Why Young Men Are Struggling With Erectile Dysfunction

The issue of erectile dysfunction (ED) in the younger male is becoming increasingly obvious in the clinic and online. While occasional ED may occur in the transitory form known as “transient erectile dysfunction”, persistent ED is more likely to result from a complex interplay of physical and psychological factors. For the younger man, physical factors might include increasing levels of cardiometabolic risk, low testosterone, prescribed medication, substance misuse and sleep problems. Corresponding psychological factors could include concerns about performance, clinical depression, stress and relationship problems. Many men are deterred from seeking help for ED due to shame, and therefore opt for quick fixes using what they perceive as healthy supplements or on-line medications that have not been rigorously evaluated. Treatment of the whole health issue rather than a single symptom is likely to be the most effective way forward.

Why It Matters

ED can be an early health warning

Clinicians must take the symptom of ED in the man under 40 very seriously. ED is more than a cosmetic problem-it is a clinical clue to possible undiagnosed health problems. Erection requires the coordination of a number of different systems, including the vascular, nervous, endocrine, and psychological systems. Any number of problems in any of these systems can cause ED, and the young man with ED offers the clinician a “teachable moment” to assess risk for undiagnosed problems such as high blood pressure, abnormal blood sugar or cholesterol levels, changes in weight, or a family history of early coronary disease.

Detecting prostate cancer can reveal the cause of ED in younger men. Many of the causes of ED in young men are completely reversible, including endocrine and metabolic conditions such as low testosterone levels. While the majority of young men with ED do not have low testosterone, when they do, they may also experience decreased libido, fatigue, depression, muscle atrophy, or other physical symptoms and morning erections that are significantly diminished. Other completely reversible causes include thyroid abnormalities and elevated prolactin. Screening for prostate cancer can be life saving while at the same time improving your sex life and detecting potentially life threatening conditions early.

Mental health and ED often reinforce each other

ED is not just about sex. It affects a man’s sense of self-worth, his concept of masculinity, and his overall confidence. And for many young men, ED is equated with failure. This can create a vicious cycle where ED causes performance anxiety, performance anxiety causes ED, and then the man avoids sex altogether, entering a cycle of ED, anxiety, avoidance, and related problems like depression, relationship difficulties, and social isolation from partners and others.

When thinking about young adults and their sexual health, it is useful to consider their stress physiology. Chronic stress can have a host of effects on a person, including hypercortisolism, sleep disturbances, decreased libido, and a general shift towards a decrease in sexual arousal. Often, individuals with stress and anxiety also suffer from co-morbid depression, for which there are efficacious treatments. However, many of the currently prescribed medications for depression decrease libido and impede normal erectile function. Other medications for conditions such as high blood pressure and for treating hair loss have been found to have sexual side effects as well. A thorough review of medications that may have sexual side effects is necessary.

Lifestyle drivers overlap with chronic disease risk

Most factors that can cause erectile dysfunction (ED) in younger men are the same factors that predict future risk of cardiovascular disease and diabetes. Using tobacco and nicotine can cause damage to vessels and decrease nitric oxide (NO), a key player in the process of achieving an erection. Consuming large amounts of alcohol decreases testosterone levels, increases the risk for nerve sensitivity problems and can cause sleep disturbances. Using recreational drugs can interfere with arousal, erections, and orgasm and exacerbate any underlying mental health condition.

Sleep. Often under-rated and under-appreciated until you don’t get enough of it and your testosterone drops. It is also important to have nocturnal erections to keep the penile tissues healthy. Many people are unaware that they suffer from obstructive sleep apnea (OSA) a condition which has been strongly linked to ED, fatigue and an increased risk of developing other serious cardiometabolic disease. However by improving sleep quality you can increase energy and enhance sexual function without the need of medication.

Pornography, expectations, and sexual learning are changing

Younger men report feeling unfulfilled by their sex lives. The internet, in creating a vast, interactive, high-stimulation medium of adult material, has shaped the sexual expectations of large numbers of men. While it is not accurate to assert that every man who watches pornography will experience Erectile Dysfunction (ED), there are some links between exposure to this medium and decreased sensitivity to normal sexual cues, sexual disconnection or distraction, and unrealistic expectations of performance. Understanding these complex factors about a patient’s sexual behaviors is the first step to understanding the patient’s medical or psychological issues, and then helping him to function optimally and connect with his sexual partner(s). A nonjudgmental clinical stance is essential to these tasks.

