Erectile dysfunction.
There. We’ve raised the subject. Just the sight of those two words can leave plenty of men feeling apprehensive and squirming in their seats. We feel you. But it’s an uncomfortable, cringeworthy topic that needs to be firmly addressed, especially if it affects you. It’s a problem that, unlike its unfortunate recipient, won’t suddenly go away on its own.
With that, let’s roll up our sleeves and get down to business. We’ll examine what erectile dysfunction is, how it differs from trouble with your libido, and how testosterone replacement therapy (TRT) may – or may not – be the answer to your problem.
ED? WHO THE HELL IS ED?
ED isn’t some dude’s name, but rather an abbreviation for “E • Dee,” an uninvited guest that has ruined many a party for millions of men. Short for “erectile dysfunction,” ED is medically defined by the Mayo Clinic as “the ability to get and keep an erection firm enough for sex.” It’s somewhat ironic that what looks like a condensed version of a man’s name is actually in reference to what could be considered a shortening of your penis – at least, when it counts most.
According to a report in Current Opinion in Nephrology and Hypertension,[1] it’s estimated that as many as 30 million American males currently suffer with erectile dysfunction. Sadly, that amount can likely be halved when it comes to men actually seeking medical diagnosis and treatment for ED.
And it’s not just a national issue, fellas. The Massachusetts Male Aging Study (MMAS)[2] calculated that the number of men worldwide that are afflicted with ED would rise (no pun intended) from 152 million in 1995 to 322 million by 2025. And it certainly doesn’t get better as you grow older, as indicated by numbers surrounding ED’s prevalence – meaning, the proportion of a population with a specific trait or characteristic over a given period of time. Mild ED in men aged 40 to 70 stayed consistent at around 17 percent. It was a far less happy ending for males in that age range who reported moderate or complete ED. Moderate ED doubled from 17 percent to 34 percent, while complete ED – in which there are no nighttime erections as well as an inability to obtain or maintain an erection during sex – tripled from 5 percent to 15 percent.
WHAT’S GOT US DOWN?
So, why the inclines in erectile declines? There’s a veritable, Costco-sized shopping list of potential causes, so let’s try to group them together into the following:
Cardiovascular disease: When sexually aroused, impulses from your brain and nerves tell your corpora cavernosa – two spongy columns of erectile tissue that make up the bulk of your penis – to relax and enjoy. This communication allows for the flow of blood vessels to build pressure inside your corpora cavernosa and Cock-a-doodle-do!, your rooster’s ready to crow. However, conditions like high cholesterol, hypertension and atherosclerosis (a hardening of your arteries) can compromise your ability to pump that blood over, thereby leaving your rooster motionless on its perch. In all seriousness, ED can be an underlying cause of or an increasingly likely precursor to stroke, cardiovascular or coronary artery disease[3]; they are among the first issues (or should be) your doctor should look for.
Endocrine disorders: Your endocrine system regulates the release of hormones into your bloodstream and organs. Diseases such as diabetes (when you can’t produce or properly use enough insulin to control blood sugar levels), Cushing’s disease (excess cortisol in the body caused by overproduction of adrenocorticotropic hormone, or ACTH), hyperprolactinemia (too much prolactin in the blood), hypothyroidism (underactive thyroid) and hypogonadism (aka low testosterone) can adversely impact that regulation.[4] They can also saddle you with the unwanted bonus problems of obesity and a perennially tired-out tallywhacker. If you suspect your ED could be connected to low testosterone levels – or you’re simply curious about where your T levels lie – we recommend you check out Peak’s at-home testing kit.
Neurologic impairment: Since erections are neurovascular in nature, it’s certainly conceivable that having any type of disease or impairment which affects your brain, spinal cord, cavernous and pudendal nerves can result in developing neurogenic ED.[5] Your doodle-dasher can be similarly dulled by nerve damage caused during pelvic or prostate surgeries, chronic diseases and multiple sclerosis (MS).
