Etiology of Erectile Dysfunction

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The causes of erectile dysfunction can be categorized as

Medical
Non-medical

MEDICAL CAUSES:
1. Vascular diseases associated with erectile dysfunction
2. Systemic diseases associated with erectile dysfunction
3. Neurogenic diseases associated with erectile dysfunction
4. Respiratory disease associated with erectile dysfunction
5. Endocrine conditions associated with erectile dysfunction
6. Penile conditions associated with erectile dysfunction
7. Psychiatric conditions associated with erectile dysfunction
8. Nutritional states associated with erectile dysfunction
9. Hematologic diseases associated with erectile dysfunction
10. Surgical procedures associated with erectile dysfunction
11. Medications associated with erectile dysfunction
12. Trauma to the penis /Penile fracture

NON-MEDICAL CAUSES:

1. Alcohol dependence
2. Smoking
3. Obesity

Erectile Dysfunction Causes (Etiology of ED)

The etiology of erectile dysfunction includes anything that can disrupt the progression of
events that result in erection. This can be due to various factors which can be organic,
physiologic, endocrine, and psychogenic in nature. The etiology of erectile dysfunction is
defines under two categories, medical and non medical. Some patients have also proved
that organic factors are associated with psychogenic ones. Diseases such as multiple
sclerosis, diabetes, trauma to the spinal chord; cardiovascular disorders etc can affect the
nervous, cardiovascular or hormonal functions or produce a change in the smooth muscle
tissue. The following four factors are quintessential for en erection to take place.

Smooth functioning of the nervous system which conducts nerve impulses in the
brain, spinal chord and penis.
Arteries near corpora cavernosa with healthy functions.
Healthy functioning of smooth muscles and fibrous tissues within the corpora
cavernosa
Ample supply of nitric oxide in the penis

MEDICAL CAUSES INCLUDES:

1.

Vascular diseases associated with erectile dysfunction

Atherosclerosis- It is a
disease of the arteries
which occurs due to
progressive deposition of
fat debris resulting in
thickening and hardening
of the walls of the
arteries. If the blood
vessels in the penis are
healthy, they help in
getting and maintaining
an erection. The arteries
that reach the penis come
via the abdomen and
branch out into smaller
branches before reaching
the penis. The rush of

blood from the heart to the penis results in a pressure that slows down the exit of blood
from the penis. This helps to sustain erection. If the arteries are clogged with fat, it can
result in poor blood supply to the penis resulting in loss of erection.

2.

Peripheral vascular disease- Also termed as peripheral arterial disease (PAD), it

is narrowing of blood vessels in the limbs. Though more common in legs, there
are also reports of this occurring in arms. It is also a potent marker of adverse
cardiovascular prognosis. This disease occurs due to a blockage in the arteries
which is termed ischemia. If the blockage is lower down in the arteries that supply
blood to the lower limbs, it can cause pain in the thighs but if the blockage is
above the groin, it can cause pain in the gluteal region (buttocks).This results in
impotency due to improper blood supply.
Myocardial infarction- This is a disease in which the myocardium (heart
muscle) undergoes necrosis (death) due to prolonged ischemia. It is caused by
narrowing of epicardial blood vessels due to atheromatous plaques. This results in
platelet aggregation, thrombus formation, fibrin accumulation, hemorrhage into
the plaque, and varying degrees of vasospasm which leads to myocardial
infarction. Again due to deficiency of blood under such scenario, erectile
dysfunction occurs. Also post myocardial infarction where the person has a near
death experience, it can lead to depression which leads to decrease in his libido.
Arterial hypertension/High blood pressure- The statistics for hypertension
differ such that a man who has had moderate hypertension for twenty years may
be at a lower risk for erectile dysfunction than a young man who has had very
serious hypertension for only a few months. But high blood pressure can damage
the small arteries of the penis. These damaged arteries are repaired by the body
but the new repaired arteries have better resistance to sudden rush of blood,
resulting in decreased supply of blood to the penis. It also results in the smooth
muscles losing their ability to relax which results in poor blood supply to the
penis. It also causes a decrease in the testosterone levels. Testosterones play an
important role in sexual arousal. Hypertension also decreases the level of zinc in
the body. Zinc is responsible in the synthesis of testosterones.
Prostate cancer treatment- Though prostrate cancer does not cause ED, its
treatments can result in erectile dysfunction. If during prostatectomy, nerve
sparing technique is used, the patient can recover within a year, but in a non-nerve
sparing technology, recovery is unlikely to happen due to permanent damage to
the nerves. Also post radiation therapy, patients have observed ED, which can be
treated.

