Causes of Male Erectile Dysfunction (Erection Problems) - and how to
solve them
The causes of male
erection problems fall into two general
categories: physical (or organic), and psychological. In the early
1970s, psychological impotence was believed to be by far the most
common. The noted sex therapy experts Masters and Johnson reported that
90 percent of impotent men suffered from a psychological problem.
However, after twenty-five years of advances in the understanding of neurogenic and vascular physiology, we have much better knowledge of the
mechanisms of erection problems. Although the psychological component
remains a very important factor in diagnosis and treatment, we now know
that at least 80 percent of men who seek medical care for erection
problems will have primary physical problems. On the other hand, it
is virtually impossible that impotence, even with an underlying physical
cause, won't have an impact on a man's psychological well-being. No one
who has failed to initiate or maintain an erection on one occasion can
keep from thinking what if the erection fails the next time they want
to have sexual intercourse.
No matter what the causes of erection problems, we need to keep
in mind the basic principles of the nerve and blood vessel mechanisms
discussed in the previous chapters. Factors that tend to prevent
initiation
of an erection usually involve the nerve supply or can be
psychological.
Factors that prevent the erectile tissue from fully filling with
blood usually have to do with problems of arterial blood flow to the
penis. Factors that lead to the loss of the erection before orgasm and
ejaculation tend to involve failure of the venous occlusive mechanism
that traps blood in the penis and thus maintains the erection. We can
easily see that a breakdown in any of these areas can result in erection
problems or erection problems.
Blood vessel abnormalities
Problems with either the arteries carrying blood to the penis or the
veins
draining blood from the penis can easily prevent a satisfactory
erection. The most common of these problems is blockage of the arteries
carrying blood to the penis. The small arteries carrying blood into the penis at the
time of an erection must dilate from five to ten times their normal
resting diameter. Even as little as 15 % percent occlusion of the small
blood vessels is enough blockage to cause a problem.
Such partial arterial blockage is the most common cause of organic
impotence and is usually associated with risk factors such as cigarette
smoking, diabetes, hypertension (high blood pressure), or even
marked elevation of blood cholesterol and fat levels. Other risk
factors associated with reduced arterial flow are a history of blunt
pelvic trauma or pelvic radiation.
The majority of men who have erection
problems as a result of reduced arterial blood flow will also have more
generalized cardiovascular problems throughout the body. Frequently, impotent
men also have a history of coronary artery occlusive disease with or
without a history of prior heart attacks. Some individuals with
erection problems also have a history of poor blood circulation to
their feet and legs, resulting from arterial occlusive disease.
Occasionally, a patient has a focal isolated blockage of one
of the arteries carrying blood to the penis. This is usually seen in
young patients, in their twenties, who have sustained blunt pelvic
trauma such as a past pelvic fracture. Diabetic men can have impotence
secondary to both effects on the nerve supply to the penis, as well as
the vascular supply. Diabetic men, as well as older men, have an
increased amount of scarring, or fibrosis within the walls of the
arteries to the penis. Plaque buildup on these different areas further
reduces the inside diameter of the arteries.
Patients with hyperlipidemia, or marked elevation of lipid (fat) levels
in the blood have a definite well-described risk for arteriosclerosis.
The extra lipid builds up in the wall of the artery and eventually
causes a significant degree of blockage. High blood pressure
(hypertension) is another established risk factor for arteriosclerosis.
A recent study reported that in one series of impotent men about 45
percent had a history of hypertension. In patients with hypertension, it
is not the increased blood pressure itself that contributes to erection
problems. Rather, the associated arterial stenosis found in patients
with hypertension is thought to be the cause of the erection problems.
Failure of the mechanism that clamps down on
the veins that drain blood from the penis has been proposed as
one of the more common causes of vasculogenic impotence. Some men may
develop large venous channels that are never quite fully occluded as the
arterial blood flows into the penis during the beginning phase of
erection. Often, this problem is seen in relatively young patients who
have experienced erection problems over their entire life. Such
patients may report relatively normal initiation of an erection, but
within a few seconds or up to a minute or so lose the erection without
ejaculation. These venous leak type problems may be surgically
corrected.
In Peyronie's disease, non-elastic scar tissue forms, primarily along
the surface of the tunica albuginea, resulting in inadequate compression
of the veins below the tunical surface, therefore preventing entrapment
of the arterial blood in the normal fashion. On the other hand, if the trabecular smooth muscle and the vascular
spaces of the penis are unable to relax sufficiently, the
sinusoidal expansion will be inadequate and the subtunical veins will not be compressed enough to maintain an erection. This may
occur in the overanxious individual with excessive adrenaline and
excitement. Alteration of the neuro receptors in the smooth muscle may give an
adverse response and, in effect, impair relaxation of the smooth muscle
in response to the usual nitric oxide stimulation.
Interestingly cigarette smoking, in addition to causing generalized
arterial blockage, may also cause the cavernous smooth muscle to lose
its ability to dilate. Again, the net effect is the same -not enough
clamping of the penile penile veins to allow for the heightened intracavernous
arterial
pressures necessary for an erection.
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