Erectile dysfunction: vascular, hormonal or mental

Erectile dysfunction is the complaint that takes longest to reach the doctor's office. The average man lets months go by, sometimes years, and when he finally talks about it he usually already has a pill bought online.

The problem with starting with the pill is not the pill. It is that an erection is a sign, and a sign gets interpreted. In a forty-five-year-old man, an erection that fails can be the first visible signal of a vascular problem that has not yet produced symptoms in the heart.

How an erection works, in two paragraphs

Clinical consensus. An erection is a neurovascular event with hormonal permission and psychological context.

The stimulus — physical or mental — travels through the nervous system, nitric oxide is released in the erectile tissue, the arteries dilate, the corpora cavernosa fill with blood and the pressure compresses the veins that would drain it. The result is sustained rigidity. Testosterone does not "cause" the erection, but it maintains desire and the proper functioning of that tissue.

That means the system can fail at four points: the arteries, the nerves, the hormones and the head. There is almost always more than one.

The questions that guide the diagnosis

Clinical consensus. Before any test, the clinical history already separates a large share of cases. These are the questions that matter:

How did it start?

• Suddenly, identifiable in time, coinciding with a life change, a break-up, a layoff, a new medication: points to a psychogenic or pharmacological origin.
• Gradually, over months or years: points to a vascular or metabolic origin.

Does it happen every time?

• It fails with one partner but not another, or fails in intercourse but not in masturbation: the equipment works. That points to something psychogenic or relational.
• It fails in every situation, without exception: organic.

Do you have morning or nighttime erections?

This is the key question. If you still have spontaneous erections on waking, the vascular, nervous and hormonal circuit is doing its job while you sleep. When those erections disappeared some time ago, the probability of an organic origin rises sharply.

Is it desire or is it erection?

Not wanting to is not the same as wanting to and not responding. Lack of desire points first to hormones, mood, medications or exhaustion; an erection that does not hold, to the vascular circuit.

The vascular origin: what is at stake

Clinical consensus. The arteries of the penis are small. When the endothelium — the inner lining of the vessels — starts to malfunction, those arteries notice it before the coronaries, which are of larger caliber.

Hence an idea every man should know: erectile dysfunction of vascular origin can precede a cardiovascular event by several years. It is not an alarm to frighten you; it is an opportunity. It is the warning arriving early, when there is still room to act.

That is why, in a man with gradual erectile dysfunction, the evaluation includes what seems unrelated:

• blood pressure
• glucose and HbA1c
• lipid profile
• waist circumference
• smoking
• family cardiovascular history

My clinical opinion. Treating only the erection in that man and not looking at his arteries is, to me, bad medicine. You solve his symptom and leave his problem intact.

The hormonal origin

Clinical consensus. Low testosterone affects desire above all, and over time the quality of the response as well. But beware of the shortcut: not all erectile dysfunction is hormonal, and correcting testosterone does not solve a vascular problem.

It is studied with morning, fasting total testosterone, confirmed in a second sample, together with SHBG, LH, prolactin and estradiol. Prolactin matters: an elevated prolactin can explain loss of desire and dysfunction, and has causes of its own that need investigating.

The thyroid also comes in here and, frequently, sleep apnea: it fragments deep sleep, impairs night-time hormone production and punishes the vascular system at the same time.

The pharmacological origin, which almost nobody reviews

Clinical consensus. There are very widely used treatments that affect sexual function:

• some antihypertensives, especially beta-blockers and thiazide diuretics
• several antidepressants, in particular SSRIs
• antiandrogens and some prostate treatments
• opioids
• sustained alcohol consumption

Never stop a prescribed medication on your own. But bringing the complete list to the consultation, including what you bought without a prescription, changes the diagnosis more often than you would imagine.

The psychogenic origin: neither minor nor imaginary

Clinical consensus. A psychogenic origin does not mean it is mild, nor that it is "in your head" in the dismissive sense. Performance anxiety creates a circuit that feeds itself: one failure generates fear of the next, the fear activates the sympathetic system, and the sympathetic system is exactly the opposite of what an erection needs.

Add depression, chronic work stress, unspoken couple conflicts and, increasingly often in practice, comparison with pornographic material and compulsive consumption.

My clinical opinion. This is where mindset work and clinical work touch, without being confused. Coaching does not treat a disease and does not replace a psychologist or a psychiatrist when they are needed; but a man who sleeps badly, drinks to switch off the day and lives in permanent alert has a life problem that no medication solves.

The reasonable route

1. Complete clinical history, with the questions above and the list of medications.
2. Physical examination, including genital evaluation and secondary sexual characteristics.
3. Lab work: metabolic, lipid, hormonal.
4. Sleep apnea screening if there is snoring, daytime sleepiness or observed pauses.
5. Correcting what can be corrected: tobacco, alcohol, weight, sleep, physical activity, implicated medications.
6. Specific treatment according to the origin, prescribed and followed by a physician. PDE5 inhibitors are effective and well studied, but they have real contraindications — in particular with nitrates — and are not meant to be bought from just any website.
7. Second-line tests, such as penile Doppler ultrasound, when the picture justifies it.

What I'd like you to take away

It is not a pill. It is a signal.

Erectile dysfunction is, very often, the first open window onto a man's vascular, metabolic, hormonal and emotional health. Treated as an isolated symptom, it is half solved. Treated as what it is, it becomes the best early warning you will ever receive.

The author is the founder and CEO of Mengenics, a men's health clinical platform. This article is educational and does not promote any treatment.