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Stress, anxiety and depression activate the sympathetic nervous system; this is a natural response to any form of stress.

Does age cause erectile dysfunction (ED)?

Unfortunately, the bulk of studies to date had limited follow-up, with most reporting out results at a mean of one month. Longer-term follow-up and data collection are topics of active inquiry, but currently there are no data to suggest that LiSWT will work as a single treatment for the majority of patients with severe ED related to prostate cancer treatment. LiSWT may eventually have a role as part of a multimodal protocol, but at this time it should be considered experimental. ED is most commonly related to aging, but it also has a wide range of psychological, neurological, vascular, hormonal and pharmaceutical causes, and may result from radiation and surgical treatments for prostate and bladder cancer. This table lays out the basics, and more detailed explanations for each cause follow.

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Aging causes a progressive decline in sexual function even in healthy patients. Studies show that as men age, erections become less turgid (stiff) and the force and volume of ejaculation decrease. Also, with age, more time is needed to achieve another erection after orgasm (the so-called refractory period). Sensitivity to touch decreases over time, as do testosterone levels, and both changes can diminish sexual desire. While it's not possible to reverse the effects of aging, there's no age at which a person is too old for sex.

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Men can avoid or at least delay the most severe manifestations of age-associated sexual dysfunction by remaining physically active, sticking to a healthy diet, avoiding weight gain, not using tobacco, and generally doing things that promote heart health. ED is the most common side effect of both surgical and radiation treatments for prostate cancer. The cavernous nerve bundles – the nerves that drive erection – are located next to the prostate gland. During a radical prostatectomy, these nerves may be injured. In many cases, this results in ED that is permanent, although pills for men the degree of dysfunction may be lessened through treatment. However, that response tends to restrict blood flow into the penis and can make erections difficult or impossible.

Careful attention to both mental and physical health is important in preserving erectile function.

A normal erection requires the penis to have intact nerves and blood vessel systems.

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Nerves that travel to the penis include fibers from the autonomic nervous system – the part of the nervous system that functions independently of conscious thought – as well as the somatic nervous system – the part responsible for sensation and contraction of muscles attached to the penis. The autonomic nervous system controls the smooth muscle in the penis, prostate and urinary sphincter – muscle that is important for initiating erections and facilitating ejaculation.

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The autonomic nervous system has two parts.

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The sympathetic division tends to restrict penile blood flow and is important for closing the bladder neck to prevent urine leakage during sex.

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This expands the three cylinders of erectile tissue in the penis, thus lengthening and enlarging the penis. The expansion of these cylinders compresses the small veins, reducing the outflow of blood. The processes of penile erection are driven by the actions of nerves and blood vessels. Hormones, such as testosterone, also play important roles. Finally, a patient's psychological state and the health of his sexual relationship with a partner are critical determinants of sexual response. The parasympathetic division increases penile blood flow and stimulates erection.

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The spongy tissue of the penis is exposed and dilated; the prosthesis is sized; and then it's placed inside the erectile tissue. The pump containing the inflation and deflation mechanism is placed in the scrotum. The patient can control his erection at will, using the hydraulic pump to inflate and a release button to deflate the prosthetic implant. Because the nerves that control penile sensation are not injured, penile sensation and the ability to have an orgasm are typically maintained after placement. Full penile length may not be restored to the patient's natural erect status.

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Despite the need for surgery, patient and partner satisfaction rates for penile prostheses are as high as 85%. Side effects are rare but include infection, pain, and device malfunction or failure. Significant strides in scientific understanding of the anatomy and physiology of sexual function are aiding the development of new therapies. For instance, more detailed knowledge of the cavernous nerves in the pelvis led to the refinement of nerve-sparing prostatectomy. Understanding the biochemistry of normal sexual function led to the development of ED medications, including Viagra, Cialis, Stendra and Levitra.

