Erectile Dysfunction

This topic is a taboo amongst many men. Erectile dysfunction (ED) is a condition where a man is consistently unable to achieve or maintain an erection of the penis in order to perform sexual intercourse. This condition affects more than half of men aged between 40 to 70 years and is related to age.


The erection

Erection of the penis is a complex process played by many components of the body. Failure at any of these components may result in the failure of erection itself. To simplify things, the mechanisms of an erection can be classified as psychogenic and reflexogenic. These two mechanisms interact and work hand in hand during sexual activity.

Psychogenic erections begin when the brain is stimulated by visual, auditory or imaginary cues.  Stimulation of the brain is associated with the desire to have sexual intercourse. This desire is known scientifically as libido or colloquially as the sex drive. Libido is affected by hormones such as testosterone.

Reflexogenic erections on the other hand are a result of sensory stimulation to the penis, which sends signals to the central nervous system (CNS). The CNS then sends a signal back to the penis causing erection.

Stimulation of either psychogenic or reflexogenic erections will ultimately convey the signal through nerves to the blood vessels and muscles of the penis. This causes blood vessels to open up, allowing more blood to flow into the penis while muscles of the penis contract preventing blood from leaving. The result? The penis becomes engorged with blood and erection ensues.


Many causes

There are many possible causes to ED. We are going to classify the causes into FIVE categories:

  1. Hormonal disturbances such as the lack of testosterone may cause reduction in libido and interest in sexual intercourse.
  2. Psychological problems may also occur, preventing a man from performing normally during sexual intercourse. These problems include stress, anxiety, depression or just plain fear.
  3. Neuronal problems are associated with nerves cells having difficulty in properly conducting the signal for erections. This usually is due to damage to nerve cells, such as spinal cord injury or diabetes.
  4. Vascular obstruction happens when the blood vessels supplying blood to the penis is blocked. Like how blood vessels in the heart may be blocked, patients with high levels of cholesterol or diabetes are also prone to this problem.
  5. Medications may also cause ED usually by affecting one, or more of the four above-mentioned causes.


Many Questions

As we can see, the erection of the penis is very complex and there are many potential areas that may go wrong, preventing an erection. This is the reason why your healthcare provider might ask you many questions before providing treatment. Examples of questions are:

  • Is the problem with ejaculation (too early or too late), a deformity of the penis, libido or inability to attain orgasm? Many patients may be confused about what exactly ED is. There are many forms of sexual health issues in men and ED is only one of them. Therefore, the healthcare provider has to clarify what exactly is the issue at hand before exploring further. 
  • Do you have a morning erection? This is the most basic question in ED. If the answer is yes, it probably means that there is nothing wrong with the nerves cells and blood vessels, hence there is no problems attaining an erection physically. The problem may lie in psychological cause or the lack of libido. 
  • Did the problem worsen over time? If it did, this may suggest that the cause is not psychological. 
  • How severe is the problem? There are many levels of severity. Some men may have problems with maintaining an erection while others are completely unable to attain an erection. The problem may also appear only once in a while or it can happen all the time. Further questions may include:
    • Under what conditions do ED occur?
    • What kind of situation is that?
    • Was there any pressure or psychological stress? 
  • Any disease that you may have? Long-term diseases such as diabetes, high cholesterol, high blood pressure may cause ED, while other diseases such as heart attacks, strokes may give an insight into any potential vascular problems that the patient already has. 
  • Any pain or previous pain to the lower back or spine? The spinal cord runs down the spine and damages to it may cause ED. 
  • What medications are you taking currently? An in-depth review of medications and timing of the occurrence of ED with the start of certain medications will be done in order to find out if medications are a possible cause of ED. Many medications, especially medications to reduce blood pressure, treat depression and very strong pain-killers known as opioids may cause ED.

 After questioning, your doctor may also wish to examine the penis for any deformities or scarring. They would also look for other problems in the body suggesting that there may be hormonal imbalance or other diseases.

Depending on the answers to the questions and findings when looking at your body, your doctor might run a few tests such as blood sugar and cholesterol levels, or even check certain hormone levels.


Medication treatment options

Treatment of ED depends on the cause of the problem. Psychological issues with erections will usually be referred to a psychiatrist or clinical psychologist, while hormonal imbalance will usually be treated with replacement of hormones.  Other causes such as uncontrolled diabetes and high cholesterol will be treated accordingly. However, these treatments may not allow the patient to perform sexually immediately. It takes time to build up good confidence, to normalize hormone levels or even reverse the ill effects of diabetes and/or high cholesterol levels.

This is where vasoactive agents come in. The most popular of these medications is sildenafil (popularized by the brand Viagra®, though other generic brands are available now). Other medications in this group include tadalafil, vardenafil and avanafil. This group of drugs increases the blood flow into the penis by causing blood vessels to become wider. Read more about them here.

There are also injectable medications which are injected directly into the penis but they are not a very popular option.


Non-medication treatment options

It is also possible to attain an erection through a vacuum erection device. This device creates a vacuum chamber around the penis drawing blood in, thus initiating an erection. This erection is then maintained by placing an elastic band over the base of the penis after the vacuum erection device is removed. This keeps the blood within the penis.  This method however, is cumbersome, and unpopular. As long as NO metal or non-elastic rings are used, this method is quite safe.

Surgery is the last resort when all else fails. Semi-rigid or inflatable implants are inserted into the penis to create an erection. Although complications are rare, it may result in infection, injury to nearby structures of the penis during surgery, etc. Satisfaction rates are good for this method of treatment as it allows spontaneous and reliable erections.



  1. McPhee S, Papadakis M, Rabow M. Current Medical Diagnosis & Treatment 2017. New York, N.Y.: McGraw-Hill Education LLC.; 2017.
  2. MILLER T. Diagnostic Evaluation of Erectile Dysfunction. Am Fam Physician. 2000;61(1):95-104.


Pou Wee Gan
Pou Wee Gan

M.Pharm, MBBS, BCPS, R.Ph

A pharmacist first, then a medical doctor. An avid tea drinker and an occasional poet.

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