilating the vascular sinuses and penile arterioles, its effect on Erectile Dysfunction is still pretty controversial. The elevated serum prolactin, which is a type of pituitary hormone, could be the reason behind the 6% cases of ED and is often due to low testosterone. In the Massachusetts Male Aging Study, which evaluates the effects of sex hormones on Erectile Dysfunction, it was found that about 40 to 70% of the 1,519 men were at the baseline. They have not established any link on the bioavailable testosterone, total testosterone, as well as the serum hormone-binding globulin to the causes of erectile dysfunction in 20s. However, in some cases, it was found that the major effect of decreased serum testosterone is a low sexual drive.

Low testosterone and erectile dysfunction

Men who have a decreased level of free testosterone would usually get their sexual boost from hormone supplementation. However, older men who have a low level of testosterone and are suffering from ED may not be able to respond well to the intramuscular testosterone injection. The reason for this is that the injected hormone will bind with blood proteins and will decrease the free portion, which will trigger a rapid increase of the serum testosterone in only 72 hours and will gradually decrease in the next 2 – 3 weeks. These days, an optimal replacement that will normalize the serum testosterone in only 24 – 72 hours can be achieved with the help of gel, patches, and some oral medications. Sometimes, testosterone injections can help to restore a patient’s erectile ability, including those men who have lost their testicles before reaching puberty and those that were castrated and have lost their testicles prior to puberty. Even though some castrated men will occasionally achieve and maintain erections without the need to supplement with testosterone, most of them don’t. Considered as an important aspect of a healthy hormonal milieu, the thyroid hormones may also have an important impact on the overall sexual functioning. Excessive hormone production of the thyroid gland, also known as hyperthyroidism, as well as deficiency of the hormones because of the thyroid gland’s under activity, can both contribute to Erectile dysfunction and lack of sexual desire.


Surgery on the rectum, pelvis, or internal genitalia may lead to sexual dysfunction in both male and female patients, although this will also depend on the type of surgery that the patient has undergone. For instance, bilateral orchiectomy, a surgery that requires the removal of testicles to treat prostate cancer are potential causes of erectile dysfunction since it lowers the testosterone level to castrated levels. Both the blood vessels and the nerves that help in the erectile process may be injured or severed during the surgery, such as the retroperitoneal, which is right beneath the abdominal cavity can also contribute to sexual dysfunction. Other instances where surgical procedures can lead to injury are during the surgery of an abdominal aneurysm, which refers to the abnormal lump at the arterial wall, and spinal cord surgery. Other causes of erectile dysfunction were linked to radical prostatectomy or the removal of the cancerous prostate. Simple prostatectomy procedure for BPH, as well as the surgery of neurogenic bladder and radical surgery for rectal cancer, may all contribute to erectile dysfunction and other sexual conditions.  

Radical prostatectomy

When it comes to radical prostatectomy, the occurrence of postoperative ED will range from 20% to 100%, depending on the individual’s age and pre-surgical erectile capabilities. Other factors are the surgical preservation of the nerve that’s responsible for supplying blood to the penis, as well as the overall experience of the surgeon. In addition, some patients could develop incontinence upon reaching orgasm, which may cause embarrassment and will cause them to avoid any type of sexual encounter. Some other factors that could affect the ability erection to return to normal after undergoing radical prostatectomy procedures are the use of certain drugs like Cialis, Viagra, and Levitra. The use of prostaglandin El injections as well as intra-urethral inserts and a combination of these medications can also be a factor. Furthermore, the inadequate interest or desire in the sex of the patient’s sexual partner can trigger psychogenic disturbances or depression on the patient. During a follow-up monitoring of a group of patients for 24 – 48 months after undergoing bilateral surgery, the erectile recovery of the patients range from 32 to 80 percent.

Physical Trauma

Trauma on the penile or pelvic nerves resulting in a vehicular accident, gunshot wound, fall, or pelvic fracture in the bladder can all contribute to the development and progression of erectile dysfunction. Injury in the adolescent years may also lead to the disruption of the flow of blood in the penile arteries. These injuries could be due to a forceful bicycle crash where the crotch hits the bicycle’s crossbar.