Care access is evolving, but not always safely

Systemically, many of our EDs are seeing a surge of younger patients with less complex medical problems who require primary care and/or specialty care services. Providers could benefit from education on how to deliver time-efficient primary care, incorporating sexual history into clinical practice, and providing patients with appropriate medication management and mental health resources to address future needs. Patients are going to direct-to-consumer EDs because they are private and convenient but this benefit comes with costs: patients are missing out on important screening (e.g. blood pressure, diabetes) in ED settings, providers are often not aware of patients’ medications that could interact with ED medications, and patients miss out on important plans for future care.

The diagnosis of ED in young men presents a public health opportunity that can be wasted by treating ED as no more than a single prescription. Rather, it serves as a clinical indicator of a man’s overall health status, necessitating intervention to improve his cardiovascular risk, sleep, mental health and substance use behaviors – both in the short-term and long-term.

Who It Affects

Young men across health profiles

The young man with Erectile Dysfunction (ED) is not the same as the man of middle age with ED. While some may experience ED due to anxiety, others experience ED due to relationship issues, substance abuse, medical illness or any other number of causes. It is also possible that the young man may be experiencing ED due to a medical condition that has not yet been diagnosed. Additionally, it is not uncommon for a man to have multiple causes of ED occurring simultaneously, such as mild vascular risk factors for ED plus high levels of stress plus poor sleep.

The likelihood of experiencing ED at a young age is higher for men with several risk factors for heart disease and other conditions known as cardiometabolic disease. Diabetes, obesity, hypertension and hypercholesterolemia can all cause permanent damage to the tiny blood vessels and nerves in the penis necessary for achieving an erection. The tissues of the penis that enable an erection require a complete and healthy blood supply. Sub-clinical changes in metabolism, which may not be associated with immediate symptoms, can already have an impact on erectile tissues. ED in young men may predict a heart attack years before it occurs. Finding and preventing ED early on is a matter of overall health.

Men affected by medications, substances, and supplements

Sexual function can be affected by many medications that are often not thought of as having that side effect. Unless a doctor asks about sexual function, patients may not volunteer this information. However, many treatments for depression, psychiatric illness, high blood pressure, and hormone replacement can impair sexual function. Fortunately, changing the dose of the current medication or switching to an alternative can cure the sexual dysfunction without compromising the effectiveness of the medication for its intended use.

Using nicotine or vaping products, alcohol and/or recreational drugs increases the risk of developing erectile dysfunction. Some substances are riskier than others. Nicotine can damage the blood vessels. Some drugs like cannabis can affect arousal and cause anxiety which can have opposite effects on sexual function in different people. Alcohol decreases levels of testosterone and has a general depressant effect on the nervous system. Stimulant drugs such as amphetamines, cocaine and methamphetamine can cause anxiety and can have an inhibiting effect on erectile function.

Unregulated dietary supplements which claim to promote sexual performance pose a substantial health risk to consumers. There is a risk of unknown or hidden drugs in these products as well as the potential hazardous doses of declared active ingredients.

Men with injuries, surgeries, or specific medical histories

Men with a history of pelvic or spinal injury (either sports related or as a result of a major accident) are at risk of developing ED at an early age due to injury to nerves or vessels. Men with prior cycling related pelvic floor pain, pain or tension, or previous pelvic or spinal surgery are also at risk. Additionally, men with a history of cancer, particularly cancer that has affected the pelvic structures and required treatment, are at risk of ED as well as other reproductive problems such as infertility and hormonal imbalances.

The male patient with hormonal symptoms or family planning goals needs appropriate counsel. Accurate evaluation of the low testosterone level and repeat measurements are also necessary. Testosterone replacement can alleviate the symptoms of testosterone deficiency in some men, but it decreases testosterone levels and reduces sperm production; therefore, fertility preserving options should be discussed. Many of these patients need to be referred to and evaluated by a reproductive specialist.

Partners, families, and the care team

Partners of men with ED report changes in the way communication, intimacy, and safety emerge as themes in their relationship. Some report that couple stop having sex due to the man’s ED, and experience feelings of closeness but also of misunderstanding that they have to negotiate. However, with supportive and clear communication, and possibly even joint problem-solving, couple can actually increase intimacy. Treatment that includes counseling can be particularly helpful.

There is a growing need for clinicians and health systems to address the evaluation and management of transgender patients. Practical pathways for evaluation and referral in primary care will likely require the input and expertise of mental health professionals and sex therapists, who are often the most knowledgeable about transgender patients’ medical, psychological, and sexual needs. However, there are many barriers to accessing cost-conscious, stigma-reducing, and insurance-sensitive mental health and sex therapy services for transgender patients.

What Changes

Screen earlier and more broadly

The young man with ED should be considered as a whole person and not just his symptom of ED. A complete evaluation of the man with erectile dysfunction need not be time consuming, invasive or offending. Measurement of blood pressure, weight, waist circumference, fasting glucose or A1C, lipid profile, sleep and depression/anxiety levels can be the starting point of an evaluation. Ask the patient and his partner about their medications (both prescribed and non-prescribed) and illicit substances. Ask about morning erections, sexual desire, and understand their relationships and the duration of their sexual dysfunction.

