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Erectile Dysfunction: Harder to Get Hard?

Chances are that you or someone you love may be experiencing some problems in the male body part department if you are reading this. Erectile dysfunction (ED) relates to the “failure to achieve or maintain a rigid penile erection suitable for satisfactory sexual intercourse” (Sooriyamoorthy, 2021). Sometimes the penis does not work as planned, leaving a man concerned about something beyond improving and a potential “new normal” to accept in an aging male body. There may be some truth to the effects of aging, but, with a thorough review, health issues may exist that, when addressed, can get the organ functioning as it did in your twenties.

Erectile dysfunction increases with age.
Photo by Vlada Karpovich on Pexels.com

Risk Factors of Erectile Dysfunction

The truth is that erectile dysfunction is not at all uncommon with aging. In the Massachusetts Male Aging Study, which included questionnaires, bloodwork, and physiologic measures for men between 40 and 70, more than half (52%) had some degree of erectile dysfunction (Feldman,1994). The prevalence increased with age and cardiovascular risk factors. However, many young men under forty report erectile dysfunction, as many as 26% (Capogrosso, 2013).

The most common type of erectile dysfunction is referred to as psychogenic impotence. In the general population, likely about 90% of people presenting with ED have this cause. However, in a majority of men, likely underlying organic causes are contributing to this.

Unless you found the fountain of youth, age is an irreversible risk factor. Nevertheless, there are important reversible risk factors of erectile dysfunction that really stand out (no pun intended) in the studies (See table below).

Major Risk factors of Erectile Dysfunction

  • Heart Disease – risk factor is atherosclerosis
  • Hypertension – 30-50% of hypertensive men affected
  • Diabetes – the most common risk, with a three-fold greater risk than nondiabetics
  • Medication-related – some blood pressure medications and others can contribute to ED
  • Cigarette smoking – twice likelihood of ED in smokers compared to nonsmokers
  • Obesity – there is a 40% increased risk of developing ED
  • Alcohol and Other drug use
  • Sleep apnea and other sleep disorders
  • Anxiety and Depression
  • Dietary Factors

(Source: Rosen, et al. 2005; Nunes et al, 2012 (hypertension))

What causes an erection?

When touch, images, words, and thoughts stimulate a man, the penis goes through changes that ready it for sexual intercourse. The process begins with parasympathetic nerve triggers that relax smooth muscles in the penile tissue known as the corpus cavernosum. The changes in the muscle allow for increased blood flow into the penis. The blood becomes trapped in the penis, and the penis hardens (Feldman, 1994).

The tissues produce nitric oxide (NO), which plays a role in the erection process. Nitric oxide is a vasodilator, relaxing the penile smooth muscle (Cartledge, 2001.) Interestingly, a decrease in production of NO occurs in chronic metabolic diseases, like hypertension, diabetes, and atherosclerosis.

Erectile Dysfunction: Don’t Chalk it Up To Psychogenic Causes

One important point is that Erectile Dysfunction (ED) is not just caused by performance anxiety or other stressors: it may be the tip of an iceberg to an underlying problem. Contributing factors include neurologic, vascular, and hormonal causes.

Age comes with an increase in smooth muscle collagen or scarring, including in the bladder, peripheral vascular system, and the penis. Some studies suggest that the age-related changes in the vascular beds may relate to the general effects of atherosclerosis and that the two conditions may be interrelated (Clavijo, 2014.) Studies have shown that 40% of men with ED have occult cardiovascular disease (Kawanashi, 2001).

Consider erectile dysfunction to be a marker of increased risk of cardiovascular diseases (Dong, 2011.) Atherosclerosis, the hardening of the arteries, injures both the systemic arterial system and the vascular supply to the penis over time. The conditions are significantly associated with aging, smoking, high blood pressure, diabetes, obesity, and lipid dysfunction. Cigarette smoking, a known cause of atherosclerosis, doubles the probability of significant erectile dysfunction (24% vs. 14%).