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Current research is focused on better understanding the specific physiological pathways responsible for normal sexual function, developing more effective agents for managing ED, and learning how cavernous nerves heal and what factors can hasten the healing process. An intriguing line of inquiry over the past 10 years has been treating the penis with low-intensity shock wave therapy (LiSWT). This counterintuitive approach to treating ED with energy transfer is based on a growing body of evidence suggesting that shock waves may stimulate new blood vessel growth, reduce scarring, and activate resident stem cells to help restore tissues. The pulses used for ED therapy are similar to – but less intense than – the shock waves that have been used for decades to treat urologic stones. A number of small, randomized, placebo-controlled studies have demonstrated benefits to erectile function in patients treated with shock waves to the penis. Coordination of these two components of the autonomic nervous system is critical to sexual response.

Sensory nerves travel to the head and shaft of the penis; these nerves are responsible for conveying sensations (such as touch, temperature and pain) to the brain and may be important for stimulating sexual response. Motor nerves control contraction of the ischiocavernosus and bulbocavernosus muscles, which are necessary to producing a fully rigid erection and to ejecting semen during ejaculation.

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Because the prostate makes most of the fluid in semen, patients who have undergone prostatectomy don't experience ejaculation. Radiation to the prostate, bladder or rectum also can damage the cavernous nerves and lead to problems with erections and ejaculation. These effects usually manifest a few years after treatment. Although ED and absence of ejaculation are common after prostate surgery or radiation, sexual desire and the ability to achieve orgasm are still possible. Doctors may be able to use nerve-sparing approaches in surgery or radiation therapy that can preserve one or both nerve bundles.

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While the nerve-sparing technique preserves the possibility of penile erections, most patients nevertheless experience a decline in erectile function that may never be completely recovered. Hormone therapy for prostate cancer (androgen deprivation therapy) can also cause ED. The drop in testosterone reduces libido and can lead to erection difficulties. Whether these effects are reversible is related to the patient's age, degree of sexual function he had before treatment, and length of time on hormone therapy. Depression and performance anxiety both can lead to ED.

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Depression is associated with decreases in energy, interest in usual activities and libido. Performance anxiety, work stress and strained personal relationships also can affect erectile function in both conscious and subconscious ways. Penile erection depends on an intact nervous system, so any neurological injury or disease can cause ED. Parkinson's disease, Alzheimer's disease, stroke or head injury can lead to ED by affecting the libido or by interfering with the nerve impulses responsible for erections. Spinal cord injuries cause a decrease in erections related to the extent of the injury. With sexual stimulation, parasympathetic cavernous nerves release chemicals (primarily nitric oxide) that significantly increase blood flow to the penis.

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Pelvic surgery – such as radical prostatectomy, cystectomy or colectomy – may injure the nerves that control erection. Long-standing diabetes may affect some nerves and lead to ED. Anything that decreases circulating testosterone in the body, including undergoing chemical or surgical castration or hormone therapy for prostate cancer, decreases libido and may make natural erections more difficult. A variety of conditions and habits can damage penile blood vessels over time and contribute to ED. High LDL ("bad") cholesterol or low HDL ("good") cholesterol Pelvic radiation therapy to treat prostate, bladder or rectal cancer Peyronie's disease (scarring with curvature of the penis) Damage to the penile spongy tissue that results in leaky veins (sometimes associated with aging) ED is common in patients with diabetes, cirrhosis (liver scarring), chronic kidney failure and many other chronic medical issues.

Table 1. Common medications and dietary supplements with interactions with phosphodiesterase-5 inhibitors (PDE-5i).

Many types of drugs are associated with developing ED. Here are some to be aware of: Certain antidepressants (including Prozac, Zoloft and Paxil) and antipsychotics, especially those that regulate serotonin, noradrenaline or dopamine. Beta-blockers and thiazide agents used to treat high blood pressure. Cimetidine, a drug for acid reflux disease. Estrogens and drugs with antiandrogenic action, such as ketoconazole and spironolactone, can lead to ED, decreased libido and breast enlargement.

Vascular damage

Many drugs of abuse, including tobacco, marijuana and narcotics. The cavernous nerves travel from the underside of the penis to the prostate. They regulate blood flow within the penis. In the flaccid state, relatively little blood flows in through the arteries and there is free outflow via the small veins exiting the spongy tissue just under the thick tunica (membrane surrounding the spongy tissue). During blue tablets erection, the smooth muscle in the penis relaxes while the arteries widen to bring in more blood.