Systemic diseases associated with erectile dysfunction

Diabetes mellitus- During erection, the enzyme neuronal nitric oxide synthetase
(nNOS) releases nitric oxide at the nerve endings of the penis. This cause an
increase in the blood flow of the penis and relaxation of the penile smoothmuscle resulting in an erection. The increased blood flow further activates eNOS
in penile blood vessels which continues the release of NO due to which the
relaxation continues and full erection is maintained. In case of diabetes, sugar in

the blood does not get broken down due to which it is high in O-GlcNAc. OGlcNAc is a blood sugar that is present in the circulation of hyperglycemic
patients. This sugar hinders the normal chain of events by inhibiting the activation
of eNOS. This affects the release of NO which prevents the smooth muscles from
relaxing.
Scleroderma- is a progressive autoimmune disorder that affects the skin and
connective tissue including blood vessels. During this disorder, there are
alterations in the arteries and arterioles due accumulation of debris which results
in vascular dysfunction. ED in scleroderma is due to this resultant fibrosis and
impaired circulation.
Renal failure/ end-stage renal disease (ESRD) In the case of this disease the
patients kidney functionS so poorly that it can prove fatal. It cannot be treated
with conventional medical treatments such as drugs and doctors opt for dialysis or
kidney transplant. During this disease there is acceleration of arthrosclerosis
which results in vasculogenic erectile dysfunction. Majority of patients display
cavernosal artery occlusive disease, resulting in erectile dysfunction.
Liver cirrhosis- Liver is responsible for the removal of many hormones including
estrogen. This disease results in hypogonadism which results in an imbalance in
the level of estrogen and testosterones where the level of estrogen goes up and the
level of testosterones come down. As stated above, testosterones are responsible
for initiating sexual arousals and decrease in their level results in a fall in the
libido. High level of estrogen results in redistribution of body fat which results in
the man acquiring feminine characters. The patients abdomen becomes paunchy
as the chest enlarges in the form of breasts and there is decrease in the muscle
mass.
Idiopathic hemochromatosis- This is a recessive disorder which results in
abnormal accumulation of iron in the parenchymal organs, due to excessive
absorption of iron form food. This excessive absorption can lead to organ toxicity.
This disorder results in liver cirrhosis and diabetes which in turn cause erectile
dysfunction.(Refer the notes above)
Cancer - In different cancers, the malignant cells tend to damage the nerve cells
of the pelvis resulting in erectile dysfunction.
Cancer Treatment- Cancer patients while undergoing cancer treatments can
suffer from erectile dysfunction due to the affects of surgeries or therapies.
Surgery -Prostrate cancer which may lead to prostrate surgery can cause nerve
damage. Similarly during testicular surgery, trauma to the arteries or veins can
result in ED.
Hormone therapy - the patient has to undergo hormone therapy or surgeries
which affect the sexual organs.
Radiation therapy This form of therapy has shown better effect to cure cancer.
But is also exposes the pelvis to radiations which can damage the nerves.
Chemotherapy- This can reduce the amount of testosterone produced.
Dyslipidemia- This is a disorder that is characterized by elevation in the plasma
cholesterol, triglycerides (TGs) or both which can lead to development of
arteriosclerosis. Also termed as hyperlipidemia, it can impair erectile functioning
by affecting the endothelial and smooth muscle cells of the penis. Corpus

cavernosum gets impaired due to oxidized low-density lipoproteins. The high

level serum cholesterol and reduced high density lipoprotein cholesterol are
among the factors that cause ED.
3.

