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Erectile Problems Causes

Erectile dysfunction, also known as erectile dysfunction (ED) or formerly impotence, is defined as the permanent or recurrent inability to get or maintain an erection (erection) of the penis sufficiently for satisfactory sexual intercourse. This definition covers a wide spectrum of difficulties – from a complete inability to achieve an erection, called anerection , through incomplete penile stiffness, to situations when an erection appears, but disappears too early, preventing satisfactory intercourse. In order to be able to talk about erectile dysfunction in the medical sense, these symptoms should persist for at least 3 to 6 months.

What are erection problems and why is it important to know their causes?

Understanding the mechanism of erection is crucial to understanding the causes of its disorders. Erection is a complex neurovascular process that is under hormonal and psychological control. In response to sexual stimuli (visual, auditory, tactile, olfactory or imaginative), nerve impulses from the brain and spinal cord reach the penis. They cause the smooth muscles in the walls of the arteries supplying blood to the corpora cavernosa (two spongy structures inside the penis) and in the corpora cavernosa themselves to relax. The relaxed arteries dilate, allowing a rapid inflow of blood to the corpora cavernosum, which, filling with blood, enlarge and harden. At the same time, the enlarging corpora cavernosa compress the veins draining blood from the penis, which leads to its retention (venoocclusal mechanism) and maintaining an erection. Any disruption at any stage of this complicated process can lead to erection problems.

Erectile dysfunction is a common problem, affecting men all over the world, including young men. Their frequency clearly increases with age. It is estimated that in Poland this problem may affect up to 3 million men , and according to other data, 1.5 million men over 35 years of age. Population studies in Poland indicate the prevalence of ED at the level of 30.1-61.1%. The Massachusetts Male Aging Study (MMAS) found varying degrees of erectile dysfunction in 52% of men aged 40-70. The incidence of ED increases by about 10% per decade of life, which may be related to the causes of incomplete erection. , affecting about 5% of men aged 35 and more than 50% of men over 60. Despite such a large scale of the problem, it is estimated that only about 15% of men in Poland seek medical help due to erectile dysfunction.

Understanding the causes of erection problems is extremely important, because ED is often not only a sexual problem, but also an important warning signal, which may indicate the presence of other, potentially serious systemic diseases. Many studies show that erectile dysfunction can precede the appearance of symptoms of coronary heart disease by several years (on average 2-4 years). This is due to the fact that the arteries supplying the penis are much smaller in diameter (1-2 mm) than coronary arteries (3-4 mm) or carotid arteries (5-7 mm). The disease processes underlying cardiovascular disease, such as atherosclerosis (atherosclerosis) and endothelial dysfunction (the inner lining of blood vessels), manifest earlier in these narrower vessels, leading to a restriction of the blood flow necessary for an erection before cardiac symptoms even appear. Similarly, ED can be one of the first symptoms of undiagnosed diabetes or high blood pressure, which can result in a lack of erection. Therefore, the appearance of erection problems, especially in men without previously diagnosed chronic diseases, should not be underestimated. This is a signal that requires medical consultation not only to address the sexual problem, but also to assess the overall state of health, in particular the risk of cardiovascular and metabolic diseases. Understanding the cause of ED is crucial to implementing appropriate treatment that can significantly improve not only sexual function, but also quality of life, partner relationships, and overall mental well-being.

Physical (organic) causes of erection problems: When the body is ailing

Organic causes, i.e. those resulting from the physical condition of the body, are responsible for the vast majority of erectile dysfunction cases – it is estimated that even about 80%. Their prevalence increases with age, which is associated with a higher incidence of chronic diseases in older men. Organic causes can be divided into several main groups: vascular (related to blood flow), neurogenic (related to the nervous system), endocrine, anatomical, and resulting from other diseases or medical interventions.

Cardiovascular diseases – the main culprit

Cardiovascular problems are the most common cause of organic erectile dysfunction. Proper inflow and retention of blood in the penis are absolutely essential to achieve and maintain an erection.

• Atherosclerosis (atherosclerosis): This is the most common single cause of organically sourced ED. It involves the deposition of atherosclerotic plaques (made mainly of cholesterol) in the walls of the arteries, which leads to their narrowing and stiffening, and thus can cause health problems such as ED. This process also affects the arteries supplying blood to the penis, limiting its inflow and making it difficult to have an erection. As mentioned earlier, ED may be the first, early sign of generalized atherosclerosis, ahead of cardiac problems.
• Hypertension: Chronically elevated blood pressure damages blood vessels throughout the body, including the penis. It contributes to the development of atherosclerosis and impairs the ability of vessels to relax properly, which is crucial for blood flow during erection. The mechanism of the negative effects of hypertension on erection is complex and includes damage to the vascular endothelium, a decrease in the production of nitric oxide (NO) – a key vasodilator, excessive activation of the sympathetic nervous system (responsible for stress responses) and activation of the renin-angiotensin system, which narrows the vessels. It is estimated that up to 50-54% of men with hypertension experience erection problems. Hypertension is a risk factor for ED regardless of the medications used.
• Other heart and vascular diseases: Ischemic heart disease (coronary artery disease), heart failure, peripheral arterial disease also negatively affect circulation and can be the cause of ED.
• Hyperlipidemia: Increased levels of cholesterol (especially LDL – “bad” cholesterol) and triglycerides in the blood are the main factor leading to the development of atherosclerosis and thus to erection problems.

Diabetes – the silent destroyer of potency

Diabetes is one of the most common chronic diseases leading to erectile dysfunction. Men with diabetes are 3 to 6 times more likely to develop ED than men without the disease , and this problem can affect up to 90% of diabetics. The risk of ED in diabetic patients is about 3 times higher than in the general population, and the prevalence is estimated at 27.5-59%.

