Erectile Dysfunction (ED): Why it May be a Warning of Underlying Physiological Issues


Most men dismiss the first or second incidence of erectile dysfunction as an embarrassing moment, one that should be brushed from memory as swiftly as possible. Perhaps, they believe, they had a bit too much to drink, or too little sleep, or a financial issue preying heavily on their mind. Work has been stressful, and a vacation long overdue. The idea that bedroom problems could indicate a need for a physical examination might not be the first idea that appeals to men, yet erectile dysfunction or erectile disorder (ED) may be a sign of physiological pathology.4

Erectile dysfunction is defined as the inability to develop and maintain an erection long enough to achieve sexual intercourse or sexual activity. At present, there is no uniform standard for how frequent the problem should be to be considered ED, but the typical criteria are that dysfunction should be present for at least six months.

The most strongly associated factor for ED in males in the United States is age, according to incidence and prevalence studies. The Massachusetts Male Aging Study demonstrated that ED becomes “increasingly prevalent with age”. Approximately 40% of men are affected at age 40 and nearly 70 % by age 70. The prevalence of complete ED increased from 5% at age 40 to 15% by age 70. The study also found approximately 617,715 cases diagnosed in the United States annually. Although other factors enter sexual health as men age, such as lower sexual desire, age remains the biggest variable.1

At Issue

Since the 1990’s, erectile dysfunction has been commonly discussed through media, movies, and television. Unfortunately, with the stunningly rapid FDA approval of Sildenafil in 1996, it seemed the “little blue pill” was everywhere by 1998. It was sitting on desks in physician offices, sample boxes handed out and then prescribed like pharmaceutical gold. Although Viagra just turned 20, it is hard to believe it was originally designed as a blood pressure medication. The wondrous effect it had on ED was an unexpected “side effect”. Alternatives (Cialis, Levitra) and generics have since arrived, but unfortunately, so has the Internet. Men can obtain medication from the wonders of their couch, with a phone call or click away from the potential dangers of medicines that could provoke an adverse event.1

This is hardly progress. They may not understand the hydraulics problem they wish to “fix” is complicated and based on psychological and physiological processes.

How an Erection Works

From a purely simplified explanation, an erection occurs when extra blood is delivered to the penis, kept there for a duration of time for a sexual event to occur, then promptly drained away. This would imply that a healthy vascular system is present, with a healthy neurological system controlling it. One of the earliest warning signs of atherosclerosis may be problems with ED, according to Harvard’s Dr. Michael P.  O’Leary, author of a report on Erectile Dysfunction, a Special Report from Harvard Medical School that discusses how erections can “serve as a barometer for overall health.”2

But this is too simplistic. There are physiological, neurological, as well as psychological issues that may affect the body’s ability to achieve and maintain erections. Men with neurological disorders such as MS, spinal disease, Parkinson’s, and similar conditions that affect the nerves’ ability to communicate messages to the genitals may have difficulties with ED. Behavioral and mental-health concerns may also affect sexuality, especially depression. Medications that are utilized to treat these conditions have side effects that could impair sexual health and function.5

Diseases Affecting ED

Men who are significantly overweight, smokers, or diabetic are more likely to have difficulty with erections. Obese men (those with a BMI > 30) are estimated to be 2.5 times more likely to be diagnosed with ED. Diabetics may be four times more likely to suffer from ED than men without diabetes; additionally men with diabetes suffer from ED at a younger age, often 10-15 years before their counterparts who are healthy. Years of diabetes may also lead to neuropathy, which affects the smaller nerve fibers required for healthy erections.3

Smoking leads to cardiovascular disease, which will likely cause ED long before it could cause an MI, as atherosclerosis affects the small blood vessels leading to the penis. This finding should encourage smokers to quit when ED is present at a young age, before significant atherosclerosis is diagnosed in coronary arteries.

Kidney, Liver Disease

Medications, especially hormones or those affecting blood pressure and circulation may affect blood flow to the penis and extremities in patients being treated for liver or kidney disease. Dramatic changes in fluids and testosterone may also affect the ability to achieve and maintain erections. Men with either of these chronic conditions may need emotional support as these conditions are ongoing and require frequent management. Men with kidney and/or liver disease may also suffer from lower sex drives as their condition worsens. Additionally, as liver and kidney disease progress, engorgement of the abdomen may place pressure on vessels in the lower abdomen, decreasing blood flow to the genitals.

Respiratory Disease

Research has demonstrated that men treated for ED are more than twice as likely to have sleep apnea as those without ED. This statistic alone supports the premise that “erections serve as a barometer for overall health.” Particularly for a young man, the presence of ED should prompt the idea that a check-up is warranted. Sleep apnea, depending upon the severity of the disorder and the degree of apneic events observed during a sleep study, could be cause for concern. Sleep apnea and cerebrovascular events (strokes) are strongly linked.3

Cardiovascular/Cerebrovascular Disease

The biggest concern for men with undiagnosed cardiovascular or cerebrovascular atherosclerosis is that they may choose to treat their ED with an agent purchased via the Internet, never suspecting they may have an underlying condition that warrants emergent diagnosis. Atherosclerosis (the artery-clogging build-up in vessels, e.g. coronary or carotid arteries) could be diagnosed by a primary care provider or specialist when ED was discussed and evaluated during an examination. However, with the ease of purchasing ED medications through the Internet, the same pills that may produce erections could also lead to hypotension, migraines, angina, arrhythmias, or a debilitating cardiovascular/cerebrovascular accident for a man with undiagnosed disease!


As easy as it could be for men to ignore ED as a normal function of aging, the condition may arise from a multitude of factors, both physiological and psychological. Internet access has led to increasing comfort for men choosing to treat the condition themselves, shopping with one-click ease. Unfortunately, this should be a case of “buyer beware” for men hoping to find a speedy answer for the occasional problem of erectile dysfunction. As stressed by Harvard Health professionals, a clean bill of health is required for sex, especially as men enter their forties and beyond. Only then should men proceed to enjoy a healthy and completely fulfilled life.


  1. “Erectile dysfunction.” Lakin, M. & Wood, H, June 2018, Cleveland Clinic venter for Continuing Education.
  2. “Erectile dysfunction often a warning sign of heart disease.” Harvard Health Publishing Staff, Posted October 24, 2011, Updated February 26, 2020, Harvard Health Publishing.
  3. International Society for Sexual Medicine “Can erectile dysfunction (ED) be a symptom of other medical conditions?” ISSH University
  4. “Erectile dysfunction.” Mayo Clinic Staff, March 27, 2020, Mayo Foundation for medical Education & Research.
  5. “Symptoms & causes of erectile dysfunction. What are the symptoms of erectile dysfunctions?” National Institutes of Health, 

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