Erectile dysfunction: causes, diagnosis and treatment

Erectile dysfunction (ED) is the persistent inability to attain and maintain an erection sufficient for satisfactory sexual performance. Epidemiological data report a prevalence of 12.5% among Italian men aged 40 to 70, though the true figure is likely to be roughly double: it is estimated that as many men again never consult a doctor about the problem. In most cases ED has an identifiable organic cause and is treatable.

Although benign in itself, ED affects both physical and psychological health and has a significant impact on the quality of life of the man, his partner and his family. It should be treated as a medical condition in its own right: like any condition, it requires accurate diagnosis to identify which mechanism has been impaired before any treatment is chosen.

Causes: organic, psychogenic or mixed

In the 1960s, ED was considered psychogenic in 90% of cases and organic in only 10%. Today those proportions are almost reversed: at least 70–80% of erectile disorders have an organic cause. The shift reflects both improved diagnostic tools and the rising incidence of cardiovascular and metabolic risk factors.

In clinical practice a clean separation is rare. A psychological component — primary or secondary — is almost always superimposed on a physical problem: stress and performance anxiety can trigger or considerably worsen a dysfunction that originated organically.

Main organic risk factors

• Diabetes
• Arterial hypertension
• Atherosclerosis and heart disease
• Cigarette smoking, an established risk factor in young men as well
• Physical inactivity, excess weight and obesity
• Hypogonadism and other hormonal imbalances
• Commonly used long-term medications: antihypertensives, anxiolytics and antidepressants, frequently taken without adequate medical supervision, can cause ED as a side effect
• Substance abuse and excessive alcohol consumption

Erectile dysfunction as a cardiovascular warning sign

Erectile dysfunction can be the first visible sign of undiagnosed cardiovascular disease. The penile arteries are narrower than the coronary arteries, so widespread endothelial damage tends to become apparent in erectile function before it does in the heart. For this reason the assessment of a man with ED should include a metabolic work-up and, where indicated, a cardiological evaluation. Dismissing the symptom means missing a diagnostic window.

Diagnosis: how erectile dysfunction is investigated

The turning point in diagnosis came with the discovery that certain drugs, when injected into the penis, induce an erection. The first agent used was papaverine hydrochloride, now abandoned; the current drug of reference is Prostaglandin E1 (PGE1).

• Intracavernous PGE1 test with colour Doppler ultrasound: PGE1 is injected using a very fine insulin needle, and colour Doppler ultrasound assesses blood inflow and the function of the organ. It has both diagnostic and therapeutic value, since PGE1 can also be used to rehabilitate the corpora cavernosa
• NPT test (nocturnal penile tumescence monitoring) with Rigiscan: the device is given to the patient, who applies it to the penis for three consecutive nights. It helps distinguish organic from psychogenic origin
• Metabolic work-up: full lipid profile, oral glucose tolerance test
• Hormonal work-up: pituitary and testicular function and, where appropriate, thyroid and adrenal glands
• Second-line investigations, in highly selected cases: selective pudendal arteriography, cavernosography with cavernosometry

Treatment

Treatment depends on the cause identified. The therapeutic pathway is stepwise, from the least to the most invasive:

• Correction of risk factors: smoking cessation, physical activity, weight loss, control of diabetes and hypertension, review of current medication
• Medical treatments: oral drugs, testosterone replacement therapy where a documented androgen deficiency exists (only once other endocrine causes such as hyperprolactinaemia or thyroid disorders have been excluded), intracavernous PGE1 injections, and psychosexual therapy in psychogenic forms
• Surgical treatments
• Penile prosthesis: the solution for cases that do not respond to the previous options

Only certain types of ED can be cured at the root — psychogenic ED and hormonal ED. Most men are treated with options that are not cause-specific, which makes the choice a structured decision balancing efficacy, safety, invasiveness, cost, and the satisfaction of both the patient and his partner.

Frequently asked questions about erectile dysfunction

Is it normal to occasionally have difficulty with an erection?

An isolated episode linked to fatigue, alcohol or stress is not pathological. Erectile dysfunction is diagnosed when the difficulty is persistent or recurrent and compromises sexual activity. In that case, an assessment should not be postponed.

Is erectile dysfunction a psychological problem?

In most cases no, or not only: at least 70–80% of erectile disorders today have an organic cause. A psychological component is almost always superimposed, even when the problem originated physically. This is why diagnosis must be instrumental rather than presumed.

Can erectile dysfunction be the symptom of another disease?

Yes. It can precede and signal diabetes, hypertension, dyslipidaemia and cardiovascular disease. This is why an andrological assessment includes metabolic and hormonal tests and, where indicated, a cardiological evaluation.

Can erectile dysfunction be treated?

Yes, in the large majority of cases. Options range from correcting risk factors to medical therapy, and on to surgery and penile prosthesis in non-responsive cases. The choice depends on the cause, the severity, and the preferences of the patient and the couple.

At what age can it appear?

At any age. Prevalence rises with age, but ED is not an inevitable consequence of ageing, and in young men smoking is a documented risk factor.

Would you like your case assessed? Ask Prof. Natali for a consultation or book an appointment at his practices in Florence and Empoli, Italy.

The information on this page is provided for general educational purposes and does not replace a medical examination, which remains the only diagnostic tool for correct and effective treatment.