Diabetes negatively affects the erectile mechanism in several ways :

• Damage to blood vessels (diabetic angiopathy): Chronic elevated blood sugar levels (hyperglycemia) damage the endothelium of blood vessels, including the small arteries of the penis. This leads to a decrease in the production and availability of nitric oxide (NO), which is crucial for vasodilation and blood flow to the corpora cavernosum. Importantly, vascular problems can appear as early as prediabetes.
• Nerve damage (diabetic neuropathy): Diabetes also damages autonomic nerves, including parasympathetic fibers, which are responsible for transmitting nerve signals that initiate and maintain an erection. Impaired nerve conduction prevents a proper response to sexual stimulation.
• Hormonal disorders: About half of men with diabetes have reduced testosterone levels (hypogonadism), which can further impair libido and sexual function.
• Psychological factors: The mere awareness of a chronic disease, its complications and the need for constant treatment can negatively affect well-being, mood and libido, contributing to mental erection problems.

The risk of erectile dysfunction in men with diabetes is additionally increased by: old age (especially after the age of 40), long duration of the disease, poor control of blood sugar levels (high level of glycated hemoglobin HbA1c), smoking, sedentary lifestyle, coexistence of other diseases (such as hypertension or abnormal cholesterol levels) and the presence of other complications of diabetes (e.g. retinopathy, nephropathy).

Neurological disorders – interruption of communication

The proper functioning of the nervous system is essential for initiating and maintaining an erection. Damage to the brain, spinal cord, or peripheral nerves can disrupt the transmission of nerve signals to the penis, leading to ED.

• Diseases of the central nervous system (CNS): Brain diseases that can cause ED include multiple sclerosis (MS), Parkinson’s disease, stroke, brain tumors, Alzheimer’s disease, epilepsy (especially temporal lobe epilepsy, where ED is a common symptom and anti-epileptic medications can exacerbate the problem), and inflammation of the brain and meninges.
• Spinal cord injuries: Spinal cord injuries, spinal cord tumors, inflammation (e.g. transverse myelitis, spinal tuberculosis) or degenerative conditions (e.g. spinal wilting in late syphilis) often lead to serious erectile dysfunction. The nature and degree of the disorder depend on the level and extent of the spinal cord injury.
• Neuropathy: This is damage to nerves located outside the brain and spinal cord. It can be caused by many factors, most often diabetes, but also by alcohol abuse, vitamin deficiencies (especially B vitamins), heavy metal poisoning, certain infections (e.g. AIDS) or autoimmune diseases. Peripheral neuropathy can manifest itself in sensory disturbances (pain, tingling, numbness), muscle weakness, but also autonomic dysfunctions, including erectile dysfunction, bladder problems or sweating disorders.

Hormonal disorders – lack of fuel for libido and erection

Hormones play an important role in regulating sexual function, although their direct effect on the erectile mechanism itself is more complex than on libido (sex drive).

• Low testosterone (hypogonadism): Testosterone is the main male sex hormone, crucial for maintaining sex drive (libido). Its role in erectile physiology is less direct, but testosterone deficiency can contribute to ED, especially when combined with other factors. Testosterone levels naturally decline with age, by an average of 1-2% per year after age 40, which is part of a process called andropause. Low testosterone levels can manifest itself in decreased libido, erection problems, chronic fatigue, loss of muscle mass and strength, fat gain (especially in the abdominal area), mood disorders (irritability, depression), concentration and sleep problems. It is estimated that between a third and more than half of men presenting with ED have reduced testosterone levels. Testosterone deficiency can result from primary testicular failure or secondarily from pituitary or hypothalamus dysfunction.
• Hyperprolactinemia: Excess prolactin, a hormone produced by the pituitary gland, can inhibit the secretion of gonadotropins (LH, FSH), which leads to a decrease in testosterone production and can be the cause of ED and a decrease in libido. Hyperprolactinemia can be caused by a pituitary tumor (prolactinoma), certain medications (e.g. neuroleptics, opioids) or chronic stress.
• Thyroid diseases: Both hyperthyroidism and hypothyroidism can negatively affect sexual function, including erection.
• Other hormonal disorders: Less commonly, the cause of ED may be adrenal gland disease or decreased levels of DHEA (dehydroepiandrosterone), another steroid hormone.

Anatomical and urological causes

Abnormalities in the structure of the penis or diseases of the genitourinary system can also cause erection problems.

• Peyronie’s disease: It is an acquired condition consisting in the formation of hard, fibrous plaques (scars) within the tunica albuginea of the corpora cavernosa of the penis. These plaques cause a reduction in the elasticity of the tissue, which leads to the characteristic curvature of the penis during erection, often combined with pain. In advanced cases, the curvature may be so large that it makes penetration difficult or impossible. The disease can also cause shortening of the penis and direct erectile dysfunction. The causes of Peyronie’s disease are not fully understood, but it is believed that repetitive penile microtrauma (e.g. during intercourse), genetic predisposition, as well as the coexistence of diseases such as diabetes, hypertension or smoking play a role. The disease usually proceeds in two phases: acute (inflammatory), characterized by pain and progressive curvature, and chronic (stable), in which the pain usually subsides and the curvature stabilizes. Peyronie’s disease is estimated to affect between 1% and 9% of the male population.
• Congenital malformations of the penis: These include congenital penile curvature (different than in Peyronie’s disease), hypospadias (the urethral orifice is located on the ventral side of the penis) or superficiality (urethral orifice on the dorsal side).
• Phimosis: It is a narrowing of the foreskin that prevents or hinders its sliding off the glans. It can cause pain during erection and sexual intercourse, as well as promote inflammation, which can lead to erectile dysfunction.
• Diseases of the prostate gland: Benign prostatic hyperplasia (BPH), which often causes lower urinary tract symptoms (LUTS), often coexists with erectile dysfunction. Chronic prostatitis or prostate cancer can also affect sexual function.
• Urinary tract infections: They can cause pain and discomfort, discouraging sexual activity.
• Penile Cancer: Although rare, it can be a cause of ED.

