Causes and Classification of Erectile Dysfunction

Normal erectile function requires the coordination of psychological, hormonal, neurological, vascular, and cavernosal factors. Alteration in any one of these factors is sufficient to cause erectile dysfunction. Not uncommonly, a combination of factors is involved.

Causes of Erectile Dysfunction

Psychologic causes
Young age with abrupt onset associated with specific emotional event Dysfunction in certain settings while normal function in others Persistence of nocturnal erections Previous history of erectile dysfunction with spontaneous improvement Excessive life stressors--work, relationships Mental status findings suggestive of depression, psychosis or anxiety disorder

Penile injury/disease
Peyronie's disease
Priapism
Anatomic abnormalities

Medications

Aging
Chronic disease
Diabetes mellitus
Heart disease
Hypertension
Lipid disorders
Renal failure
Liver disease
Vascular disease

Life style
Cigarette smoking
Chronic alcohol abuse

Organic causes
Vasculogenic--arterial

Persistent interest in sex Older age with gradual onset Impaired function in all settings Presence of chronic disease (particularly diabetes, hypertension) Use of prescription/over-the-counter medications associated with erectile dysfunction

Smoking
Elevated blood pressure, evidence of peripheral vascular disease (bruits, decreased pulses, skin and hair changes consistent with arterial insufficiency)

Vasculogenic-venous
Inability to maintain erection once established
Prior history of priapism
Local anomalies of thepenis

Neurogenic
History of spinal cord/pelvic trauma or surgery
Presence of chronic disease (diabetes, alcoholism)
Presence of neurologic condition (multiple sclerosis, stroke)
Abnormal neurologic examination of genitals/perineum

Hormonal
Loss of interest in sexual activity
Small atrophic testis
Low testosterone, elevated prolactin

Most causes of erectile dysfunction were once considered to be psychogenic, but current evidence suggests that up to 80 percent of cases have an organic cause. Regardless of the primary etiology, a psychologic component frequently coexists.

Psychogenic influences are the most likely causes of intermittent erectile failure in young men.

Anxiety about "performance" may result in inhibitory sympathetic nervous system activity, and anticipatory anxiety can make the condition self perpetuating. Common causes of psychogenic erectile dysfunction include performance anxiety, a strained relationship, lack of sexual arousability, and overt psychiatric disorders such as depression and schizophrenia. A psychogenic component is often present in older men, secondary to an organic cause.

Neurologic disorders such as Parkinson's disease, Alzheimer's disease, stroke, and cerebral trauma often cause erectile dysfunction by decreasing libido or preventing the initiation of an erection. In men with spinal cord injuries, the degree of erectile function depends largely on the nature, location, and extent of the lesion. Sensory involvement of the genitalia is essential to achieve and maintain reflexogenic erection, and this becomes more important as the effect of psychological stimuli abates with age.

Androgen deficiency decreases nocturnal erections and libido. However, erection in response to visual sexual stimulation is preserved in men with hypogonadism, demonstrating that androgen is not essential for erection. Hyperprolactinemia from any cause results in both reproductive and sexual dysfunction because prolactin inhibits central dopaminergic activity and therefore the secretion of gonadotropin-releasing hormone, resulting in hypogonadotropic hypogonadism.

Common risk factors associated with generalized penile arterial insufficiency include hypertension, hyperlipidemia, cigarette smoking, diabetes mellitus, and pelvic irradiation. Focal stenosis of the common penile artery most often occurs in men who have sustained blunt pelvic or perineal trauma (e.g., from bicycling accidents). In men with hypertension, erectile function is impaired not by the increased blood pressure itself but by the associated arterial stenotic lesions.

Failure of the veins to close during an erection (veno-occlusive dysfunction) can cause erectile dysfunction. Veno-occlusive dysfunction may be caused by the formation of large venous channels draining the corpora cavernosa, degenerative changes to the tunica albuginea (due to Peyronie's disease, old age, or diabetes mellitus) or traumatic injury (penile fracture), structural alterations of the cavernous smooth muscle and endothelium, poor relaxation of trabecular smooth muscle (in anxious men with excessive adrenergic tone), and shunts acquired as a result of operative correction of priapism.

Sexual function progressively declines in healthy aging men. For example, the latent period between sexual stimulation and erection increases, erections are less turgid, ejaculation is less forceful, the ejaculatory volume decreases, and the refractory period between erections lengthens. There is also a decrease in penile sensitivity to tactile stimulation, a decrease in the serum testosterone concentrations, and an increase in cavernous muscle tone.

Patients with diabetes mellitus have high rates of erectile dysfunction as a result of vascular disease and autonomic dysfunction. About 60-65 percent of men with chronic diabetes mellitus have erectile dysfunction. In addition to affecting small vessels, diabetes may affect the cavernous nerve terminals and endothelial cells, resulting in a deficiency of neurotransmitters.

Chronic renal failure has frequently been associated with diminished erectile function, impaired libido, and infertility. The mechanism is probably multifactorial, involving low serum testosterone concentrations, vascular insufficiency, use of multiple medications, autonomic and somatic neuropathy, and psychological stress. Men with angina, myocardial infarction, or heart failure may have erectile dysfunction due to anxiety, depression, or concomitant penile arterial insufficiency.

In general, drugs that interfere with central neuroendocrine or local neurovascular control of penile smooth muscle have the potential for causing erectile dysfunction.

As many as 25 percent of cases of erectile dysfunction are related to medication side effects.

Drugs Causing Sexual Dysfunction

Drug/Drug Class

Possible Alternative

Antiarrhythmics
Amiodarone
Mexiletine
Procainamide
Anticonvulsants
Carbamazepine
Ethosuximide
Phenytoin
Valproic acid
Antidepressants
Amitriptyline
Amoxapine
Clomipramine
Doxepin
Maprotiline
Protriptyline
Trazodone
Imipramine
Desipramine

* Some patients who experienced sexual dysfunction with amoxapine and clomipramine were successfully switched to imipramine and desipramine, respectively.

Antihypertensives
Atenolol
Clonidine
Hydralazine
Labetolol
Methyldopa
Metoprolol
Pindolol
Prazosin
Propranolol
Verapamil
Reserpine
Guanethidine
Penbutolol,
Timolol
Captopril
Enalapril
Diltiazem
Nifedipine
Antipsychotic
Chlorpromazine
Haloperidol
Thioridazine
Trifluoperazine
Loxapine
Antispasmodic
Baclofen
Dantrolene
Diuretics
Amiloride
Indapamide
Thiazide diuretics
Spironolactone
Furosemide
Anti-Ulcer
Cimetidine
Ranitidine
Metoclopramide
Famotidine
Antihyperlipidemic
Clofibrate
Gemfibrozil
Non-Steroidal Anti-lnflammatory
Naproxen
Ibuprofen
Diclofenac