Neurogenic diseases associated with erectile dysfunction

Epilepsy- Also termed as seizure, it is a series of uncontrolled electrical activity

in the brain that can cause physical convulsions, minor physical signs and thought
disturbances. Patients of epilepsy suffer from erectile dysfunction due to various
factors which could be emotional or physical in nature. These patients suffer from
poor self esteem and social phobia which does not let them interact with the
opposite sex. They are also concerned that sexual activity may trigger a seizure as
it involves hyperventilation and physical exertion. Along side these psychological
factors, they are also caused due to neuralgic and endocrine factors. The treatment
of this disease through antiepilectic drugs (AEDs) decrease the level of
testosterones in blood which results in decreased libido.

4.

Respiratory disease associated with erectile dysfunction

5.

Stroke- Also termed as CVA (cerebrovascular accident) is sudden death of some

brain cells due to lack of oxygen when the blood supply to the brain in interrupted
by blockage or rupture of an artery to the brain. As a result of this disease the
patient may suffer from temporary loss of speech, paralysis of a side of the body
or weakness of muscles. This can affect the libido or during paralysis the patient
may suffer from erectile dysfunction. Depression and strained relationships with
the partner post an attack is also said to be a cause of erectile dysfunction.
Multiple sclerosis- this is an autoimmune disease of the central nervous system in
which the immune system attacks myelin that serves as a nerve insulator and
helps in the transmission of nerve signals. The clinical features of this disease are
marked by numbness, weakness, loss of muscle coordination along with problems
of vision, speech and bladder control. When erection occurs as a part of genital
stimulation, the stimulus bypass the brain as they occur using the nerves of the
spinal chord. So a patient who is suffering for multiple sclerosis may find it easy
to achieve erections due to physical stimulation but not through foreplay or erotic
situations or vice versa.
Guillain-Barr syndrome- also called as acute inflammatory demyelinating
polyneuropathy (AIDP) is an autoimmune disorder in which the bodys immune
system attacks the peripheral nerves. Since the peripheral nerves residing in the
brain and the spinal chord are most gravely affected, the brain cannot send
stimulus for increased supply of blood to the penis resulting in loss of erection.
Alzheimer disease- this incurable, degenerative disease, termed as dementia, is
characterized by impairment of memory due to damage of the nerves. Alzheimer
patients post the age of 60 also display erectile dysfunction and loss of libido due
to peripheral nerve damage. Due to this the nerves around the penis do not get any
stimulus to initiate erection.
Parkinsons disease- This is an autonomic disease associated with a loss of
dopaminergic nigrostriatal neurons which manifests itself in the form of tremors
which are barely noticeable and later become more pronounced. In this case also,
the nerves around the penis do not receive stimulus from the brain or the spinal
chord to stimulate erection leading to erectile dysfunction.

Chronic obstructive pulmonary disease- is a disease in which due to chronic

bronchitis (blockage of airways in the lungs) and emphysema (shortness of
breath), there is obstruction of air flow through the airways which is usually
permanent and progressive over time. Patients usually suffer from dyspnea
(shortness of breath), cough and medicinal side effects which can result in loss of
libido. This gets worse as they suffer form decreases self esteem resulting in fear
of sexual failure. All this can have a psychological effect on their erection.
Sleep apnea- is an obstruction that occurs when soft tissues in the back of the
throat collapse and block the airway during sleep. Due this there is lack of oxygen
which hampers the blood flow to the penis which results in erectile dysfunction.

Endocrine conditions associated with erectile dysfunction

Thyroid disorder- Men suffering from hyper or hypothyroidism usually rend to

suffer from erectile dysfunction. In hyperthyroidism, the body produces excess
hormones which in turn produce toxins which can cause erectile dysfunction. In
the case of hypothyroidism, the bodys BMR (Basal Metabolic Rate) goes down
which can cause obesity. Obesity is accompanied by various complications which
cause erectile dysfunction.

Hypogonadism- This is a term in which there is decreased functioning of the testes.

Though this can happen due to a series of underlying causes, its clinical features include
erectile dysfunction due decreased level of testosterones.