With aging comes a natural decline in hormones, which can contribute to erectile dysfunction. Low testosterone levels cause decreased libido and may reduce nocturnal erections. Thyroid dysfunction states, either over or under-functioning, can lead to decreased libido from various hormonal imbalances. However, some people may require further investigation. For example, low testosterone levels occur in the setting of sleep apnea, long-distance cyclists, and chronic opiate use.

Does anything improve erectile dysfunction?

Fortunately, there are things that can help one get improved erections. Studies support that lifestyle interventions can produce significant improvements (Gupta, 2011). Medications such as statins, which treat atherosclerosis, can provide some benefits as well. The treatment recommendations for erectile dysfunction are not explained in this post. If you are interested in reading more about medication treatment, here is a link.

Chronic diseases tax the system. Studies link chronic diseases to inflammation and the normal tissue and hormonal mechanisms decline in this state; there is less testosterone and endothelial nitric oxide and more cortisol. Less nitric oxide production in the vascular tissue impairs the ability to have an erection (Maiorino, 2014).

There are benefits in reversing chronic disease states that lead to improved functioning in all vascular tissues – including the penis! How does one improve or prevent chronic diseases, like diabetes, obesity, and hypertension? It is incredible to imagine that living a healthy life includes longevity, maintenance of cognitive functioning, and good sexual health. In supercentenarian studies, there was preserved vascular disease. Need I say more?

Here are five ways to achieve optimal weight and functioning:

  1. Plant-based diet
  2. Daily aerobic exercise
  3. Regular Sleep Schedule of 7-9 hours of Sleep Each Night
  4. Mindfulness Meditation
  5. A Good Social Support Structure


Capogrosso P, et. al. One Patient Out of Four with Newly Diagnosed Erectile Dysfunction Is a Young Man-Worrisome Picture from the Everyday Clinical Practice. Journ Sexual Med. 2013. 10(7): 1833-1841.

Cartledge J, Minhas S, Eardley I. The role of nitric oxide in penile erection. Expert Opin Pharmacother. 2001. 2(1):95=107. doi:10.1517/14656566.2.1.95.

Clavijo R, Miner M, Rajfer J. Erectile Dysfunction and Essential Hypertension: The Same Aging-related Disoder? Rev Urol. 2014; 16(4):167-71.

Dong J, Yong-Hong Z, Li-Qiang Q. Erectile dysfunction and risk of cardiovsacular disease: meta-analysis of prospective cohort studies. J Am Coll Cardiol. 2011 Sept 20; 58(13): 1378-87. doi: 10.1016/j.jacc/2011.06.024.

Feldman HA, Goldstein I, Hatzichistou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychological correlates: results of the Masssachusetts Male Aging Study. J Urol. 1994 Jan; 151(1): 54-61. doi:10.10016/s0022-5347(17)34871-1.

Gupta B, Murad H, Clifton M, et al. The Effect of Lifestyle Modification and Cardiovascular Risk Factor Reduction on Erectile Dysfunction. Arch Intern Med. 2011; 171(20): 1797=1803. doi: 10.1001/archinternmed.2011.440.

Kawanashi Y, et al. Screening of ischemic heart disease with cavernous artery blood flow in erectile dysfunction. Int J Impot Res. 2001; 13:100-103.

Maiorino M, Bellastella G, Esposito K. Lifestyle modifications and erectile dysfunction: what can be expeected? Asian J Androl. 2015. 17(1):5-10.

Nunes KP, et al. New insights into hypertension-associated erectile dysfunction. Curr Opin Nephrol Hypertens 2012; 21:163-70.

Rosen RC, Wing R, Schneider S, Gendrano N 3rd. Epidemiology of erectile dysfunction: the role of medical comorbidities and lifestyle factors. Urol Clin North Am. 2005; 32:403-17.

Sorriyamoorthy T, Leslie S. Erectile Dysfunction. In: StatPearls. 2021. ID: NBK562253

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