Background Information on Erectile Dysfunction 

Home ] Introduction to ED ] Beliefs which cause erection problems ] Background information on ED ] [ Background information on erectile dysfunction ED ] Physical causes of ED ] Personality and relationship issues as a cause of erectile dysfunction (ED) ] Endocrinological causes of ED ] Vascular disease and ED ] What's causing your erection problems? ] Emotional & psychological problems in ED ] More on causes of ED ] Sleep apnea and erectile dysfunction ] How to control the risk of ED ] Lack of arousal and ED ]

Erectile Dysfunction

  • What causes an erection?
  • What is the reason for erectile dysfunction (ED)?
  • How is ED identified?
  • How can ED be effectively treated?
  • Things to remember
  • Sources of help

Erectile dysfunction has been known in the past as impotence, but whatever term you use for this condition, the symptoms are always the same: an inability to maintain an erection which is firm enough for intercourse on repeated attempts to have sex.

Erectile dysfunction is a specific term which refers only to erection problems, which may occur every time you attempt to have sex or only in specific situations, or even with specific partners.

As mentioned above, erectile dysfunction can refer to a complete inability to obtain an erection hard enough for sex, or it can refer to an intermittent or inconsistent problem which only affects a man from time to time.

The former condition obviously renders a man impotent and unable to engage in sexual activity with his partner, so it is devastating for a man's self-esteem and sexual confidence.

 However the latter condition is almost more anxiety provoking in that the unpredictability of the erectile failure means that every episode of sexual pleasure is tarnished by the fear of not being able to maintain an erection.

In addition, the difficulty of measuring the frequency of erectile dysfunction is compound it by the fact that some men are able and willing to engage in sexual intercourse with a semi-erect penis.

All that said, we estimate the frequency of erectile dysfunction to be around one man in 10 at any one time, with a much lower rate of about 22  visits to the doctor's surgery for every 1000 men in the United States each year.

This data is rather out of date, and it may be even higher, now that the well-publicized success of Viagra has reached most of the population.

What we do know is that men find it very embarrassing to talk to their doctors about ED, because one third of all discussions with a doctor about this rise in the context of a completely different subject.

It has been claimed that ED is caused by physical issues in older men, and there is and outwardly certain amount of truth in this statement, in that ageing processes in the body do have an effect on the circulatory system which is essential for maintaining firm erection, and possibly also in cases of diabetes, changes in the nervous system and the vascular system in the penis can be responsible for a failure of erection.

Interestingly, however, many cases of apparently physically induced ED can be treated successfully with a psychological approach -- a fact that reinforces the profound impact of ED on a man's psyche.

Furthermore, ED occurs in younger men at an increasingly high frequency -- this is unlikely to be due to circulatory problems, and is much more likely to be due to the impact of anxiety, stress, and other emotional issues.

The really good news is that erection problems can be treated at any age with a variety of approaches which include Viagra. We shall look at these in a moment.

Delayed Ejaculation

But before we do, consider the issue of delayed ejaculation: Delayed ejaculation is also known as retarded ejaculation and presents a major problem to men who have it if they and their partner wish to conceive a baby. Click here to read more about delayed ejaculation.

The man simply cannot ejaculate during sex, and this has profound implications for both his emotional security and that of his partner. The condition is also known delayed or retarded ejaculation. Now, this may sound like a great boon, but it's frustrating and often painful for both man and woman.

It also causes the woman distress because she thinks she's not attractive or sexy enough for her man, and he may in fact take this view too as an easy option to avoid self-blame.

However, there are many simple causes of male orgasmic disorder, the most common being anti-depressants.

As always, get a full medical, since prostate problems may be responsible.

And again, ask yourself if you can masturbate to orgasm? If you can, the cause is most likely psychological - such as focusing too much on your partner's pleasure, fear of letting go, anger, or the lack of the final stimulation that just gets you over the edge into your own orgasm. (A finger inserted in your anus, for example. You may not want to ask for this.)