Diabetes- (refer above)

6.

Penile conditions associated with erectile dysfunction

Peyronie disease- In this disease a plaque, or hard lump, forms within the penis.
The plaque, a flat plate of scar
tissue, develops on top or bottom
side of the penis, inside a thick
membrane called the tunica
albuginea, which envelopes the
erectile tissues. Initially this
plaque begins as a localized
inflammation and later develops
into a hardened scar. This can
cause pain in the penis and
abnormal curvature of the penis.
The patient may experience an
erection but the abnormal
curvature does not allow him to have an intercourse with his partner.

Hypospadias- It is an abnormality of
anterior urethral and penile development
in which the urethral opening is
ectopically located on the ventrum (toward
the belly) of the penis proximal (near the
point of attachment) to the tip of the glans
penis, which, in this condition, is
awkwardly opened out. This can be
surgically corrected but during this time,
patients experience loss of erection.
Priapism- It is a condition wherein a
patient experiences persistent painful
erection which is not related to sexual

arousal. This occurs when a part of the circulatory system like blood, blood
vessels or nerves affect the course of normal blood flow. Subsequently the patient
suffers form an involuntary prolonged erection unrelated to sexual stimulation
which does not get relieved even by ejaculation. This can exist for a long time
resulting in extensive tissue damage to penis and erectile dysfunction, if not
treated on time.
7.

Psychiatric conditions associated with erectile dysfunction

Depression- For a healthy sexual life a person need to be a in a healthy mental

state. To get sexually aroused a person needs to be attracted and motivated. Once
a person is depressed, he is withdrawn, loses temper easily, is self conscious and
apathetic which results in loss of sexual desire. Due to this the penis fails to
maintain an erection. People who are prone to depression also suffer from socialanxiety problem. So when they finally get some sexual interactions, the anxiety
around sex may inhibit the patients reaction.
Widower syndrome- This is termed as a psychological problem in which a
person feels guilty about cheating on his deceased spouse resulting in lack of
erection. It is also observed in divorced men who have not participated in sexual
intercourse for a long time. Some also say that this could be due to side effect of
prolonged inactivity of the penis. The tissues of the penis get oxygen during
erection which is important to keep them healthy. During the REM phase of sleep
men have frequent erections which result in large quantity of blood and oxygen
being brought into the penis which oxygenate the tissues. As they age, there is a
marked decrease in the nocturnal erection which results in the penis getting less
supply of oxygen. Inactivity of the penis for a long period of time just compounds
the problem leading to inability in having an erection.

8.

Nutritional states associated with erectile dysfunction

9.

Performance anxiety- During this disorder the person gets highly anxious about
his performance resulting in loss of libido. This is said to be due to excess rush of
blood to the brains, resulting in decreased blood supply to the penis resulting in
the penis continuing to be flaccid even after physical stimulation.
Posttraumatic stress disorder- This psychiatric disorder is a long lasting
response of the patient to a traumatic event. This event could be frightening, life
threatening, or mentally disturbing due to which the person keeps relieving them
mentally. Due to this they tend to avoid people, places or other things that remind
them of the past bad experience. They also become extremely sensitive to normal
life (hyperarousal). Due to all this, the person may slip into depression. This
results in loss of libido and erectile dysfunction.