Other chronic diseases and conditions

A number of other chronic diseases that affect overall health, metabolism or organ function can also contribute to erectile dysfunction:

• Chronic kidney disease (CKD): Kidney failure is associated with hormonal imbalances, neuropathy, vascular problems, and often concomitant heart disease, leading to a high incidence of ED in patients on dialysis or after kidney transplantation.
• Hepatic: Chronic liver diseases (e.g. cirrhosis) can lead to hormonal disorders (e.g. decreased testosterone, increased estrogen), which negatively affects sexual function.
• Chronic obstructive pulmonary disease (COPD): This disease is associated with hypoxia, inflammation, reduced physical performance, and often concomitant heart disease, which can contribute to ED.
• Obstructive sleep apnea (OSA) is one of the health problems that can contribute to ED. As discussed in detail in the lifestyle section, OSA through hypoxia, sleep fragmentation, and hormonal imbalances is a significant risk factor for ED and a cause of poor erection.

Iatrogenic (resulting from treatment) and post-traumatic causes

Erectile dysfunction can also be an unintended result of medical interventions or injuries.

• Pelvic surgeries: Surgical procedures in this area, especially radical prostatectomy (removal of the prostate due to cancer), but also surgery on the bladder, rectum or large vessels (e.g. aorta), carry the risk of damage to the delicate nerves and blood vessels responsible for erection. Erectile dysfunction is a very common complication after radical prostatectomy, regardless of the surgical technique used.
• Pelvic radiation therapy: Irradiation used to treat pelvic cancers (e.g. prostate cancer, rectal cancer) can lead to gradual damage to blood vessels and nerves, resulting in the development of ED even some time after treatment has ended. ED is a common complication of both external field radiation therapy and brachytherapy.
• Injuries: Blunt or penetrating injuries to the pelvis, perineum, penis (including the so-called penile fracture during intercourse) or spinal cord can lead to direct damage to vascular or nerve structures crucial for erection.

Many of the listed organic causes, such as cardiovascular diseases, diabetes, hypertension, smoking or obesity, lead to erectile dysfunction through a common pathophysiological mechanism. Central to this mechanism is endothelial dysfunction – the inner layer of cells lining blood vessels. A healthy endothelium plays a key role in regulating vascular tone, mainly through the production of nitric oxide (NO), which is necessary for smooth muscle relaxation in the penile arteries and corpora cavernosum, allowing blood to flow and erections. Risk factors such as atherosclerosis, high blood pressure, increased sugar levels, chronic inflammation or oxidative stress (associated with e.g. smoking) damage endothelial cells. The damaged endothelium produces less NO or it becomes less bioavailable, which directly makes it difficult to achieve and maintain an erection. Understanding this shared pathway highlights the fundamental importance of blood vessel health for normal sexual function and reinforces the case for lifestyle modification as the foundation of ED prevention and treatment.

Drugs and substances as causes of erection problems

Erectile dysfunction can also be a side effect of many commonly used drugs and the use of psychoactive substances. It is estimated that drugs may be responsible for up to 25% of ED cases. This is important information because in many cases the problem can be reversible after modification of treatment. However, it should be categorically emphasized that you should never discontinue or modify the dosage of prescribed drugs on your own without consulting your doctor. Sudden discontinuation of therapy, especially in the case of chronic diseases, can be dangerous to health.

Medications for hypertension

Drugs used to treat high blood pressure (antihypertensive drugs) are one of the most common groups of pharmaceuticals associated with ED. However, not all drugs in this group work the same.

• Beta-blockers (β-blockers) can affect the quality of sex life, including the occurrence of poor erections. Especially older, non-selective beta-blockers (e.g. propranolol) and some cardioselective (blocking mainly β1 receptors) of the older generation (e.g. atenolol, metoprolol) are often mentioned as the cause of ED. Their mechanism of action consists in blocking beta-adrenergic receptors, which leads, m.in , to a slowdown of the heart rate and a decrease in blood pressure. However, they can also affect the blood vessels of the penis, making it difficult for them to relax, reduce blood flow, and also inhibit the activity of the sympathetic nervous system in a way that negatively affects erections. Some can also lower libido. It is worth noting that newer beta-blockers, especially those with additional vasodilators (e.g., nebivolol, carvedilol), appear to have much less or no negative effect on sexual function.
• Diuretics (diuretics): Especially thiazide diuretics (e.g. hydrochlorothiazide, chlorthalidone) and potassium-sparing diuretics such as spironolactone can cause erection problems. The mechanism may consist in a reduction in the volume of circulating blood and blood flow to the penis, as well as an effect on the electrolyte balance (e.g. thiazides can leach zinc, important for the production of testosterone). Spironolactone also has antiandrogenic properties (blocks the action of male sex hormones).
• Other antihypertensive drugs: Older centrally acting drugs such as methyldopa or clonidine are also known to have a negative effect on erection.

Fortunately, there are many groups of hypertension medications that are considered safer in terms of ED risk or may even have a neutral or beneficial effect on sexual function. These include: angiotensin-converting enzyme inhibitors (ACEIs) (e.g., ramipril, perindopril, lisinopril), angiotensin II receptor antagonists (ARBs, sartans) (e.g., losartan, valsartan, telmisartan), calcium channel blockers (especially dihydropyridine derivatives, e.g., amlodipine, lercanidipine), and alpha-blockers can be used to treat health problems that affect ED. (e.g., doxazosin). If ED occurs during hypertension therapy, the doctor often has the option of switching to a lower-risk medication, which can help with health problems associated with ED.

