Erectile Dysfunction

What it is, why it occurs and how to combat it?

The most common health disorder inflicting older men is not hypertension, or arthritis, but Erectile Dysfunction; ED, for short. In the United States alone between 10-20 million males are affected with some form of severe erectile dysfunction. When including less severe degrees of erectile dysfunction this number swells to nearly 30 million!

Erectile dysfunction typically appears in males in their fifth decade of life. Estimates are that over half of all males between the ages of 50 and 70 exhibit some degree of erectile dysfunction. Surprisingly, the incidence of erectile dysfunction in males in their 40s is only around 5%, nearly ten-times less, demonstrating an alarmingly steep increase during middle age (45-65 years of age). Furthermore, environmental factors such as drug abuse, stress, anabolic steroids, poor diet and bad health, can accelerate the development of erectile dysfunction causing it to manifest at an earlier age. Sadly, despite the high incidence of erectile dysfunction in otherwise generally healthy males,less than 5% ever seek treatment.

Erectile dysfunction IS NOT an inevitable consequence of aging! Viable treatments do exist that will allow one to continue healthy sexual relations well into later life.

Penile Anatomy and Physiology

Corpora Cavernosa Cross Section

Images courtesy of Markis Rix Labs.

Corpora Cavernosa Cross Section

In essence, an erection results from blood flowing into two chambers on either side of the penis, the Corpora Cavernosa (see figure on right). This process is greatly facilitated by the fact the corpora cavernosi act as a single functioning unit due to the existence of an extensive system of interconnected blood vessels. This vascular arrangement is the reason why most treatments for erectile dysfunction are targeted at promoting penile blood flow.

Blood flow into each cavernosal chamber is regulated by a criss-crossing matrix of smooth muscle cells and cartilage filaments. When the smooth muscle cells contract (shorten), the corporal chambers collapse and blood flow into the penis is impeded; the penis becomes flaccid. On the other hand, when the smooth muscle cells relax, the cavernosal chambers open and the penis engorges with blood. Furthermore, as these chambers swell with blood (and intra-cavernosal pressure increases) they press against, the small veins that drain the penis, effectively closing them; hence, penile blood flow increases as drainage is impeded when the cavernosal smooth muscle matrix is relaxed. The net result of these events is penile rigidity, i.e. an ERECTION.

Therefore, contrary to popular myth, an erection results from muscle relaxation, not contraction!

Nervous System Control of Erection

Unfortunately, obtaining an erection is not an entirely voluntary act. It might not happen when you want it to and, conversely, may happen when you least expect it. It thus makes sense that the Involuntary, or Autonomic Nervous System, controls penile erection. The Autonomic Nervous System has two principal branches, the Parasympathetic and Sympathetic branches.

Parasympathetic Nervous System: Smooth muscle relaxation is achieved with an agent known as cyclic Guanosine MonoPhosphate, or cGMP, for short. cGMP is degraded by an enzyme known as cGMP Type V Phosphodiesterase, or PDE. This fact will become important a little later.

Activation of the Parasympathetic Nervous System innervating the penis produces cGMP and thus gives rise to an erection.

Sympathetic Nervous System: Sympathetic activation produces smooth muscle contraction which results in flaccidity (detumescence). Sympathetic Nervous System stimulation also causes ejaculation.

Factors that Contribute to Erectile Dysfunction

Erectile deficiency can arise from physiological, psychological or environmental factors. Although initially they can be divided into either psychogenic (of the mind) or organic (of the body) causes, they are not mutually exclusive. Below we outline the most relevant.


Psychogenic: Erectile dysfunction of psychogenic origin is thought to make up 10-50% of all cases. Daily stress, divorce, death of spouse, loss of job can all contribute to the incidence of psychogenic erectile dysfunction. Often guilt, or anxiety, contribute to the development of psychogenic erectile dysfunction.