Malnutrition- Studies have shown that thiamin, a water soluble b-complex

vitamin is vital in the optimization of nerve and energy transmission throughout
the body. Deficiency of this vitamin has proved that the person may suffer from
tremors; loss of concentration and in very extreme and rare cases may result in
loss of erection. This condition can be reversed but taking vitamin supplements.
Selenium- This trace element is an antioxidant and a part of the enzyme
glutathione peroxidase. It metabolizes hydroperoxides formed from
polyunsaturated fatty acids. It is also a part of enzymes that deiodinate thyroid
hormones. More than half the selenium in a male is located in the testicles and
semen ducts. Decrease in the level of selenium results in low sperm count and can
lead to erectile dysfunction. Chicken, legumes, cereals and meat are rich sources
of selenium.
Zinc deficiency- This is another trace element that is necessary to maintain
normal serum testosterone. Deficiency of this mineral restricts the pituitary gland
from releasing luteinizing and follicle stimulating hormones which are
responsible for stimulation of testosterone production. It also functions as an
inhibitor to the aromatase enzyme which converts testosterones into excess
estrogen. With age, there is an imbalance between the testosterone and estrogen
ratio. Higher estrogen activities result in the patient getting effeminate, gaining
weight and loosing his libido. Also testosterones play a major role in sexual
arousal, so decrease in their level due to zinc deficiency leads to erectile
dysfunction. Beef, lamb, pork, crabmeat, turkey, lobster, legumes, pumpkin seeds,
string bean and salmon are rich in zinc.

Hematologic diseases associated with erectile dysfunction

Sickle cell anemia- is an inherited blood disorder that affects red blood cells. This
is caused by an abnormal hemoglobin called as hemoglobin S. This hemoglobin,
which is S shaped distorts the shape of oxygen blood cells. The distorted blood
cells are crescent shaped, representing a sickle. These fragile, sickle-shaped cells
deliver less oxygen to the bodys tissues. They can also clog more easily in small

blood vessels, and break into pieces that disrupt healthy blood flow. All this can
cause priapism which results in erectile dysfunction.
Leukemia- This is a cancer of the white blood cells in which the growth and
development of the white blood cells (leukocytes) is abnormal. In this case, the
white blood cells block the outflow of blood from the penis which results in
erectile dysfunction. It can also lead to priapism. In fact, in some cases, the only
clinical feature of acute myeloid leukemia could be priapism.
10. Surgical procedures associated with erectile dysfunction

Erection can takes place only if the sequence of events takes place in proper order. As
stated above, these events include stimulus to the nerve and circulation of blood. The
nerve route includes impulses passing between the brain, spinal chord and the area
around the penis. The blood circulation includes response in the muscle, fibrous tissues,
veins and arteries in and around corpora cavernosa. While performing surgeries, the
muscle, arteries, veins and nerves around the penis may get damaged, resulting in erectile
dysfunction. Besides this, chemotherapy and radiation also result in loss if erection. The
following surgeries can result in this disorder.
1. Procedures on the brain and spinal cord
2. Retroperitoneal or pelvic lymph node dissection
3. Aortoiliac or aortofemoral bypass
4. Abdominal perineal resection
5. Surgical removal of the prostate for cancer
6. Surgical treatment of the prostate for benign disease
7. Proctocolectomy
8. Radical prostatectomy
9. Transurethral resection of the prostate
10. Cryosurgery of the prostate

11. Cystectomy
11.

Medications associated with erectile dysfunction

Antidepressants- These are a class of selective
serotonin reuptake inhibitor (SSRIs) which are
primarily known as antidepressants which are used to
treat depression. These along with atypical
antidepressants target neurotransmitters such as
serotonin, norepinephrine and dopamine. Since the
action of these neurotransmitters is inhibited, the brain
stops sending stimulus to the nerves around the penis
which results in loss of erection.

