Erectile dysfunction is often a blood vessel problem, and most cases go untreated
Erectile dysfunction is the commonest sexual problem in men, affecting 18% of those in their fifties and 37% of men aged 70 to 75. Yet about three quarters of diagnosed cases are never treated, often out of embarrassment. Most have physical roots, and the condition is closely bound up with heart disease and diabetes.
Clinically it means a persistent or recurring inability to get or keep an erection firm enough for satisfactory sex, lasting at least three months. The DSM's related diagnosis, erectile disorder, requires six months and personal distress. Only about 10% of cases trace chiefly to psychological or relationship factors; the rest stem from vascular, nerve, hormonal, local or drug-related causes. Known predictors include ageing, cardiovascular disease, high blood pressure, obesity, abnormal blood fats, smoking and depression.
The mechanics explain why. Nerve signals trigger the release of nitric oxide, which relaxes smooth muscle in the spongy erectile tissue so it fills with blood; adequate testosterone and a working pituitary are needed too. Narrowed arteries, often from atherosclerosis, let too little blood in, while a faulty valve-like mechanism lets too much drain out. Smoking narrows arteries, and some researchers have gone so far as to call tobacco an anaphrodisiac. Diabetes damages nerves. Several classes of prescription drugs, including SSRIs and beta blockers, can contribute, as can prostate cancer treatment, even though the gland itself is not needed for an erection. Cycling raises the risk about 1.7-fold through pressure on nerves and vessels.
Some worries are overstated. A 2015 literature review found little epidemiological support for the idea that pornography causes the problem, and a 2026 review concluded the relationship is far more complicated than simple cause and effect. Diagnosis usually starts with history. Men who still have erections during sleep, normally five to six a night, mostly in REM, probably have working plumbing, which points toward a psychological element, although many men without any dysfunction lack regular night-time erections. Doppler ultrasound can measure penile blood flow directly.
Treatment begins with underlying causes, lifestyle and psychological issues. The best-known drugs, PDE5 inhibitors such as sildenafil, widen blood vessels so more blood reaches the tissue. Less common options include urethral prostaglandin pellets, injections, pumps, implants and vascular surgery. Sildenafil has even been tried in ageing stallions in Brazil: an 18-year-old Quarter Horse responded fully, a 25-year-old stallion only partly.
Source: Erectile dysfunction
