Overview

Erectile Dysfunction (ED) has been publicly considered a disorder that primarily affects older men. Particularly, men between 50 and 75 years old are most affected by ED, with its prevalence exponentially growing with age.¹ Elsewhere, the incidence of ED in younger men has become more common in recent years, with up to 50% of UK men under 50 experiencing ED.² Although age-dependent, ED tends to be more associated with physiological causes, young ED also brings mental/emotional factors into the equation, which greatly complicates the identification of cause and treatment.³

Understanding erectile dysfunction

ED is the inability to get or keep an erection firm enough for sex. Some medical trainers refer to ED as impotence, however, ED is the more frequently used term to describe its condition. Treatment of ED, especially in the younger population, is necessary for improving fertility, mental health issues and relationships. Even if physiological factors cause the condition, ED can result in psychological complications, including low self-esteem, loss of confidence, shame, anxiety and depression.³

Mechanism of erection

Erection occurs when the penis responds to sensory stimuli from the brain, resulting in the following steps:⁴  

• Dilation of penile arteries and arterioles to allow blood flow
• Muscle structures in the penis expand and compress to trap the blood
• An increase in blood partial pressure of oxygen (PO2) from 35 mmHg to 90 mmHg raises the penis from the dependent position, resulting in an erection
• Pressure is maintained, allowing the penis to keep a rigid structure

Penile erection is carried out by both the autonomic and somatic nervous pathways. The former is responsible for the neurovascular dilation via the sympathetic and parasympathetic nervous systems, while the latter detects the sensation and carries out muscular contraction.⁴

As for blood hormones, testosterone is believed to be responsible for erection. This is because hypogonadal individuals show improved sexual desires and erection when treated with testosterone.⁵

Types of erectile dysfunction

• Psychological ED – The primary causes of psychological ED is thought to be anxiety, hyposexuality and depression.⁶ Recently, the importance of psychology in ED has been gathering increasing attention
• Organic ED – Organic ED is caused by physiological abnormalities, particularly in the penile artery, vein or both. The risk of organic ED increases with age
• Mixed ED – In addition to physiological disorders, psychological obstacles are observed in mixed ED

Causes of erectile dysfunction in young men

Physiological factors

A range of health issues can result in young ED: 

• Cardiovascular diseases
• High blood pressure
• Obesity
• Diabetes
• Low testosterone

Unhealthy lifestyles also contribute to ED. For example, high alcohol dependency is associated with low sexual desires and ED.⁷ ED is also frequently observed in individuals with high tobacco usage, as vascular activity is affected, mainly due to the depletion of nitric oxide.⁸ With that said, the likelihood of regaining penile function depends on the age of the individual and the extent of tobacco dependency – those above the age of 50 and who have a long history of smoking failed to regain penile function after quitting smoking.⁸ Anti-hypertensive medication is one of the most common drugs that can cause ED as a side-effect. Particularly, diuretics and beta-blockers have the greatest risk of ED. 

Psychological/social factors

Depression and anxiety can be caused by interpersonal problems that occur in workplaces and other social occasions. Still, many psychological causes of ED, also happen due to relationship issues arising from poor communication, emotional distance and conflict. Since physiological risks tend to increase with age, ED in young males is more likely to have a psychological background.³

Diagnosis and assessment

Questionnaires

A patient with ED is advised to speak to a medical expert, such as a urologist, where they will be asked a range of questions about their health/sex life. According to the National Institute of Diabetes and Digestive and Kidney Diseases, these questions could include: 

• How long/firmly can you keep your penis erect
• How much are you satisfied with your sex life
• How often are you able to climax
• How would you rate your sexual desire
• Are you on any drug subscription
• How often do you smoke or drink alcohol

Patients need to communicate accurately about their sex life, even if it may be uncomfortable. The more information the clinician is given, the diagnosis and assessment becomes more accurate, resulting in better treatment outcomes. It is also possible that the clinician asks questions to the patient’s sexual partner, which could provide additional insights into possible reasons for ED.