Antipsychotics- These drugs are also commonly

called as tranquilizers and administered to patients suffering from serious
psychiatric disorders such as schizophrenia, bipolar disorder and alcohol and drug
addiction. Once administered, they act by blocking dopaminergic transmission
within the brain. They are neurotransmitters that send messages across the brain.
Once their action is inhibited, they not only result in erectile dysfunction but also
cause premature ejaculation, no ejaculation, decrease in libido and priapism.
Antihypertensives- Patients who are on any hypertensive drugs for long
experience erectile dysfunction. This is attributed to the fact that the primary
actions of these drugs are inhibiting the bindings of the norepinephrines to the
receptors on the membrane of vascular smooth muscle cells. This results in the
muscles undergoing vasodilatation leading to decrease peripheral vascular
resistance which results in decreased blood pressure. Since the blood pressure is
decreased, the rush of blood to the penis is lowered, which results in arresting the
action of erection.
Drugs such as Cimetidine and Finasteride- Cimetidine are a histamine H2receptor antagonist which inhibits the production of acid in the stomach. It is used
to treat peptic ulcers. But this drug also acts on the smooth muscle of the erectile
corpus cavernosa of the penis and relaxes them which results in loss of erectile
dysfunction. Similarly Finasteride is a form of antiandrogen which inhibits the
action of testosterone. With a decrease of the male hormone, men experience loss
of libido and erectile dysfunction.
5-Alpha reductase inhibitors- These are a group of antandrogenic drugs that are
used in the treatment of benign prostatic hyperplasia (BPH) and androgenic (or
androgenetic) alopecia. These drugs inhibit the conversion of testosterone to
dihydrotestosterone. Dihydrotestosterones is the principle regulator of nitric oxide
and cGMP (Cyclic guanosine monophosphate), which are responsible for penile
erection.
Cholesterol-lowering agents- Called as statins, these drugs are used to lower
level of plasma cholesterol in the body. Since cholesterol is important for the
production of testosterones, its important to maintain a healthy level of this in the

body. Cholesterol lowering agents inhibit the action of cholesterol which results
in a decrease in the level of testosterone.
12.

Trauma to the penis /Penile fracture.

Trauma, either blunt or sharp- on or

around the penis can result in erectile
dysfunction. Patients who have suffered
trauma on the pelvic region from a blunt
injury can suffer from hemodynamic
(movement of blood) impairment that can
result in abnormal venous drainage or
arterial supply. These patients may suffer
from
corporeal
veno-occlusive
dysfunction,
cavernous
artery
insufficiency. In both the cases, the
movement of the oxygenated and deoxygenated blood gets hindered. Most of
these injuries occur to sportsmen who play without appropriate protective perineal
equipment. Sharp injury may permanently damage the nerves around the penis.

Fracture- This is penile fracture is the traumatic rupture of the corpus

cavernosum. It is considered as a urologic emergency. Sudden trauma to the penis
or twisting the penis while in an erect state can unplug the penis partially from the
thin tunica albuginea. This is termed as fractured penis. This can involve one or
more corpora and an associated injury to the penile urethra may occur. In both the
cases, the injury is usually permanent.

NON MEDICAL CAUSES INCLUDES:

There are various lifestyle disorders that can cause erectile dysfunctions which are

Alcohol dependence- There are many theories regarding alcohol consumption

and its effect on the erection of a man. Researchers have observed that long term
dependency and alcohol abuse can affect the production of testosterone and shrink
the testes (testicular atrophy). Alcoholism can also cause hypogonadism.
Hypogonadism is a disorder of the sex glands in which they produce little or no
hormones. Conditions like diabetes and hypertension can aggravate because of
alcohol abuse. These conditions are strongly linked to alcohol abuse. Alcohol can
also react with certain drugs to produce an adverse event which can include
erectile dysfunction.
Smoking- Smoking for over a long duration is also said to be the culprit in
making men suffer from ED. Men who have smoked for a long time can suffer
from arthrosclerosis which occurs due to build up of plaques in the arteries.
Smoking can also cause arterial lesions. Vasoconstriction (constriction of blood
vessels) may further drop the flow of blood to the penis, within the arteries as a
result of direct nicotine intake. The can also be excessive blood flow out of the

penis which can inhibit erection. In case of a healthy male, during sexual
stimulation, the veins constrict to withhold to blood in order to sustain erection.
Nicotine in the blood impairs the constriction of veins due to which the veins
dilate and the blood flows out. This results in impairments of the valves which
trap the blood in the penis. This results in inhibition of erection.
Obesity- This disease bring along with it a lot of other diseases including
hypertension, diabetes, arthrosclerosis and cancer, all of which are among the
leading causes of erectile dysfunction. Obesity can be hereditary, drug initiated,
due to psychological imbalance or idiopathic. This disorder also increases the
chance of decline in testosterone levels as it can create hormonal imbalance. It can
also lead to inferiority complex which also results in loss of libido. The good
thing is that patients who have undergone weight loss have experienced an in
increase in their libido and erection without the help of a drug.

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