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Erectile Dysfunction: An Overview

Erectile dysfunction (ED) is the occasional failure to achieve or maintain an erection, which is caused by a variety of things, such as fatigue or excessive alcohol intake. ED can have a serious psychological impact for both you and your partner. Those with ED often experience common feelings of lost self-confidence, insecurity, sadness, loss of manhood and shame.

With ED, there are problems with the mechanism to engorge the penis with blood, as well as the process to sustain this engorgement. The penis has two chambers known as the corpora cavernosa, and they extend the length of the upper side of the penis. Filling these chambers is a spongy material made of fibrous tissue, spaces, arteries, and veins. An erection begins with sexual stimulation, which produces electrical impulses that run along nerves going directly to the penis. This leads to a release of nitric oxide and increased production of cyclic GMP. These substances cause the corpora cavernosa muscles to relax and let rapid blood flow to the penis. The veins and surrounding structures trap this blood in the corpora cavernosa to sustain an erection (WebMD, 2013).

More Common than You Think

When ED researchers Selvin and associates (2007) assessed the prevalence of this disorder, they found that approximately 19% of men aged 20 years and older reported the problem or roughly 18 million men in the United States alone. The doctors evaluated 2,126 males who participated in the 2001 – 2002 National Health and Nutrition Examination Survey (NHANES) in the U.S. In 2002, researchers Prins and colleagues found that 85% of men 80 years and older had ED.

The Aging of America

Americans are enjoying longevity and better physical health today than in previous decades. In 2010, 40 million people age 65 and older made up 13% of the total U.S. population. That number is expected to grow, too, to 20% by the year 2030. However, with this increased longevity comes an increase in medical issues.

Medical experts Haas and associates (1998) evaluated the modifications in nitric oxide synthesis in relation to age-related ED. This involved the careful analysis of the cavernosal smooth muscle (that tissue inside the penis) and endothelial dysfunction of rabbit subjects. Their data showed that ED in the aging subjects was due to a dysfunction of the endothelial tissue and directly associated with nitric oxide and intracellular calcium fluxes. Basically, this meant that the tissue didn’t respond when the levels were low, and aging subjects experienced this phenomenon.

In human males, vasculogenic ED is caused by an impairment of penile cavernosa smooth muscle relaxation (problems with the penis muscle tissue). Remember, the penile cavernosa is the anatomy component responsible for an erection. Ineffective nitrogen neurotransmission is the underlying problem in neurogenic ED, so as men age, this becomes a problem. In contrast to vasculogenic ED, neurogenic ED is caused by endothelial damage and loss of smooth muscle cells (Gonzalez-Cadavid & Rajfer, 2004).

Your Aging Heart

With advancing age, your heart rate slows and your heart size grows. The blood vessels and arteries get stiff, and your heart must work harder to force blood through. Cardiovascular disorders and high blood pressure are common among older men, and they are caused by age-related heart and vascular changes (Mayo Clinic, 2013). In 2005, ED researchers Thompson and associates studied the association of ED and developing cardiovascular disease and found that ED was an indication of cardiovascular disorders. So, if you have ED, there is a good chance you could have heart problems.

Causes of Erectile Dysfunction

To achieve an erection, your nerves must function properly, and your circulatory system must provide adequate blood flow to the organs and body tissues. Additionally, a stimulus from the brain jump-starts the whole process. ED is thought to be a problem of both physical and psychological inadequacy. Common factors that contribute to ED include:
• Physical Illnesses – Diseases and disorders that affect the flow of blood in the penis include hypertension, diabetes, high cholesterol, and cardiac disease.
• Psychological Conditions – ED is related to excess stress, financial problems, work concerns and relationship difficulties. Many who suffer with depression and anxiety also experience impotence.
• Combination Factors – Many experts believe that ED is related to both physical afflictions and psychological factors.
• Medications – Some medications cause ED.
• Performance Anxiety - For men with ED, anxiety occurs when you do not get an erection fast enough or when you feel that the erection is not firm enough. A vicious cycle develops causing performance anxiety, and you may have repeated episodes of impotence.
• Unknown – The cause of ED is still under investigation, and many ED researchers believe there is an underlying vascular problem associated with the condition.(Lewis, et al. 2004)