Antidepressants

Drugs used to treat depression and anxiety disorders are the second, very important group of pharmaceuticals that often cause sexual dysfunction, including erectile dysfunction. This problem may affect even more than 70% of patients treated with certain antidepressants.

• Selective serotonin reuptake inhibitors (SSRIs): This is the most commonly used group of antidepressants (examples: fluoxetine, paroxetine, sertraline, citalopram, escitalopram). Unfortunately, these drugs are also most commonly associated with causing sexual dysfunction, including decreased libido, difficulty reaching orgasm, and erectile dysfunction. Paroxetine and escitalopram appear to carry the greatest risk of these side effects. The mechanism of action of SSRIs is to increase the concentration of serotonin in the brain. Their negative effects on sexual function are complex and may result from inhibition of brain centers responsible for sexual responses, effects on other neurotransmitters (e.g., decreased dopamine levels), effects on endocrine balance (e.g., increased prolactin levels), as well as direct effects on serotonin receptors (e.g., 5HT2, 5HT3) and potential reduction in nitric oxide (NO) secretion. In a small percentage of patients, sexual dysfunction may persist even after discontinuation of the drug (PSSD – Post-SSRI Sexual Dysfunction syndrome).
• Serotonin and norepinephrine reuptake inhibitors (SNRIs): Drugs such as venlafaxine or duloxetine also often cause similar side effects as SSRIs.
• Tricyclic antidepressants (TLPDs): The older group of drugs (e.g. imipramine, amitriptyline, doxepin) is also at high risk of causing ED and other sexual problems.
• Monoamine oxidase inhibitors (MAOIs): Medications such as phenelzine, although less commonly used, can also negatively affect sexual function.

Fortunately, there are antidepressants that have a much lower risk of causing sexual dysfunction. These include, m.in, medications that can be prescribed to improve the quality of sex life. bupropion, mirtazapine, agomelatine, tianeptine, as well as mianserin and reboxetine. If you are experiencing erection problems while on antidepressant treatment, it is essential to talk to your psychiatrist about it. It is possible to adjust the dose, change to another with a more favourable profile, or sometimes add an erection medication (e.g. in the case of erectile problems). PDE-5 inhibitor, like sildenafil).

Other medicines

Many other groups of drugs can potentially affect your ability to have an erection:

• Antipsychotics (neuroleptics): Used to treat schizophrenia and other psychoses.
• Anxiolytics (anxiolytics): Especially benzodiazepines for long-term use.
• Antiepileptic drugs: Especially older generations (phenobarbital, phenytoin, carbamazepine, valproic acid), but some newer ones (gabapentin, clonazepam) can also cause problems.
• Hormonal medications can be part of the causes and treatment of ED. Drugs with antiandrogenic effects (e.g. finasteride, dutasteride used in the treatment of BPH and alopecia, can also affect erectile problems, GnRH analogues and estrogens (used e.g. in hormone therapy) can have a similar effect in the treatment of prostate cancer).
• Some cardiac drugs: Digoxin, amiodarone.
• Lipid-lowering drugs: Less commonly, but cases of ED have been reported after fibrates (gemfibrozil) and statins (simvastatin).
• H2 receptor antagonists: Medicines used to treat peptic ulcer disease and reflux (e.g. cimetidine, ranitidine – currently less commonly used).
• Older generation antihistamines:.
• Opioids: Strong painkillers.
• Cytostatics (chemotherapy drugs) can lead to health problems such as ED..

Psychoactive substances

Substance abuse is a significant risk factor for erectile dysfunction.

• Alcohol: Regular consumption of large amounts of alcohol damages the nervous, vascular and endocrine systems. It can lead to neuropathy, liver damage (which affects hormone metabolism), decreased testosterone levels and directly inhibit erectile mechanisms. Additionally, alcohol can exacerbate stress and depressive symptoms, which also negatively affect potency, leading to poor erections.
• Nicotine (smoking): Smoking cigarettes is one of the main modifiable risk factors for ED. Nicotine and other toxins contained in tobacco smoke damage the endothelium of blood vessels, accelerate the development of atherosclerosis, restrict blood flow through the penile arteries and may lower testosterone levels. Studies indicate that men who smoke a pack of cigarettes a day have a 50-60% higher risk of developing ED than non-smokers. Quitting smoking is a key part of improving your sexual health.
• Drugs: Various psychoactive substances, such as cocaine, amphetamines, heroin, marijuana, opiates, anabolic steroids or so-called designer drugs, can lead to erectile dysfunction by negatively affecting the nervous, endocrine and vascular systems. They can lower testosterone levels and interfere with nerve conduction (e.g., marijuana can impair peripheral sensation).

Medications often linked to erectile dysfunction

A group of drugs	Examples of substances/groups	Potential effects on erection	Comments
Medications for hypertension			The risk depends on the specific drug; Many newer drugs are safer.
	Beta-blockers (older, e.g. atenolol, metoprolol, propranolol)	Frequent
	Thiazide diuretics (e.g. hydrochlorothiazide, chlorthalidone)	Frequent
	Spironolactone	Frequent	Anti-androgenic effects.
	Centrally acting drugs (older, e.g. methyldopa, clonidine)	Frequent
Antidepressants			Sexual dysfunction is a common side effect of many antidepressants.
	SSRIs (e.g. paroxetine, sertraline, fluoxetine, citalopram)	Very common	Risks vary between drugs; Paroxetine and escitalopram are often mentioned as the riskiest.
	SNRIs (e.g. venlafaxine, duloxetine)	Frequent
	TLPD (e.g. amitriptyline, imipramine)	Frequent
	MAOIs (e.g. phenelzine)	Frequent
Antipsychotics	(e.g. haloperidol, risperidone, olanzapine)	Frequent	They can increase prolactin levels.
Antiepileptic drugs	(older: phenobarbital, phenytoin, carbamazepine; newer: gabapentin)	Possible/Frequent	The risk is higher with older drugs.
Hormonal drugs	Antiandrogens (e.g. finasteride, dutasteride, flutamide), GnRH analogues	Very common	Used, for example, in the treatment of prostate cancer, BPH.
Opioids	(e.g. morphine, oxycodone, tramadol)	Frequent	With long-term use.
Other	Digoxin, Amiodarone, Cimetidine (less commonly used)	Possible