Psychological disorders: It’s hard to become…well, hard…when depression, stress, fatigue or a lack of stimulus from your brain can affect you physically as much as they do your mental or emotional state. This type of dysfunction, referred to as psychogenic ED,[6] also applies to performance anxiety, when a fear of performing sexually, or previously having difficulty doing so, builds so much in your head upstairs that you find yourself unable to build anything downstairs. Like most forms of ED, it is treatable…provided one is willing to come forward and speak with a doctor about it.
Prescription medications: Some prescription medications that are vital to your health can, unfortunately, also prohibit you from achieving erections.[7] They may keep other functions of your body functioning normally, but if they also directly impact your body’s blood flow, nerves or hormones, it’s not uncommon for new problems to manifest themselves below the belt. ED is a known side effect for those who take antihistamines, antidepressants, anti-inflammatory drugs, antacids, diuretics, blood pressure or chemotherapy meds and muscle relaxants, to name just a few. If you’re on a new medication and notice that your fighter won’t come out swinging once the bell rings, don’t hesitate in telling your doctor.
YOUR LIBIDO AND YOUR ERECTIONS: DRIVING HOME THE DIFFERENCE
Let’s be perfectly clear: Erectile dysfunction is not the same as having a lifeless libido or sex drive. Suffering from ED may at some point cross over into issues with your drive, or vice versa, but the two are different.
ED is primarily a vascular problem, whereas your libido suffers generally as a result of hormonal imbalances. As we’ve explained, erectile dysfunction is the inability to achieve or maintain an erection during intercourse. Well, having a sluggish libido means you’ve lost the desire to have intercourse. Think of it this way: Our libidos inform us when our spirit is willing. Our erections, or lack thereof, determine whether or not our flesh is weak (or as Futurama’s Zapp Brannigan might tell us, “spongy and bruised”).
In many instances, the two conditions can coexist – it’s understandable that one can’t achieve an erection when they don’t feel an urge to have sex – but it’s not an absolute. Some men can become “upright citizens” even when they’re not necessarily in the mood. Yet, some studies[8] reveal that isn’t the case if conditions are turned the other way around. Testosterone is required to help achieve healthy erections, but you can still experience ED even when your T levels are normal.
A decreased libido, like ED, can be brought on by stress, fatigue, anxiety or problems with your partner. Oftentimes, though, the problem lies within one’s testosterone levels. If you’re hypogonadal and your testosterone is low, your sex drive suffers. Having a sex drive in park can take its toll on you emotionally and physically, not the least of which is that it can forcibly set your sail at half to no mast.
We reiterate, though, that having normal range testosterone levels doesn’t ensure smooth sailing for your erections. You can experience ED for any one or several of the reasons we outlined above, which can significantly increase your risk of cardiovascular disease.[9] The best way to easily determine whether or not your ED is related to your T levels is to get your hormones tested and schedule a consultation with a physician as soon as possible.
TRT TO THE RESCUE?
We've previously addressed how our hormones work and what constitutes low testosterone. We’ve also gone into great detail about the physical, mental and emotional benefits offered by testosterone replacement therapy (TRT). It has been proven that TRT can bring your testosterone back up to speed, but can it actually improve your erections? Can TRT actually declare ED DOA?
The answer to that million-dollar question, friends, is…it depends. A 2017 report published in Current Opinion in Urology showed that optimizing your hormone levels via replacement therapy not only can resuscitate your absent sex drive, but – when used as a singular treatment – it can also improve erectile function[10] for males with mild ED. The study also reported that TRT was particularly helpful for men that were unresponsive to ED drugs like sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis).
Before we start celebrating, though, we must emphasize that TRT is showing success for men with cases of mild ED. It’s a different story for those who experience moderate to severe erectile dysfunction. Some men may report an increase or improvement in erection, but to this point, there is no empirical evidence that testosterone replacement therapy, on its own, is successful against moderate to severe ED.
Thankfully, the news isn’t all doom-and-gloom. Research has confirmed that TRT has a better track record against more serious cases of ED when it works in tandem with phosphodiesterase 5 (PDE-5) inhibitors[11] like sildenafil, tadalafil, vardenafil and avanafil (Stendra). Further studies have also shown that Viagra can also increase testosterone[12] by a direct action on the testes.