Desensitization techniques can help you to ejaculate with a partner. It's progressive desensitization - you begin by masturbating in a separate room to your partner with the door open. Then you masturbate to orgasm with her in the same room but some distance away.

As you gradually work your way closer the idea is you'll eventually be able to get yourself to orgasm while she lies next to you. From there on, it's small steps till you're inside her vagina, happily thrusting, problem solved.

What causes an erection?

As you may know, the internal structure of the penis contains three chambers which are filled with spongy erectile tissue. The nature of this tissue, with connective tissue, smooth muscle, lacunae, epithelia, and small veins and arteries, allows it to expand many times when blood flows into the tissue.

The corpora cavernosa are two parallel chambers surrounded by a tough fibrous membrane called the tunica albuginea. They lie on top of the urethra, under which is another channel called the corpus spongiosum.

An erection originates with some kind of stimulation, which may be either mental or emotional as in fantasy, or physical as in touch stimulation of the body, and in particular the genitals.

Nerve impulses from both the brain and the tissues of the genitals or surrounding areas are fed into the spinal column erection centre where messages are processed and passed to the muscles of the corpora cavernosa, allowing the muscles to relax and thereby increasing blood flow through the small arteries into the penis.

As the blood increases the volume of the tissues of the penis, the tunica albuginea has limited flexibility and at some point will compress the veins of the penis through which will blow that would normally flow out.

With a differential between the blood in the flow and blood out flow, direction is maintained until sexual climax, or if climax is not achieved, until sexual arousal diminishes sufficiently to allow the penis to return to its flaccid state.

What is the origin of erectile dysfunction?

It is no exaggeration to say that an erection is almost a miracle of bioengineering. Unfortunately because it is such a complex and delicate process, involving many elements of body biochemistry, things can go wrong at many stages of the erection process.

For example, any kind of deterioration in the nervous system, the ability of the arteries to conduct blood flow freely, the fibrous tissue of the penis, or even just the biochemistry of the body will result in a less firm erection.

There are many conditions which can cause these deterioration is in the erectile mechanism: they include diabetes, kidney disease, alcoholism, vascular problems, neurological deterioration, multiple sclerosis, and atherosclerosis.

It has been said that these conditions account for as much as seven cases out of every 10 of erectile dysfunction, and certainly the number of men with diabetes who experience ED is rather high.

It follows that each individual is largely responsible for the health of his arteries and can therefore exercise a considerable degree of control over the risk of erectile dysfunction. The most obvious examples of this are the cessation of smoking and drinking to excess, or losing weight and lowering cholesterol in the blood stream.

Other conditions which are rather harder to control include surgery for prostate cancer or any kind of surgery on the bladder, penis, damage to the nerves of the spinal column and pelvic surgery.

A rather less well-known source of ED, or even partial ED, are many common drugs prescribed by doctors to deal with other common conditions including drugs for mood problems such as depression, tranquillizers, antihistamines, and appetite altering drugs. Even drugs prescribed for stomach ulcers can cause erectile problems.

And, having said all that, we firmly believe that psychological issues including anxiety depression low self-esteem and sexual anxiety are all very significant factors in ED regardless of the primary presenting symptoms and underlying causes. What we mean by this is that very significant improvements in the degree of erectile difficulties can be achieved in almost all cases -- even those conventionally regarded as not susceptible to treatment.

How is ED identified?

When a man visits a doctor with a complaint difficulties in bed, the first thing that should happen is a full medical history is taken, for there may be clues to the origin of ED in other associated conditions such as premature ejaculation or delayed ejaculation.

This history should also identify any difficulties with orgasm and ejaculation, the use of prescription or illegal drugs, and if the doctor is trained in relationship issues, any emotional/psychological issues which may be contributing to the problem.