Important: The table above is for informational purposes. The effect of drugs on sexual function is individual. If you suspect that the medications you are taking may be the cause of your erection problems, consult your doctor. Do not stop treatment on your own.

Psychogenic Causes of Erectile Dysfunction: The Head Matters

Although organic causes dominate statistically, psychological factors play an extremely important role in the etiology of erectile dysfunction. It is estimated that they are responsible for about 20% of ED cases, being a particularly common cause of problems in younger men, under 35-40 years of age. However, it should be remembered that psychogenic factors very often coexist with organic causes or can intensify them, creating a picture of mixed etiology. The process of sexual arousal and erection begins in the brain, which is why a man’s mental state is fundamental to his sexual performance.

Stress, fatigue, overwork

The modern lifestyle, full of tensions and demands, is one of the main culprits of psychogenic erection problems, especially in young, professionally active men. Chronic stress, whether related to work, family or financial situation, chronic fatigue, sleep deprivation and overwork can effectively inhibit sexual responses, which leads to erectile dysfunction. The mechanism of this influence is complex. Stress leads to increased levels of stress hormones such as cortisol and prolactin, which can lower testosterone levels. In addition, stress activates the sympathetic system (“fight or flight”), which acts antagonistically to the parasympathetic system, responsible for initiating erections. Excessive activity of the sympathetic nervous system can directly inhibit nerve signals that lead to an erection.

Anxiety and Worries

Anxiety is a powerful inhibitor of sexual responses and a common cause of psychogenic erectile dysfunction.

• Performance anxiety: This is probably the most common form of anxiety associated with ED. A man is afraid that he will not be able to achieve or maintain an erection, that he will not live up to his partner’s expectations, that he will be ridiculed or disgraced. This type of fear very often leads to a vicious circle. Even a one-time, accidental failure to achieve an erection (caused, for example, by fatigue, stress or alcohol) can cause a strong fear of the next intercourse. This fear alone, by activating the sympathetic nervous system and inhibiting erectile mechanisms, increases the likelihood of another failure. As a result, the man may begin to avoid intimate situations, which further exacerbates the problem (leading to the so-called “disappearance of erection from inactivity”) and negatively affects the relationship with his partner. This creates a self-reinforcing spiral: failure → anxiety → avoidance → greater anxiety / deterioration of the relationship → another failure. Breaking this vicious circle is crucial in therapy and may require psychotherapeutic support, relaxation techniques, and sometimes pharmacotherapy to help regain self-confidence.
• Situational anxiety can contribute to erectile dysfunction. Erection problems can only occur in certain circumstances, such as when you are in contact with a new partner, in a new place, or in situations that are perceived as stressful.
• Other fears: It can also be caused by fears of unwanted pregnancy, contracting a sexually transmitted disease, fear resulting from a sense of guilt (e.g. on religious grounds) or fear resulting from traumatic sexual experiences from the past.

Depression and mood disorders

Depression is a serious mental disorder that has a strong negative impact on all spheres of life, including sexuality. People suffering from depression often experience low mood, loss of interest, lack of energy and motivation, which naturally translates into reduced libido and problems with achieving an erection. An additional problem is the fact that many antidepressants, as discussed in the previous section, can aggravate or induce erectile dysfunction as a side effect.

Relationship problems and relational factors

The quality of the partner relationship has a huge impact on sexual satisfaction and erectile performance. Conflicts, frequent arguments, lack of honest communication, unexpressed resentment, betrayal, a sense of boredom and monotony in the sexual sphere can lead to the extinction of desire and erection problems. Also, relationship dynamics, such as a struggle for dominance, excessive control or criticism from the partner, her overprotection, or lack of trust, can negatively affect male potency. Sexual problems in the female partner (e.g., pain during intercourse, lack of desire) can also contribute to ED in a man. Open, honest communication in the relationship and mutual support and understanding are crucial to overcoming erection problems, regardless of their root cause.

Low self-esteem and personality problems

A negative self-image, lack of self-confidence, complexes (e.g. regarding body appearance or penis size – the so-called “small penis complex”), shyness, excessive need for control or a generally immature personality structure can be fertile ground for the development of psychogenic erectile dysfunction. Men with low self-esteem are more prone to fear of being judged and failing sexually.

Other psychogenic factors

Other causes of psychological erection problems also include:

• Traumatic sexual experiences: Sexual violence and past harassment can leave deep traces in the psyche and lead to aversion or fear of sex.
• Educational and socio-cultural factors: Upbringing in a pathological family environment, excessive educational rigor (especially in the sphere of sexuality), unsuccessful marriage of parents, guilt related to masturbation instilled in the process of upbringing, lack of reliable sex education or passing on negative stereotypes about sex.
• Addiction: Excessive use of pornography can lead to desensitization to normal sexual stimuli and difficulty achieving an erection with a real partner.
• Other: Premature sexual initiation, professional frustrations, undertaking sexual activity against one’s own orientation or preferences.

