Two yellow canaries


What exactly does Erectile Dysfunction mean?

Erectile dysfunction (ED) is any type of problem getting or maintaining an erection that interferes with sexual intimacy. Along with decreased sex drive (libido) and abnormal ejaculation (premature ejaculation, delayed ejaculation, or inability to climax), ED is part of a broader spectrum called male sexual dysfunction.


What causes erections?

Erections are caused when blood flows from the hypogastric artery into the spongy tissues of the penis (corpora cavernosa and spongiosa) faster than flows out, much like filling a water balloon or an inner tube. It’s a pretty neat system, because the erection itself puts pressure against the draining veins, thereby maintaining the erection.

They begin by psychogenic causes such as erotic thoughts or visual. Auditory, or olfactory stimuli, even fantasy. The can also occur as a reflex by tactile (touching) stimuli. (Nocturnal erections, somehow associated with REM sleep, are the most common cause of having erections upon awakening.)

Chemically, nitrous oxide helps relax the infrastructure of the erectile tissues (just as it does in relaxing blood vessel walls to increase blood flow to the heart, e.g., nitroglycerine). This is the way sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), and avanafil work; it is also why it is dangerous to take these with other medicines for high blood pressure: too much relaxation of the blood vessels!

Anything that interferes with nitric oxide, circulation in the hypogastric arteries, healthy libido, or mutual sexual attraction can result in ED. Even performance anxiety can cause it.


How common is ED?

Of ED, abnormal ejaculation, and decreased libido, ED is the most common male sexual dysfunction. 16% of men suffer from ED, ranging from 8% in men aged 20-30 to 37% in men aged 70-75. If someone suffers another medical illness, these percentages are likely to be higher, e.g., cardiovascular disease, 47%. Diabetics, especially as they age, get higher rates of ED.


Who are at risk for ED?

The men who have the lowest risk for Ed are those in good health, who exercise regularly, and who have sex regularly. (“Honey, we have to have sex again. You don’t want me to get ED, do you?”)

Alternately, men more likely to have ED will have one or more of the following risk factors below:

  • Age is a significant factor. Simply, the older a man is, the more he is likely to experience ED1.
  • Low frequency of intercourse2. Having intercourse less than once a week increases the risk of ED. (“Honey? Do you?”)
  • Obesity. Besides creating a generalized unhealthy condition, fat cells take an adrenal hormone and convert it into an estrogen, which can oppose testosterone.
  • Smoking. Nicotine is a vasoconstrictor, which squinches blood vessels and results in less blood flow.
  • Decreased libido (sex drive) due to low testosterone, medications, or psychological effects can remove the physical and/or mental stimulus that begins an erection. Depression, fatigue, recreational drugs, and relationship problems can all result in a decreased libido.
  • Diabetes mellitus (when added to age, can increase the risk of ED almost ten times. This may be because of the cardiovascular damage seen in diabetes). Even Type II diabetes, which can result in a testosterone deficiency, can cause ED (possibly related to obesity as a risk, above).
  • Hypertension and cardiovascular disease. Generally decreased circulation in the body will not exclude the penis, which depends on adequate blood flow to become erect.
  • Medication use (antidepressants are common causes). In fact, eight of the twelve most commonly prescribed medicines list ED as a side effect. Besides the antidepressants, diuretics (“fluid pills,” such as spironolactone and the thiazides), antifungals (ketoconazole), acid reducers (cimetidine, Tagamet)
  • Sleep apnea (even when it isn’t from obesity or smoking).
  • Psychosocial factors such as relationship problems, history of childhood sexual abuse, fear of pain when other conditions make erections painful like Peyronie’s disease.
  • Neurologic problems (stroke, back injury, multiple sclerosis, dementia)
  • Bicycling? Yes, it has been linked with ED, albeit controversially. It is theorized that constant pressure on the pelvic nerves or compromising the blood flow to the pelvic circulation may contribute.
  • Low testosterone. Testosterone is the “male” hormone, although women have testosterone, too—just less of it. A lower than normal testosterone level for men or for women can cause sexual dysfunction in each.
  • Other endocrine disorders, such as pituitary tumors and thyroid problems, as a cause for ED, will also see ED resolved when these problems, as the cause for ED, are treated.


How is ED treated?. Pills, what else?

In treating ED, both libido and erections must be considered. The libido may be a testosterone, psychological, or marital issues, which must be addressed at the same time. Besides these, attending to the erection problem itself is via a management flow sheet developed by the American Urological Association:


1. First line therapy: medicines that increase effects of nitric oxide to relax the channels in the penis for increased blood flow.


2. Second line therapy: directly interacting with the penis (urethral suppository, injectable alprostadil, vacuum pump).


3. Third line therapy: surgery (penile implant, surgical correction of the scarring in Peyronie’s disease, surgical repair of the vascular supply).


As can be surmised, these go through the ever-increasingly aggressive therapies.


Where does the singing canary fit in?

Erectile dysfunction is common and devastating, because expressing intimacy physically is crucial to a healthy sexual or marital relationship. In fact, it should be treated as an emergency, because losing one’s relationship is no less important than losing one’s health in any organ system. As long as other organ systems are being considered, however, the following should be the important take-home message here:

ED, when not caused by psychological reasons or abnormalities of the endocrine system (diabetes, thyroid disorders, low testosterone), should prompt a mandatory screen for cardiovascular problems, because the ED may be the only noticeable effect of circulation problems—that is, until a heart attack. Certainly, throwing Viagra at someone on request, without checking out one’s general cardiovascular health, is medically negligent. The circulation to the penis is no different than the circulation to everywhere else (especially the coronary arteries), so ED may be the canary in the mine. Your penis is like the canary: when it stops singing, there may be trouble ahead. 


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  1. Bacon CG, Mittleman MA, Kawachi I, et al. Sexual function in men older than 50 years of age: results from the health professionals follow-up study. Ann Intern Med 2003; 139:161.
  2. Koskimaki J, Shiri R, Tammela T, et al. Regular intercourse protects against erectile dysfunction: Tampere Aging Male Urologi Study. Am J Med 2008; 121:592
  5. Montague DK, Jarow JP, Broderick GA, et al. The Management of Erectile Dysfunction. American Urological Association. Baltimore, MD 2005.
  6. McVary KT. Clinical practice. Erectile dysfunction. N Engl J Med 2007; 357:2472.
  7. Lindau ST, Schumm LP, Laumann EO, et al. A study of sexuality and health among older adults in the United States. N Engl J Med 2007; 357:762.

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