Risk Factors of Erectile Dysfunction

ED researcher Corona (2004) studied the relational, organic, and intrapsychic elements of ED and how these elements related to age. A structured interview design called SIEDY enabled him to evaluate almost 1,000 men with ED to learn about the contributing factors of the disorder. Older men had lower cavernosal velocity on ultrasound penile examination. This meant there was a reduction of the tissue that holds blood in the penis during erections. Also, participants with low sex drives had lower testosterone levels compared to those with normal sexual desire. Many studies suggest that ED is not just a psychogenic condition, but a physical problem, as well (Sullivan, Keoghane, & Miller, 2001).

There are risk factors you can change, and there are risk factors that you cannot change. The World Health Organization (WHO) determined several risk factors for ED. These include:
• Prescription Medications – A recent study found a relationship between ED and vasodilators, antihyertensives, cardiac medicines, anticholinergics, cytotoxics, hormones, histamine-2 receptor antagonists, and hyperglycemic agents.
• Lifestyle – Lifestyle related risks include use and abuse of alcohol, street drugs, and tobacco.
• Heart Disease – For men with cardiovascular disease, the probability of ED is around 50% for smokers and 20% for nonsmokers.
• Advancing Age – Age is directly connected to ED.
• Chronic Diseases – Diabetes, cardiac disease, hypertension, and hyperlipidemia all increase the risk for ED. Other diseases associated with the problem are Alzheimer’s, Arnold-Chiari syndrome, multiple sclerosis, Peyronie’s disease, scleroderma, chronic renal failure, liver disease, and chronic lung conditions.
• Obesity and Being Overweight – ED is decreased with weight loss and by changing your lifestyle from sedentary to active.
• Injuries – ED results from any trauma to the nerves that facilitate erection.
• Psychological Conditions – Excessive stress, depression and anxiety all can lead to ED.
• Prolonged Bicycling – Some researchers believe that this compresses necessary erectile nerves and affects the blood flow to the penis.
(Derby, 2000; Lewis, 2001)

Treatment for Erectile Dysfunction

There are several ways to treat ED, and each has pros and cons. Consult your physician to find the treatment option that best suits you. These options include:
• Oral Medications – Your doctor can change your medication if it causes ED. Also, Viagra, Cialsis, and Levitra work for many with this condition.
• Sex Therapy – Counseling helps many with ED.
• Penile Injections – CaverjectTM and EdexTM cause erection when injected into the side of the penis.
• Vacuum Pumps – External vacuum devices create blood flow to the penis so it remains erect.
• Surgery – Vascular reconstructive surgery enhances the blood supply of the penis.
(WebMD, 2013)

It’s in Your Genes

While many medications and androgen replacement appear to somewhat treat this condition, gene researchers are investigating gene transfer. Gene therapy to the penile corpora cavernosa improved ED in aging rat subjects with the condition. In 2012, genetic researchers Lopushnyan & Chitaley conducted a comprehensive literature review of the gene predictors of ED. While most research has involved the study of the genetic pathways mediating erection, new reports compared the frequency of predetermined genetic polymorphism in men with ED to that of those with few genes persistently replicated. Furthermore, the Journal of Radiation Onocology recently announced 12 genetic markers that were associated with male sexual dysfunction. The scientists of the Mount Sinai School of Medicine found these markers after testing hundreds of subjects who had undergone radiotherapy for prostate cancer. The aim of this research is to help doctors predict when men may develop ED from radiotherapy (Gonzalez-Cadavid & Rajfer; Lippi et al., 2012).