In differential diagnosis, it is important to distinguish between psychogenic and organic ED. Psychogenic causes are usually supported by: sudden onset of problems, occurrence of spontaneous night or morning erections, preserved ability to achieve a full erection during masturbation, problem that occurs only in certain situations (e.g. only during intercourse with a partner), young age of the patient and lack of chronic diseases and organic risk factors. However, the final diagnosis requires a thorough medical history and examination.

Lifestyle and erection: How do daily habits affect potency?

A growing body of scientific evidence confirms that lifestyle has a fundamental impact on men’s sexual health. Daily choices regarding diet, physical activity, sleep or stimulants can either protect against erectile dysfunction or significantly increase the risk of its occurrence. Modifying unhealthy habits is often a fundamental element of both prevention and treatment of ED. In many cases, lifestyle changes can bring about significant improvement or even complete resolution of erection problems, especially if they are not caused by advanced organic diseases.

Obesity and overweight

Excessive body weight is one of the key risk factors for erectile dysfunction. The mechanisms of this influence are manifold:

• Increased risk of disease: Obesity and overweight significantly increase the risk of developing cardiovascular diseases (hypertension, atherosclerosis), type 2 diabetes and metabolic syndrome – all of which are the main causes of organic ED.
• Hormonal disorders: Excess body fat, especially in the abdominal area, leads to hormonal disorders. The activity of the aromatase enzyme, which converts testosterone into estrogens, increases, leading to a decrease in active testosterone levels. Obesity is also often associated with insulin resistance, which can also negatively affect the hormonal balance.
• Endothelial inflammation and dysfunction: Adipose tissue, especially visceral tissue, is metabolically active and produces pro-inflammatory substances (cytokines). Chronic low-grade inflammation associated with obesity contributes to damage to the endothelium of blood vessels and impaired nitric oxide (NO) production, making it difficult to have an erection.
• Psychological Impact: Excess body weight can negatively affect self-image, self-esteem and self-confidence, which can lead to fear of intimacy and psychogenic problems.

Weight reduction through a healthy diet and regular physical activity brings measurable benefits for sexual function. It improves hormonal balance (increase in testosterone levels), improves blood circulation, reduces inflammation, lowers the risk of comorbidities and has a positive effect on mental well-being.

Unhealthy diet

The way we eat has a direct impact on the health of blood vessels, metabolism and the overall condition of the body, and thus also on potency. A diet typical of Western countries, rich in:

• saturated and trans fats (present in fatty meat, processed meats, fast food, confectionery),
• simple sugars (sweets, sweetened drinks),
• highly processed food,
• salt

and at the same time poor in vegetables, fruits, whole grains, fish and healthy fats (e.g. olive oil, nuts), promotes the development of obesity, hypertension, atherosclerosis, type 2 diabetes and dyslipidemia – the main causes of ED.

Recommended for heart health and potency are nutritional models such as the Mediterranean diet or the DASH diet (Dietary Approaches to Stop Hypertension). They rely on a high intake of vegetables, fruits, whole grains, legumes, fish, lean dairy and healthy vegetable fats, while limiting red meat, sweets and processed foods. It is also important to eat regularly and avoid distractions (e.g. TV, smartphone) while eating, which helps to control the amount of food you eat and recognize the feeling of satiety.

Lack of physical activity

A sedentary lifestyle and lack of regular physical activity is another significant risk factor for erectile dysfunction. Lack of exercise contributes to:

• The development of obesity and its consequences.
• Deterioration of the cardiovascular system (increased risk of hypertension, atherosclerosis).
• Development of insulin resistance and type 2 diabetes.
• Deterioration of blood circulation, including blood flow through penile vessels.
• Deterioration of vascular endothelial function.

Regular physical activity has numerous benefits for sexual health. At least 150 minutes of moderate physical activity per week (e.g. brisk walking, cycling, swimming) or 75 minutes of vigorous activity is recommended. Exercise improves circulation, helps maintain a healthy body weight, lowers blood pressure, improves insulin sensitivity, reduces stress and improves mood. However, it is worth noting that very intense and prolonged cycling, especially on an unsuitable saddle, can cause pressure on the nerves and vessels in the perineal area, leading to temporary erection problems.

Sleep disorders

The quality and quantity of sleep are of great importance for overall health, including sexual function.

• Sleep deprivation and insomnia can negatively affect the quality of sex life and lead to erectile problems. Chronic sleep deprivation leads to fatigue, increased susceptibility to stress, concentration problems and low mood – all of which can negatively affect libido and erection. What’s more, sleep deprivation can lead to a decrease in testosterone levels, the production of which is highest during sleep.
  • Chronic hypoxia: Repeated drops in blood oxygen levels damage the endothelium of blood vessels and can lead to nerve damage.
  • Disruption of sleep architecture: OSA causes frequent awakenings (often unconscious) and significantly shortens the REM sleep phase (dream phase). The REM phase is crucial for the occurrence of physiological nocturnal erections (NPT – Nocturnal Penile Tumescence), which occur in healthy men several times during the night. These spontaneous erections are thought to be important for maintaining proper oxygenation and the health of penile tissue. The lack or shortening of the REM phase in OSA leads to the disappearance of NPT, which can deteriorate erectile function in the long term.
  • Lowering Testosterone Levels: Testosterone production peaks during deep sleep phases, including REM. Sleep fragmentation caused by apnea can lead to a decrease in levels of this hormone.
  • Increased oxidative stress and inflammation can be the cause of erectile problems. Associated with repeated episodes of hypoxia and reoxygenation.
  • Coexistence of other risk factors: OSA very often co-occurs with obesity, hypertension and cardiovascular diseases, which are themselves causes of ED. Obstructive sleep apnea (OSA): This is a serious condition in which breathing stops repeatedly or becomes significantly shallow during sleep, leading to hypoxia and fragmentation of sleep. Typical symptoms include loud, irregular snoring interrupted by silence (apnea), excessive daytime sleepiness, morning headaches, concentration problems, irritability, as well as frequent urination at night. OSA is an important, though often underestimated, risk factor for erectile dysfunction. The mechanisms that link OSA to ED include:

Treatment of OSA, most commonly with a CPAP (constant positive airway pressure) machine that keeps the airway open during sleep, can bring significant improvements. It improves sleep quality, eliminates hypoxia, can lead to an increase in testosterone levels and improved erectile function, as well as eliminates snoring, which has a positive effect on partner relationships.

