Erectile Dysfunction: Only affects the elderly?

Take-home points

• Erectile dysfunction is more common with advancing age but still affects at least 10% of young males.
• In young men, erectile dysfunction is more likely to include a psychogenic (originating ‘in the mind’) component.
• In some cases, erectile dysfunction at a young age is an early sign of cardiovascular disease.

What is erectile dysfunction?

Erectile dysfunction is the consistent and recurrent inability to sustain an erection of sufficient rigidity and duration to engage in satisfactory sexual intercourse. It’s a health concern that greatly affects quality of life, sexual relationships, and a man’s overall confidence and wellbeing. 

The severity of erectile dysfunction exists on a spectrum, with multiple potential causes, but each individual case is usually categorised as either psychogenic or organic. 

• Psychogenic erectile dysfunction means that the primary cause originates in the mind and is attributable to psychological or emotional factors. People with psychogenic erectile dysfunction tend to have a sudden onset of symptoms, possibly following a major life event or psychological problem, and have greater difficulty maintaining an erection than achieving one.
• Organic erectile dysfunction is mostly a symptom of another health concern, such as cardiovascular disease, low testosterone, or a neurodegenerative condition. People with organic erectile dysfunction tend to have a gradual onset of symptoms, struggling to achieve an erection even with normal libido. 

Erectile dysfunction in young men

Erectile dysfunction is an age-related condition. With advancing age, erectile dysfunction becomes more and more prevalent. Approximately half of men between 40 to 70 years old describe some degree of ED, and men in their 70s have a fourfold increase in the prevalence of ED compared with men in their 20s. A striking statistic is that most men over 65 years old will develop signs and symptoms of erectile dysfunction.¹

But this condition is not exclusive to the elderly. Erectile dysfunction in young men is frequently reported and is one of the few disorders that motivate them to consult a urologist. Based on numerous analyses across Europe (totalling thousands of young adults), the estimated prevalence of erectile dysfunction in men aged 18–40 years old is between 15 - 30%.^2,3,4 One of these studies, in Florence, also found that erectile dysfunction diagnoses are increasing each year, from 5% in 2010 to more than 15% in 2015.³ Whether this is due to there being more cases of erectile dysfunction, or more young men openly reporting their symptoms to a health professional, however, is unknown. Experts have argued for a long time that it is relatively underdiagnosed, partly because of the perceived shame and embarrassment associated with the condition.⁵

Causes of erectile dysfunction in young men

Age aside, erectile dysfunction can have multiple and often interacting causes. Cardiovascular disease, diabetes, urinary tract infections, obesity, metabolic syndrome, anxiety, depression – these are all possible organic causes of erectile dysfunction that a health professional will evaluate. Situational causes of psychogenic erectile dysfunction can involve psychological distress (i.e. depression, job instability, post-traumatic stress disorder), performance anxiety, and partner-related difficulties. More recently, evidence has even suggested that erectile dysfunction is a relatively common and sometimes long-lasting side effect of COVID-19.

Compared to elderly populations, however, some researchers have stated that the cause of erectile dysfunction in young males is more likely of psychogenic origin, not organic.⁶ This is slight adjustment from scientific consensus until the 1970s, when erectile dysfunction in young men was believed to be always of psychogenic origin (one's psyche). More recent studies outline that around 17% of cases of young men with erectile dysfunction are categorised as primarily organic. This is in stark contrast to the 59% of patients older than 40 years old who presented with organic erectile dysfunction.⁴

But we note that most cases of erectile dysfunction have more than one contributing factor, involving a mix of psychogenic and organic components. Even in young men. Each patient has their own medical history and intricate set of circumstances. The potential causes might also work in viscous cycles. For example, life stressors and pre-existing comorbidities can contribute to the development of erectile dysfunction, while emotional and physical stress associated with the erectile dysfunction exacerbates the situation. It is also possible that a patient’s concerns over his erectile capacity and durability could potentiate a previously innocuous organic cause of erectile dysfunction.

Erectile dysfunction can be an early sign of cardiovascular disease

An important and overlooked consideration for erectile dysfunction is its link to atherosclerosis (i.e. the buildup of plaque in the arteries) and cardiovascular disease. We recently interviewed world-leading cardiologist, Professor Albert Ferro, who stated, “Something that’s being increasingly recognised is the presence of erectile dysfunction in men as an early predictor of silent atherosclerosis”. Later in the interview, he continues to say that “...we now know that atherosclerosis can affect the arteries supplying the penis just as well as the other arteries in your body, and because of that it can cause problems with erections, and that can be an early warning of the presence of atherosclerosis elsewhere and an indicator that those patients should be investigated.”

Erectile dysfunction and coronary artery disease seem to result from similar underlying vascular insults, and so the occurrence of one can predict the occurrence of the other.⁷ A lot of research supports this. One research group followed men under 50 years old with erectile dysfunction and found an 80% increased risk of developing coronary artery disease after 10 years.⁸ Another study found that young men with erectile dysfunction had more subclinical (albeit within normal range) cardiovascular risk factors compared to young men without erectile dysfunction: elevated systolic blood pressure, C-reactive protein levels, cholesterol, triglycerides, and carotid intimal-media thickness.⁹ Please do not wait to report any symptoms to a healthcare professional. 

References:

1. Goldstein I et al. Sex Med Rev. 2020;8(1):48-58.

2. Mialon A et al. J Adolesc Health. 2012;51(1):25-31.

3. Rastrelli G & Maggi M. Transl Androl Urol. 2017;6(1): 79–90.

4. Caskurlu T et al. Int J Urol. 2004;11(7):525-9.

5. Shabbir M et al. Curr Med Res Opin. 2004;20(5):603-6.

6. Corona G et al. Int J Impot Res. 2005;17(3):252-8.

7. Elesber AA et al. Eur Heart J. 2006;27(7):824-31.

8. Inman BA et al. Mayo Clin Proc. 2009;84(2):108-13.

9. Yao F et al. Int J Androl. 2012;35(5):653-9.