Obesity and Smoking

Obesity that’s associated with lack of exercise, overeating, sedentary lifestyle, and smoking, can all lead to erectile dysfunction. Fortunately, about 30% has been found to recover, after following a healthy balanced diet, regularly exercising, and quitting smoking. The study suggests that loss of weight can indeed help a person to recover his sexual function without the need to undergo therapy. And although it has been found that 26% of those who are suffering from Erectile Dysfunction have an elevated serum cholesterol level, such a figure will increase to 40 – 80 percent if they are also diagnosed with hypertension. The actual mechanism on the loss of the normalcy of sexual functioning resulting from a higher level of serum is not yet known. There have been several theories but these were based on experimental studies done on rabbits and rats. Most theories have attributed the link to the vascular bed’s poor endothelium-dependent relaxation, accumulation of LDL or bad cholesterol level in plaques, clogging of the penile arteries, as well as a higher concentration of the smooth muscle cells. Some other factors are neurologic and vascular changes on atrophy and the decrease in the size and number of axons, the degeneration of cavernosal smooth cell, as well as the loss of the growth factor of the vascular endothelial.


In terms of smoking, several studies show a direct relationship between the duration of smoking as well as the number of cigarettes that the patient smokes to the severity and development of erectile dysfunction. Some of the possible contributors to the sexual condition are deficiency of endothelium-dependent muscle relaxation in the penile vasculature. Other possible factors are poor rigidity in the event of nocturnal erections and the narrowing of pudendal arteries. Endothelial damage, impaired autonomic functioning, and vasospasm of the penile arteries are also factors that contribute to erectile dysfunction to men who smoke.

Lower Urinary Tract Symptoms

Benign or non-cancerous swelling of the prostate could passively or actively squash the urethra or the urinary channel. This can also lead to incomplete emptying of the bladder, hesitancy, slow stream, post voiding dribbling, and urgency to urinate. In some cases, incontinence could happen in about 40 – 50 percent of men over the age of 50 and are suffering from BPH. These symptoms can be quite annoying and may possibly affect the patient’s overall life quality. Recent studies have correlated the LUTS to the causes of Erectile Dysfunction in 20s, although this depends on its severity. The condition has also been linked to painful ejaculations and ejaculatory incompetence. In a study that observed more than 12,000 men around the age of 50 – 80, it was found that the severity of the urinary symptoms is a major factor in the progression of ejaculatory disturbances and erectile dysfunction, regardless of age and some other risk factors. Several theories, although they have not yet been confirmed, have attributed the link between the sexual symptoms and urinary to the sympathetic nervous system’s hyperactivity in the penis and prostate, which leads to the contraction of the penile arteries and smooth muscles. Over recent years, much emphasis has been put on the role of Rho-kinase in both LUTS and ED. Rho-kinase is responsible for regulating the various cellular processes in the body and that includes the contraction of smooth muscles.


In terms of hypertension, there are medications used for treating urinary symptoms that could possibly affect sexual function be one of the causes for erectile dysfunction. For instance, 5-alpha reductases, such as Avodart and Proscar, have the tendency to lower one’s sexual desire. These medications have also been found to affect sexual potency, sexual desire, with a tendency to inhibit ejaculation. Alpha-blocker medications, such as Flomax, have also been found to trigger ejaculatory disturbances on about 30% of patients. This negative consequence is said to be due to the inhibitory influence of the drug on the vas deferens and seminal vesicles. Meanwhile, uroselective alpha-blockers like Uro-Xatral and Flomax, including phosphodiesterase type 5 inhibitors may help to improve the patient’s sexual and urinary symptoms. Unfortunately, the US Food and Drug Administration has warned that taking Viagra or other Sildenafil based ED medicine such as Cenforce or Sildamax in more than 25 mg should be avoided within four hours of taking the alpha-blocker. But some clinical studies confirmed that the combination of Flomax and Cialis, or Uro-Xatral and Cialis, for the treatment of ED and LUTS, does not come with any dangerous side effects.


To summarize, if the patient does not know the causes of erectile dysfunction or impotence and the penile curvature has been found to be less than 60-degree and is accompanied with a difficulty of penetration, for as long as the penis has an adequate length, the application of the wedge-shaped tunica may yield a positive result in most cases. However, if it has been established that the curvature is more than 60-degrees and the penis small, then creating an incision on the plaque as well as grafting it with some synthetic or natural materials might work. In addition, a new study has found that having non-palpable scarring at the penile septum can be considered aPeyronie’s disease.

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