It’s worth noting that negative lifestyle habits rarely occur in isolation. Overweight man He often leads a sedentary lifestyle, which can contribute to erectile dysfunction, eats unhealthily and often smokes cigarettes or abuses alcohol. Each of these factors (obesity, lack of exercise, poor diet, smoking, alcohol) is an independent risk factor for ED, acting through different, often overlapping mechanisms (vascular, hormonal, nervous). When these factors coexist, their negative effects on vascular health, hormone levels, and overall body health accumulate, significantly increasing the risk and severity of erectile dysfunction. What’s more, an unhealthy lifestyle is a major cause of chronic diseases such as diabetes, high blood pressure, and heart disease, which are themselves the most common organic causes of ED. That is why a comprehensive approach to lifestyle change is so important. Focusing on just one aspect, such as diet, may not bring the desired results if other harmful habits, such as smoking or lack of exercise, remain unchanged. A holistic approach, including a healthy diet, regular physical activity, maintaining a healthy body weight, giving up smoking, limiting alcohol and taking care of sleep hygiene, is a key element of prevention and treatment of erectile dysfunction.

Age and erection problems: Is it inevitable?

One of the most well-documented facts about erectile dysfunction is its strong correlation with a man’s age. Numerous epidemiological studies around the world consistently show that the prevalence of ED increases significantly with age. As mentioned earlier, statistics show an increase in the incidence of ED from about 5% in men over the age of 35 to more than 50% in men over 60. Other studies report the incidence of ED at 6-8% in the 40-49 age group, 16-22% in the 50-59 age group, 20-40% in the 60-69 age group, and even 44-75% in men over 70-75 years.

This clear relationship between age and ED is due to several factors:

• Natural physiological changes associated with aging: As we age, certain changes occur in the male body that can affect sexual function:
  • Vascular lesions: The process of atherosclerosis progresses, blood vessels become less elastic and more rigid, which can hinder the proper flow of blood to the penis and lead to a lack of erection.
  • Hormonal changes: Testosterone levels gradually but steadily decrease (the andropause process), which can affect libido and partly the erection itself.
  • Changes in penile tissues: The elasticity of the connective tissue in the corpora cavernosa decreases, which can make it difficult for them to be fully filled with blood and maintain stiffness.
  • Neurological changes: Nerve conduction can slow down, which prolongs the reaction time to sexual stimuli.
  • Changes in sexual response: In older men, the need for stronger and longer stimulation to achieve an erection, a prolongation of the refractory period (the time needed to regain the ability to erect after orgasm), a decrease in orgasm intensity and ejaculate volume are often observed.
• Increased risk of comorbidities: The most important factor explaining the increase in the incidence of ED with age is the fact that with age the risk of chronic diseases, which are the main organic causes of erectile dysfunction, increases significantly. These include, above all, cardiovascular diseases (atherosclerosis, hypertension, coronary artery disease), type 2 diabetes, prostate diseases, as well as neurological diseases or kidney failure.
• Taking more medications can increase your risk of ED, which should be discussed when you see your doctor. Older men are more likely to take medications for a variety of medical conditions, and as discussed earlier, many of these can cause ED as a side effect.

However, it is extremely important to emphasize that medical history is crucial in identifying the causes and treating ED. Age itself is a risk factor, but not a direct cause of erectile dysfunction. This means that ED is not an inevitable and natural consequence of the aging process. Many elderly men maintain full sexual performance. Erection problems in older men are most often the result of concomitant diseases (often untreated or poorly controlled), an unhealthy lifestyle or medications taken, and not the fact of aging itself.

Understanding this difference between physiological aging and pathology is crucial. Yes, a certain slowdown in sexual reactions or the need for longer stimulation can be a normal part of aging. However, the persistent inability to achieve or maintain an erection sufficient for satisfactory intercourse is usually a signal of the presence of a specific pathology (vascular disease, diabetes, hormonal problems, neurological problems, etc.) and not just “old age”. Therefore, men of all ages, including older men, should not accept ED as normal or inevitable. Instead of giving up, they should see a doctor to diagnose the cause of the problem. In many cases, it is possible to effectively treat the underlying disease or implement targeted therapy for ED, which allows you to regain a satisfying sex life and improve your overall quality of life, regardless of age.

Mixed etiology: When causes overlap

In clinical practice, it very often turns out that erectile dysfunction does not have a single, clearly defined cause. They are usually the result of the coexistence and interaction of several factors – both organic (physical) and psychogenic. We then speak of a mixed etiology.

The prevalence of mixed etiology is difficult to determine precisely, but it is believed to be a very common, and perhaps even the most common, form of erectile dysfunction. Some sources estimate that it accounts for about a third of cases , but it must be taken into account that almost any erectile dysfunction of organic origin can secondarily cause psychological problems (anxiety, stress, depressed mood), which makes the psychogenic component present in most cases.