Promising Topical Treatment in the Works

In 2009, the Makefield Therapeutics Company developed Hybrid Nanoparticle technology that delivers nitric oxide locally to the penile tissue for treating ED. This topical hydrogel contains saline nanoparticles the release nitric oxide slowly. The treatment creates a vasodilating effect making it ideal for ED therapy. This treatment option would allow you to avoid those uncomfortable side effects associated with the current oral drugs. The Makefield group plans to advance the research of this product in clinical trials (Potera, 2010).


Braun, M., Wassmer, G., Klotz, T., Reifenrath, B., Mathers, M., & Englemann, U. (2000). Epidemiology of erectile dysfunction: results of the ‘Cologne Male Survey’. International Journal of Impotence Research, 12(6):  305 – 311. DOI: 10.1038/sj.ijir.3900622

Cohan, P. & Korenman, S.G. (2001). Erectile dysfunction. The Journal of Clinical Endocrinology and Metabolism 86(6):  2391 – 2394. doi: 10.1210/jc.86.6.2391

Derby, C.A. et al. (2000). Modifiable risk factors and erectile dysfunction:  Can lifestyle changes modify risk? Adult Urology, 56(2), 302 – 306.

Feldman, H.A., et al. (2000). Erectile dysfunction and coronary risk factors. Preventive Medicine, 30(4):  328 0 338. DOI: 10.1006/pmed.2000.064

Gonzalez-Cadavid, N.F. & Rajfer, J. (2004). Molecular pathophysiology and gene therapy of aging related erectile dysfunction. Experimental Gerontology, 39(11 – 12):  1705 – 1712.


Haas, C.A., Seftel, A.D., Razmjouei, K., Ganz, M.B., & Hampel, M. (1998). Erectile dysfunction in aging: upregulation of endothelial nitric oxide synthase. Urology, 51(3):  516 – 522.

Kubin, M., Wagner, G., & Fugi-Meyer, R. (2003). Epidemiology of erectile dysfunction. International Journal of Impotence Research, 15, 63 – 71. doi:10.1038/sj.ijir.3900949

Lewis, R.W. (2001). Epidemiology of erectile dysfunction. Urologic Clinics of North America, 23(2).

DOI: 10.1016/S0094-0143%2805%2970132-4

Lewis, R.W. et al. (2004). Epidemiology/risk factors of sexual dysfunction. The Journal of Sexual Medicine,

1 (1):  35 – 39. DOI: 10.1111/j.1743-6109.2004.10106.x

Lippi, G., Plebani, M., Montagnana, M., & Cervelin, G. (2012). Biochemical and genetic marker of erectile dysfunction. Advances in Clinical Chemistry, 57:  139 – 162.

Lopushnyan, N.A. & Chitaley, K. (2012). Genetics of erectile dysfunction. The Journal of Urology, 188(5):  1676 – 1683.

Mayo Clinic (2013). Aging – what to expect. Retrieved on February 13, 2013 from:

National Institute on Aging (2012). Older Americans 2012. Retrieved from:

Potera, C.  (2010). Nanoparticles Deliver Nitric Oxide Locally:  Technology from Albert Einstein Medical School Being Developed by Makefield Therapeutics. Genetic Engineering & Biotechnology News, 30(14).

Prins, J., Blanker, M.H., Bohnene, A.M., et al. (2002). Prevalence of erectile dyfunction. International Journal of Impotence Research, 14: 422 – 432. doi:10.1038/sj.ijir.3900905

Selvin, E., Burnett, A.L., & Platz, E.A. (2007). Prevalence and risk factors for erectile dysfunction in the U.S. The American Journal of Medicine, 120(2):  151 – 157. DOI: 10.1016/j.amjmed.2006.06.010

Sullivan, M.E.,Keoghane, S.R., Miller, M.A (2001). Vascular risk factors and erectile dysfunction. BJU International, 87 (9):  838 – 845. DOI: 10.1046/j.1464-410x.2001.02211.x

WebMD  (2013). Erectile dysfunction. Retrieved from:

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