  • Performance Anxiety: After an initial episode of erectile failure, further attempts at sexual contact may produce anxiety, which could further contribute to lack of response. This is referred to as Performance Anxiety.
  • Widower’s Syndrome: Widower’s Syndrome refers to a male who experiences erectile dysfunction after the death of a spouse.


  • Endocrinologic: Hormone levels strongly influence our sexual performance. A reduction in serum testosterone lowers our libido and makes it more difficult to maintain an erection. Interestingly, an elevation in serum prolactin also reduces serum testosterone and can have the same effect.
  • Neurogenic: Damage to the Autonomic Nervous System may result in erectile dysfunction. Common causes are lower spinal cord injury and multiple sclerosis. Erectile dysfunction has been determined in 50-70% of men with multiple sclerosis.

  • Vascular: Atherosclerosis and venous leaks of the penile blood vessels are the two most common forms of vascular erectile dysfunction. Vascular disease is estimated to cause 10-20% of all cases of erectile dysfunction. Importantly, elevated serum homocysteine levels is a leading cause of vascular disease in later life and has been recently been shown to be involved in the manifestation of certain forms of erectile dysfunction.
    Click here for more information about homocysteine and coronary heart and vascular disease.

    Importantly, the incidence of vascular erectile dysfunction increases to nearly 50% in men over 50 years of age.

  • Drugs: Alcohol and tobacco abuse can also result in milder forms of erectile dysfunction; smoking causes vascular disease and alcohol abuse disturbs nervous conduction and lowers testosterone levels. Marijuana and cocaine use have also been implicated in causing erectile dysfunction.
  • Diabetes: The prevalence of erectile dysfunction occurs earlier in diabetics. Erectile dysfunction is observed in ~30% of diabetics at age 30 and increases to nearly 55% at age 60. The cause is often vascular disturbances that are a secondary result of diabetes.

Erectile Dysfunction Treatments

Natural Treatments

  • Yohimbe: Yohimbe is made from the inner bark of the Yohimbe tree from West Africa. Yohimbe increases the norepinephrine content of the corpus cavernosum which is essential for erections. Yohimbe stimulates chemical reactions in the body to help impotence. Yohimbe also boosts the adrenaline supply to nerve endings, which can quicken male sexual stimulation. Yohimbe expands the blood vessels in the genitals. Poor circulation can cause impotence. Yohimbe also inhibits serotonin. This is important because increased serotonin levels inhibit sexual performance. Yohimbe can help impotence so that men can experience fuller and longer lasting erections. Yohimbe is also responsible for psychic stimulation, heightening of sexual, emotional sensations and a useful substance for treating male sexual dysfunction.
  • Epunedum Sagitum: Also known in China as Yin Yang Huo or in the Western World as Horny Goat Weed. Eastern doctors boosts that Yin Yang Huo enhances libido and improves erectile function. Yin Yang Huo works by liberating testosterone thereby increasing sex drive and endurance. Yin Yang Huo is a proven powerful natural aphrodisiac which will enhance physical and sexual sensations.
  • Saw Palmetto: Saw Palmetto (Fructus Serenoae) is known to stimulate male libido and increase sexual energy. Components in saw palmetto are also believed to have aphrodisiac qualities, reduce prostate size, enhances sexual functioning, increase desire, reduce serum cholesterol and fatty acids.
  • Catuaba Bark Extract: Catuaba has a long history in herbal medicine as an aphrodisiac. The Tupi Indians in Brazil first discovered the qualities of the plant and over the last centuries, have composed many songs praising it’s wonders. Indigenous people and local people have used Catuaba for generations and it is the most famous of all Brazilian aphrodisiaca plants. In the state of Minas there is a saying which goes, “Until a father reaches 60, the son is his, after that the son is Catuaba’s.” According to Dr. Meira Penna, Catuaba “functions as a stimulant of the nervous system, above all when one deals with functional impotence of the male genital organs… it is an innocent aphrodisiac, used without any ill effects at all.