Common examples of mixed etiology are:

• A man suffering from diabetes (an organic cause – vascular and neurogenic) begins to experience erection difficulties. This leads to the development of fear of another failure and a decrease in self-confidence (psychogenic component), which further exacerbates the problem.
• A man with hypertension (an organic-vascular cause) experiences relationship difficulties and chronic stress (psychogenic component) at the same time, which weakens his sexual responses.
• The man is taking medications (e.g. antidepressants) that cause ED (organic – drug-induced cause) as a side effect. This results in a depressed mood, frustration and fear of intimacy (psychogenic component).

The interplay of organic and psychogenic factors often has the character of a vicious circle, where one problem drives the other. As described earlier, fear of failure (psychogenic) can exacerbate ED resulting from organic causes [Insight 4.1]. On the other hand, chronic stress or depression (psychogenic) can lead to neglecting a healthy lifestyle (e.g. poor diet, lack of exercise, reaching for stimulants ), which in turn increases the risk of developing organic diseases such as obesity, hypertension or diabetes, which are the main causes of ED. Additionally, medications used to treat mental illness can cause erection problems on their own. This means that organic and psychogenic factors not only coexist, but often reinforce each other, creating a complex clinical picture that requires a comprehensive approach.

The diagnosis of mixed etiology is crucial for planning effective treatment. It is necessary to take a holistic view of the patient, taking into account his general physical health, mental condition, life situation, partner relationships and lifestyle. Therapy in these cases often requires an integrated approach, combining treatment of the underlying condition (if any), lifestyle modification, erectile dysfunction medication and psychological support or psychotherapy (individual or couples). Effective treatment of mixed ED often requires the cooperation of doctors of various specialties, such as urologists, family doctors, cardiologists, diabetologists, endocrinologists, psychiatrists or sexologists/psychotherapists.

Summary: When to seek help and what next?

Erection problems are a complex issue that can be caused by a variety of causes. As presented in this article, they can be divided into several main categories:

• Physical (organic) causes: Including cardiovascular diseases (atherosclerosis, hypertension) can lead to a lack of erection. Peyronie’s disease), as well as other chronic diseases or the consequences of injuries and surgeries.
• Drugs and substances: Many medications (especially for hypertension and antidepressants) and psychoactive substances (alcohol, nicotine, drugs) can negatively affect erection.
• Psychogenic causes: Stress, anxiety (especially of failure), depression, relationship problems, low self-esteem, and other psychological factors.
• Lifestyle: Unhealthy habits such as obesity, poor diet, lack of physical activity, and sleep disorders (including sleep apnea) significantly increase the risk of ED.
• Age: While age is not the cause in itself, it does increase the risk of diseases and physiological changes leading to ED, including the causes of poor erection.
• Mixed etiology: Very often, erection problems are the result of the coexistence and interaction of organic and psychogenic factors.

Whatever the suspected cause, the key message is that erectile dysfunction is a condition that can and should be treated. They should not be ignored, shamed, or treated as an inevitable part of aging. A medical consultation is necessary to make the correct diagnosis and implement appropriate treatment. Depending on the situation, help can be sought from a family doctor, urologist, sexologist, cardiologist, endocrinologist or psychiatrist.

The diagnostic process typically includes:

• Thorough medical and sexological history: The doctor will ask about the history of erection problems, their nature, duration, circumstances of occurrence, as well as the presence of night and morning erections, libido, sexual satisfaction, comorbidities, medications taken, stimulants, lifestyle and psychological situation, and partner relationships. Standardized questionnaires, such as IIEF-5 (International Index of Erectile Function), can be helpful.
• Physical examination: It includes a general assessment of health, blood pressure measurement, weight and waist circumference assessment, genital examination, sexual characteristics assessment, and neurological and vascular examination if necessary.
• Laboratory tests: They usually include basic blood tests, such as a complete blood count, fasting glucose (sugar) or HbA1c levels, lipid profile (cholesterol, triglycerides), and a determination of total testosterone levels in the blood. Depending on the suspicions, the doctor may also order a test of thyroid hormone levels (TSH), prolactin or prostate-specific antigen (PSA).

In some cases, more specialized tests may be necessary, such as Doppler ultrasound of the penile vessels or neurological examinations.

Modern medicine offers a wide range of effective methods of treating erectile dysfunction, tailored to the cause of the problem and the individual needs of the patient. Therapy may include:

• Lifestyle modification: Changing diet, regular physical activity, weight reduction, quitting smoking, limiting alcohol, stress management, taking care of sleep hygiene.
• Treatment of underlying diseases: Effective control of diabetes, hypertension, heart disease or hormonal disorders.
• Oral pharmacotherapy: Phosphodiesterase type 5 (PDE-5) inhibitors, such as sildenafil, tadalafil, vardenafil and avanafil, are first-line drugs for the treatment of ED and can be used if you do not have an erection. They make it easier to achieve and maintain an erection in response to sexual stimulation.
• Topical treatment can be an effective solution in the absence of an erection. Injections of vasodilators (e.g. alprostadil) directly into the corpora cavernosa of the penis or application of alprostadil as an intraurethral cream or stick.
• Vacuum devices (erection pumps): Mechanical devices that induce an erection by creating a vacuum.
• Hormone therapy: Testosterone supplementation in men diagnosed with hypogonadism.
• Psychotherapy and sexological counseling: Especially important in the case of psychogenic or mixed ED, helpful in coping with anxiety, stress, relationship problems and improving communication.
• Low-Intensity Shockwave Therapy (LSWT): A newer method that can improve blood flow in the penis.
• Surgical treatment: Penile implants (prostheses) are an option for men in whom other treatments have failed or are contraindicated.

In conclusion, erection problems are a common, but not necessarily permanent problem. Understanding their potential causes is the first step to finding an effective solution. Remember that ED is a medical problem that can and should be treated. Don’t hesitate to seek professional help to improve your sexual health, overall well-being, and quality of life.