Physical Examination

Over the years that we have been dealing with men's sexual issues on the Internet we have come across many cases of penile insensitivity, an disturbing problem which remains unclear in origin. for the purposes of determining whether a man is suffering from ED or not, penile insensitivity would  reflect an issue with the nervous system rather than necessarily an issue with the reptile system.

 Hormonal problems may be indicated by abnormal patterns of body hair, low sex drive, mood problems and symptoms of the male andropause. circulatory difficulties could be diagnosed by observing the pattern of circulation at the extremes of the hands and feet, and finally any degree of bending on erection of the penis could be an indicator of Peyronie's disease. All of these conditions required different treatment specific to the issues concerned.

Naturally, hormone profiles, urine analysis, measurement of lipids in the blood, creatinine and liver enzymes, plus tests for other diseases should be a natural part of any medical checkup of a man suffering from erectile failure, particularly if he is in late middle age or older. It's also possible for a man to have a nocturnal penile tumescence test, a simple test which will show if he gets in direction during the night -- a clear indication that there is not necessarily a major physical problem, and that the ED may originate in psychological/emotional issues.

Interview about relationship issues

Needless to say this is where a sensitive health practitioner can uncover the critical issues that may be causing erectile failure: attitude to partner is a major element of erectile failure, so it may also be helpful to get a view from the man's partner.

How is ED treated?

The question of treatment for ED has become much simpler of late with the advent of Viagra. Nonetheless, psychotherapy, sexual therapy and behavior changing strategies reminiscent of CBT are all valuable adjunct to the treatment of ED. it may also be necessary for a man to change his lifestyle, particularly where he has been drinking excessively or has very high lipid levels in his blood; needless to say any prescription medication which may be causing erectile dysfunction should be substituted with one which is less likely to cause erection problems.


Whether you except the view or not that psychological issues play a major part in all cases of erectile dysfunction, reducing anxiety associated with sex and exploring and resolving issues such as childhood sexual abuse have a vital role to play in restoring a man's self-confidence around sexual interaction with his partner. These techniques are also important in reducing anxiety caused by the loss of sexual potency in cases of ED resulting from physical issues such as diabetes.

Drug Therapy

The most important advance in the treatment of ED is Viagra, and  also the later developments of Levitra and Cialis, drugs which can be more effective to certain men and also have a longer half life in the body, thereby meaning that they do not necessarily need to be taken in the strictly scheduled way that Viagra needs to be -- that is, between 30 minutes and one hour before sex.

Viagra, Levitra and Cialis are all known as phosphodiesterase (PDE) inhibitors. They work by reducing the activity of an enzyme responsible for destroying nitric oxide, a chemical which plays a vital role in the maintenance of erection. The initial dose of Viagra is 50 mg, and according to the effect on the man's erection, this dose may be increased or reduced as necessary. Levitra or Cialis are administered in rather lower doses, and in all cases the dose may be adjusted to avoid interaction with other medications.

While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. The recommended dose for Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for either Levitra or Cialis is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is insufficient. A lower dose of 5 mg is available for patients who take other medicines or have conditions that may decrease the body's ability to use the drug. Levitra is also available in a 2.5 mg dose.

These drugs do not work for all men, possibly because they are not in themselves aphrodisiacs, but they do promote erection when other sexual desire and stimulation is present. It follows therefore, that if a man is not sexually aroused, or does not desire his partner, Viagra or the other drugs will not help him achieve an erection firm enough for sex.

It is this observation that more than anything else emphasizes the necessary city for dealing with the emotional/psychological issues that may be contributing to the sexual problems of the man concerned.

For men who have symptoms of testosterone deficiency, hormone replacement therapy may be needed to complement the Viagra, although testosterone replacement should always be given by a doctor who is qualified and knowledgeable on the subject.

There are also a number of other drugs including yohimbine which have been claimed to act in support of penile erections, but scientific studies are lacking, there are side-effects such as increased anxiety, and anecdotal reports from users do not support the view that these are an effective way of dealing with ED.

Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed on the penis.

The older generation of drugs used to treat erectile dysfunction included papaverine hydrochloride, phentolamine, and alprostadil (Caverject), although the unpleasantness of injecting a needle into the penile chamber made these a less than optimum solution for many men; others found it quite an acceptable solution.

Alprostadil was inserted as a pellet into the urethra, and although it did produce an erection, it was also capable of producing and pleasant sensations of aching and burning and even priapism.

Vacuum Devices

Mechanical vacuum devices cause erection by creating a partial vacuum, which draws blood into the penis, engorging and expanding it. The devices have three components: a plastic cylinder, into which the penis is placed; a pump, which draws air out of the cylinder; and an elastic band, which is placed around the base of the penis to maintain the erection after the cylinder is removed and during intercourse by preventing blood from flowing back into the body (see figure 2).

One variation of the vacuum device involves a semirigid rubber sheath that is placed on the penis and remains there after erection is attained and during intercourse.

Rather more well-known is the simple mechanical vacuum device or pump which creates a partial vacuum in a cylinder placed around the penis, with the result that blood flows into the penile tissues and gives an erection, albeit artificially induced.

When the penis is constrained around its base with a rubber ring, the erection is sustained because the ring has the effect of the compression of the tunica albuginea on the emissory veins of the penis - it's obviously important that this artificial erection is not maintained for a prolonged period of time since blood flow is limited and damage to the tissues of the penis can result.

However this method does gain wide exceptions amongst users and it does seem to have an effective approach to treating erectile problems of the penis in particular in relationships which are long-standing and where the partners know each other well.


A surgical approach has been adopted from time to time either to address the lack of arterial blood flow to the penis, or the leakage of venous blood from the penis, either of which can reduce the man's capacity to sustain erection. the best results obtained with arterial surgery and young men were discreet damage to an artery has occurred because of injury or pelvic fracture. The ligation or tying off of the veins is less successful and is not widely practiced, if at all in reputable medical circles.

When not addressing the issue of surgical implants because we believe these to be an extreme form of treatment for erectile dysfunction, one which is invasive, destructive and often unnecessary -- not to mention unsuccessful. Since men can in fact with training achieves ejaculation without direction, the destruction of the penile tissues and the implantation of mechanical devices to sustain an artificial erection really seems extreme and possibly perverse.

Points to Remember

  • (ED) is the inability to get or keep an erection firm enough for sexual intercourse
  • ED affects one in ten American men
  • ED has both physical and emotional causes
  • ED is treatable regardless of age
  • Treatments include psychotherapy, behavior therapy, drug therapy, vacuum devices, and in extreme cases, surgery.

For More Information

American Urological Association (AUA)

AUA can refer you to a urologist in your area.

American Diabetes Association (ADA)
Phone: 1–800–DIABETES (342–2383)

ADA can help you find a doctor who specializes in diabetes care in your area.

American Association of Sex Educators, Counselors, and Therapists (AASECT)
Phone: 804–752–0026

Check the AASECT website to find a certified sexuality educator, counselor, or therapist in your area.


Other pages on this website about the causes of erectile dysfunction and impotence

Home ] Introduction to ED ] Beliefs which cause erection problems ] Background information on ED ] [ Background information on erectile dysfunction ED ] Physical causes of ED ] Personality and relationship issues as a cause of erectile dysfunction (ED) ] Endocrinological causes of ED ] Vascular disease and ED ] What's causing your erection problems? ] Emotional & psychological problems in ED ] More on causes of ED ] Sleep apnea and erectile dysfunction ] How to control the risk of ED ] Lack of arousal and ED ]

Other sections on erectile dysfunction

Home ] Diagnosis of Erectile Dysfunction ] The Causes of Erectile Dysfunction ] Effects of Erectile Dysfunction On Men and Their Partners ] Treatment for Erectile Dysfunction ]