It’s time to talk about ED – compact overview of causes and treatments

Most men find it difficult to talk about Erectile Dysfunction (ED). They simply live with it and accept that it’s just part of life. But it doesn’t have to be that way. If they understand what ED is, what causes it and what treatments are available to them, then they can help increase their quality of life, possibly ED-free. This article offers a compact overview of the causes and treatments for ED.

ED stats
An overall prevalence of 52% ED in non-institutionalised men aged 40 to 70 years old is reported in the Massachusetts Male Aging Study (MMAS). The Cologne Study also reported a prevalence of 19.2% ED of men aged 30 to 80 years old with an increase of 2.3% up to 53.4%. The incidence rate is 26 new cases per 1000 annually reported in the MMAS. In the Krimpen study, an incidence rate of 19.2  is reported.(1)

Causes for ED
Age, other physical factors, some surgical procedures and medicines can cause ED.

The most well-known cause of ED is when a patient has undergone radical prostatectomy or radiotherapy (brachy or external) as the blood vessels and/or the nerves in the pelvic region could have been damaged during the procedure. ED can also occur when a patient has hormonal treatment. (1,2)

Being overweight (BMI > 25) or having a waist circumference of more than 100 cm are risk factors. Overweight patients often suffer from Metabolic syndrome, which can lead to Diabetes Mellitus, chronic vascular diseases or hypertension. All of these chronic diseases can lead to ED.

Neurogenic disorders such as Multiple Sclerosis, Parkinson’s disease, spinal cord injury, stroke or polyneuropathy can cause ED. Primary hypogonadism or late onset hypogonadism can contribute to ED, as well as several other diseases.(1)

Cardiovascular risk factors such as smoking, atherosclerosis, Angina Pectoris or myocardial infarction, cardiac failure, and hypertension can also cause ED. Some medicines have negative side effects such as β-blocking medicines and antihypertensive e.g. thiazide diuretics.(1)

After the age of 40, the quality of the corpora cavernosa starts to deteriorate. But even younger men can have ED. One of the causes can be venous leakage of blood from the penile vessels into the abdominal vessels. This can be diagnosed by using a Duplex ultrasound of the penis. These men predominantly have a psychogenic cause of their ED e.g. stress, feelings of fear for failure, relational problems, low self-esteem, and problems with mood such as depression or psychosis.

In the 1970s Masters and Johnson suggested that ED is caused by psychogenic factors. This notion is not accurate anymore due to the growing knowledge of ED and pathophysiology. Of course, psychogenic causes can be a part of the problem, and stress and tension in (sexual) relations can contribute to ED. But ED can vary in different circumstances. For example, a man who has ED with his regular sexual partner can have morning erections and a (full) erection while masturbating or with another partner. This is called situational ED.(3)

Treatment of ED depends on the cause. Therefore it is important to do a full patient history.

In the Netherlands, the mini-sexual anamneses is developed. It is helpful to clinical nurse specialists and physicians in the outpatient clinics. (3) In addition, filled-out International Index of Erectile Function (IIEF) or the IIEF 5 questionnaires are useful in outpatient clinics during patient assessments and counselling. (1,3,4)

Treatment options for ED are widespread especially since the availability of oral medication. PDE-5 inhibitors can be prescribed, or intra cavernous injections with Androskat® or Muse®. A vacuum-assisted device is also an option, as well as penile prosthesis implantation which is placed in the corpora cavernosa. The implantation is a complex operation and is usually a final resort since any form of spontaneous erection is improbable after operation. (1)


  1. Hatzimouratidis K, Giuliano F, Moncada I, Muneer A, Salonia A, Verse, P. EAU Guidelines on Erectile Dysfunction, Premature Ejaculation, Penile Curvature and Priapism. Arnhem: EAU Guidelines Office, Arnhem, The Netherlands. 2016:7-24.
  2. Mottet N., Bellmunt J., Briers E., Bolla M., Bourke L., Cornford P., De Santis M., Henry A., Joniau S., Lam T., Mason M.D., Van den Poel H., Van den Kwast T.H., Rouvière O., Wiegel T.; members of the EAU – ESTRO – ESUR –SIOG Prostate Cancer Guidelines Panel. EAU – ESTRO – ESUR – SIOG Guidelines on Prostate Cancer. Edn. presented at the EAU Annual Congress London 2017. 978-90-79754-91-5. Publisher: EAU Guidelines Office, Arnhem, The Netherlands.
  3. Porst H, Reiman, Y, editors. ESSM Syllabus of Sexual Medicine. Amsterdam: Medix Publishers; 2012. P.537-563
  4. Boer B-J de, Heijnen A, redactie. Functioneel urologische en seksuele klachten bij de man. Houten: Bohn Stafleu van Loghum; 2016

Jeannette Verkerk-Geelhoed, Clinical nurse specialist in training , St. Antonius Hospital, Nieuwegein (NL),