Additional tests

In response to the interview tests, clinicians may conduct additional examinations to characterise the cause of ED precisely. These tests can look for:⁹

• Blood glucose levels
• Lipid levels
• Testosterone levels
• Prostate-specific antigen tests

Ultrasound testing can also be utilised to examine for anatomical abnormalities that could be causing ED, while doctors could give drugs that elicit erection to test penile function. Another test is penile biothesiometry which measures nerve sensitivity by sending vibrations.¹⁰

Role of therapy and counselling

Psychotherapy is vital in treating the psychological causes of ED. The use of therapy in ED diagnosis has 4 main aims:¹¹ 

• Identify potential resistances that intervene in medical treatment
• Reduce or eliminate performance anxiety
• Understand the context of their sexual intercourse
• Educate and modify sexual scripts by correcting/removing unhealthy social expectations of males

Such therapies are available both, online and in person, allowing patients to choose their preferred mode of counselling. Therapies usually involve questionnaires that try to clarify why the patient may feel anxious about sexual intercourse, for example, lack of confidence, or relationship issues. This helps the clinician design a more individualised approach to ED treatment. Therapy is important in understanding ED in young males, as anatomical and physiological abnormalities are less likely to be the cause compared to ED in older populations.^3,11 

Treatment options

Lifestyle modifications

As mentioned previously, lifestyle plays a major role in the development of ED. Therefore, modifying the patient’s lifestyle is one of the key approaches for the treatment. Cutting off tobacco and alcohol has shown some improvement in male sexual performance, although its effectiveness depends on the severity of this condition and history of tobacco/alcohol usage. Additionally, consistent physical activity improves mild ED caused by heart/vascular problems. Studies suggest that 40 minutes of supervised aerobic training over 6 months, 4 times a week, decreased ED.¹²

Therapy

Therapy is useful in the treatment of psychological and mixed ED. If ED is caused by mild depression or anxiety, therapies like cognitive behavioural therapy (CBT) and counselling could be helpful. Mental health issues that arise from unsuccessful sex life can be improved with the help of a sex therapist, who can provide sex education, and insights, into more patient-specific sex concerns. This is gaining greater importance in recent years due to increased access to misinformation regarding sex and gender roles on the internet. Because of this, men can set unrealistic or incorrect expectations on themselves, which together with poor communication with their partner, results in anxiety and poor sexual performance.¹¹

Stress management is also a key factor in removing anxiety. Therapists can provide tips that help eliminate stress that is hindering a healthy sex life. Examples could include:

• Healthy diet
• Sufficient sleep
• Yoga, meditation
• Better time management

Medications

One of the major types of drugs used in ED treatment is phosphodiesterase type 5 (PDE5) inhibitors, such as Sildenafil (Viagra) and Tadanafil (Adcirca, Cialis).¹³ These enhance the effects of nitric oxide to increase muscle relaxation and amplify blood to flow into the penis when a stimulus is detected. It is important to note that they do not trigger sexual stimulus, but only enhance the erection function. Just like any other drug subscription, the clinician will choose the most appropriate medication while considering the severity of ED, patient's medical history and possible side effects.

Hormone therapy

Logically, testosterone replacement therapy is the correct approach to treating ED, however its treatment outcome is rather conflicting. Although meta-analysis suggests its potential effectiveness, further research regarding the duration and timing of treatment is required for clinical application.¹⁴

Surgical treatment 

Penile prosthesis implantation is a common surgical approach to treating ED. It has undergone multiple renovations to improve its ability to achieve a rigid erection and reduce the risk of infection.¹⁵ Such implants are conducted only when other approaches are ineffective. 

There are mainly two types of implantations, including: 

• Inflatable implants – salt water is pumped into the rod to inflate the implant, producing rigidity. Salt water is reversed as the valves open up, ending rigid state
• Semirigid rods – The penis will be always firm, and it is concealed by pushing it towards the body

The shape of implantation differs depending on the patient’s needs. Inflatable implants can be either two-piece or three-piece, which have a slightly differing mechanism but similar effect.

Summary

Treatment of ED in the young population does not differ greatly compared to usual ED, but there is a greater influence of psychological factors, for example, depression and anxiety, in the development of the condition. Hence, treatment and diagnosis of ED in young males is likely to depend on questionnaires, therapy and counselling. With that said, physiological factors, are not entirely anonymous in ED in young males. Lack of exercise, high alcohol and tobacco dependency, poor diet and certain health diseases are all risk factors in ED. Patients need to approach an expert to examine their reasons for ED, to ensure appropriate treatment and a timely recovery.