Natural Ayurveda Treatments

  • Ashwagandha (Withania Somnifera): Recommended in the ancient Kama Sutra for heightening sexual experience, Ashwagandha is easily the most potent aphrodisiac in the entire botanical kingdom. It has the ability to restore sexual drive, increase endurance and improve overall vitality while promoting a calm state of mind. Ashwagandha is an “adaptogenic” herb which nourishes nerves and improves nerve function to help your body adapt to stress, one of the common cause of sexual problems. Hormones (such as adrenaline) produced during difficult times cause arteries to constrict, keeping blood from the extremities and negatively impacting sexual performance. Ashwagandha brings the body back to equilibrium by relaxing it when stressed and energizing it when fatigued. It also strengthens the reproductive and respiratory systems while serving as a powerful Medhya Rasayana, which means that it enhances all aspects of mind power. Ashwagandha has been used for thousands of year to treat impotence, premature ejaculation, infertility, and erection disorders.
  • Shatavari (Asparagus Racemosus): Shatavari is a rejuvenating herb that soothes the body to relieve stress, nurtures the reproductive system, and strengthens and nourishes tissues. It supports proper liver function and metabolic processes to remove toxins from the blood. This herb is also known to increase Sattwa, or positivity and healing power. It enhances the feelings of spiritual love and opens Ojas (“that through which consciousness enters the physiology”). When combined properly with Ashwagandha, Shatavari takes lovemaking capacity to new levels.
  • Gokshura (Tribulus Terrestris): Gokshura is a sex and mood enhancer that stimulates the production of the Luteinizing Hormone (LH). When LH levels are elevated, the natural production of testosterone also increases. LH is a hormone that also increases sex drive and virility. Laboratory studies have found that Gokshura increases sperm count after being taken for 30 days and can result in better than 50% increase in testosterone levels. This herb also has a stimulating effect on the liver by helping to convert cholesterol and fats into hormones and energy. When this action is combined with the increase in testosterone levels which promote protein synthesis, positive nitrogen balance as well as faster recuperation and recovery from muscular stress, Gokshura has a tremendous positive impact on strength and stamina.
  • Atmagupta (Mucuna Pruriens, or Velvet Bean): This rare herbal extract from India contains high levels of naturally occurring L-Dopa, the world’s most extensively researched amino acid. L-Dopa is one of the few substances that cross the blood brain barrier to convert into Dopamine. Dopamine is a very powerful neurotransmitter that stimulates the hypothalamus and pituitary glands to release growth hormone, increase testosterone levels, boost libido, and increase sperm count. Besides having a powerful impact on sex drive, Atmagupta enhances mental alertness, improves coordination, elevates energy levels, and promotes lean muscle growth.
  • Vidari (Pueraria Tuberosa, or Indian Kudzu):The root of this plant has alterative, aphrodisiac, tonic, stimulant properties which are traditionally used to treat male infertility.

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Synthetic Treatments

  • Sildenafil: Popularly known as Viagra. Sildenafil blocks the breakdown of cGMP by inhibiting the actions of PDE. Inhibition of PDE allows relaxation of the smooth muscle of the Corporal Cavernosa. This, in turn, increases blood flow into the cavernosal spaces, leading to erection. Viagra has been used with great success in the treatment for erectile dysfunction.
  • Trazodone: Trazodone’s mechanism of action isn’t well understood. Trazodone might cause smooth muscle relaxation by interfering with the sympathetic control of penile flaccidity, or detumescence.
  • Pentoxifylline: Pentoxifylline decreases red blood cell membrane rigidity making them more flexible, and allowing them to pass more readily through partially obstructed arteries. Use of pentoxifylline in erectile dysfunction is limited to patients with penile vascular disease.
  • L-Arginine: L-Arginine is an amino acid precursor to nitric oxide with limited evidence to support its use in treating erectile dysfunction.


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“Thank you.”

DR, Arizona

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