We won’t lie. There’s a lot of information here to process, and it’s easy to get turned around by all the information that floats around in cyberspace. What you can take away from here, though, is that if you suffer from low testosterone and mild erectile dysfunction, testosterone replacement therapy is a viable treatment for you, as is a prescribed add-on of a PDE-5 inhibitor. If your testosterone levels are within range but your arbor vitae is wilting, then you and your doctor need to discuss other potential causes for your ED and, as such, alternate forms of treatment. We don’t want all of you suddenly going stiff; only the parts that are designed to make you and a loved one feel satisfied.
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References:
[1]Nunes KP, Labazi H, Webb RC. New insights into hypertension-associated erectile dysfunction. Curr Opin Nephrol Hypertens. 2012 Mar;21(2):163-70. doi: 10.1097/MNH.0b013e32835021bd. PMID: 22240443; PMCID: PMC4004343.
[2]Ayta IA, McKinlay JB, Krane RJ. The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences. BJU Int. 1999 Jul;84(1):50-6. doi: 10.1046/j.1464-410x.1999.00142.x. PMID: 10444124.
[3]Ibrahim A, Ali M, Kiernan TJ, Stack AG. Erectile Dysfunction and Ischaemic Heart Disease. Eur Cardiol. 2018 Dec;13(2):98-103. doi: 10.15420/ecr.2017.21.3. PMID: 30697353; PMCID: PMC6331774.
[4]Soran H, Wu FC. Endocrine causes of erectile dysfunction. Int J Androl. 2005 Dec;28 Suppl 2:28-34. doi: 10.1111/j.1365-2605.2005.00596.x. PMID: 16236061.
[5]Shridharani AN, Brant WO. The treatment of erectile dysfunction in patients with neurogenic disease. Transl Androl Urol. 2016 Feb;5(1):88-101. doi: 10.3978/j.issn.2223-4683.2016.01.07. PMID: 26904415; PMCID: PMC4739980.
[6]Rosen RC. Psychogenic erectile dysfunction. Classification and management. Urol Clin North Am. 2001 May;28(2):269-78. doi: 10.1016/s0094-0143(05)70137-3. PMID: 11402580.
[7]Razdan S, Greer AB, Patel A, Alameddine M, Jue JS, Ramasamy R. Effect of prescription medications on erectile dysfunction. Postgrad Med J. 2018 Mar;94(1109):171-178. doi: 10.1136/postgradmedj-2017-135233. Epub 2017 Nov 4. PMID: 29103015.
[8]Rajfer J. Relationship between testosterone and erectile dysfunction. Rev Urol. 2000 Spring;2(2):122-8. PMID: 16985751; PMCID: PMC1476110.
[9]Jackson G. Erectile dysfunction and cardiovascular disease. Arab J Urol. 2013 Sep;11(3):212-6. doi: 10.1016/j.aju.2013.03.003. Epub 2013 May 3. PMID: 26558084; PMCID: PMC4442980.
[10]Rizk PJ, Kohn TP, Pastuszak AW, Khera M. Testosterone therapy improves erectile function and libido in hypogonadal men. Curr Opin Urol. 2017 Nov;27(6):511-515. doi: 10.1097/MOU.0000000000000442. PMID: 28816715; PMCID: PMC5649360.
[11]Aversa A, Francomano D, Lenzi A. Does testosterone supplementation increase PDE5-inhibitor responses in difficult-to-treat erectile dysfunction patients? Expert Opin Pharmacother. 2015 Apr;16(5):625-8. doi: 10.1517/14656566.2015.1011124. Epub 2015 Feb 3. PMID: 25643866.
[12]Spitzer M, Bhasin S, Travison TG, Davda MN, Stroh H, Basaria S. Sildenafil increases serum testosterone levels by a direct action on the testes. Andrology. 2013 Nov;1(6):913-8. doi: 10.1111/j.2047-2927.2013.00131.x. Epub 2013 Sep 18. PMID: 24106072; PMCID: PMC6036338.
Related:
• Peak: Who we are, and why we're serious about your health
• 10 things to know when consulting with your hormone doctor
• How to tell your partner you want to go on TRT
• WATCH: How to do a subcutaneous testosterone injection
• Order your at-home hormone testing kit