Patients with symptoms of underlying serious illness should be evaluated or referred more quickly. For example, evidence of more serious disease, such as curvatures, neurological abnormalities, decreased libido, testicular abnormalities indicating possible cancer, or evidence of cardiac disease, such as symptoms of cardiac disease, especially severe shortness of breath (dyspnea), or chest pain, especially with exertion (angina). Patients with symptoms of cardiac disease should have an urgent evaluation.

Integrate care pathways

Management of men with erectile dysfunction should address both the symptoms and the underlying cause(s) of the problem. Many young and healthy men with erectile dysfunction would benefit from a two-track approach to treatment and care. A short-term focus on function and restoration of confidence, and a longer term focus on promoting a healthy lifestyle and good mental health. A useful way to organize the management of erectile dysfunction is to think of it in terms of primary care for initial screening and management of the cardiometabolic risks, urology for the man with persistent or severe symptoms, endocrinology for the man with erectile dysfunction caused by a hormonal imbalance, and mental health or sex therapy for the man with erectile dysfunction caused by performance anxiety, depression, or other relationship or couple issues.

Counselling should be part of the treatment for a man with an eating disorder, not an afterthought. A short course of CBT can help a man with ED to reduce his performance anxiety, address sexual dysfunction and work on his sexual confidence. Partners also often require help to regain their sense of intimacy and connection with the man suffering from ED. Most men will benefit from a short-term therapy that uncovers the cause of their problem and informs them of their capability to engage in sexual activity. Couples-based therapy is particularly effective for men who are avoiding sex due to fears of failure.

Use medications appropriately, with safety and follow-up

Younger men with primary low testosterone may be candidates for first-line therapy. PDE5 inhibitors can help enhance the biochemical cascade of the body’s blood flow responsiveness, providing an important guidepost for patients as to whether or not nutritional and lifestyle changes are “on the right track.” It is essential for patients to understand the best time of day to take their medication, realistic patient expectations, potential side effects, as well as important drug interactions (e.g., nitrates and some blood pressure medications).

Testosterone therapy for adult testosterone deficiency requires consideration of both fertility and monitoring. Adequate pre-treatment testing, discussion of both benefits and risks with the patient, and regular follow-up monitoring are crucial to prevent harm to the patient. The man who wishes to have children in the future needs to be made aware that current standard medical therapy for testosterone deficiency is unlikely to serve him, and that alternatives and strategies exist to preserve future fertility.

Prioritize lifestyle and sleep as core treatment

Unlike traditional urological lectures about lifestyle change, Lifestyle Medicine treats lifestyle disease by setting realistic goals that need to be met. In addressing weight, muscular strength and endurance, cardiovascular fitness, smoking and alcohol, patients can quickly and dramatically improve their erections and overall health. In addition, learning to go to sleep at the same time every night, avoiding the late night screen, and treating sleep apnea can significantly enhance a man’s capacity for good erectile function.

Addressing stress and mental load can improve sexual function for many young men with sexual difficulties. In addition to providing a psycho-educational understanding of the relationship between stress, mental load, and sexual function, several techniques can be taught to help men manage stress and increase feelings of relaxation. Regular exercise, relaxation training, and incorporating mindful attention to experience during sexual contact can improve sexual function. In addition, helping men reframe the experience of negative events and re-make positive memories of sexual experiences can help them focus on connection and experience over performance and the idea that he is passing a test.

Rethink access and coverage

There are many benefits to the health system and payers when all aspects of evidence-based treatment for the reproductive effects of hormonal therapy for cancer (such as gynecologic screening, family planning options, appropriate diagnostic testing, counseling and/or sex therapy) are addressed by all relevant healthcare providers and fully included in the health insurance plan. Many aspects of reproductive effects of hormonal therapy for cancer can be addressed in a telehealth visit. It is critical that the patient has access to timely lab work, blood pressure measurement, mental health screening, and follow-up as indicated. A one-time prescription is not enough.

Don’t fall for unsafe and ineffective products and quick fixes. Counsel your patients with erectile dysfunction to avoid unregulated sexual enhancement products and to get evaluated by a medical professional before any sexual enhancement treatments. Provide confidential care for your patients with ED. Make ED as common and treatable as it is.

Improve training and public messaging

There is a growing recognition of the need for good quality training of healthcare clinicians to ensure that all those who need access to good quality sexual health services are able to receive them. Incorporating simpler communication into training and using short scripts or modifying initial interview questions could make sexual history taking and first line management of ED more straightforward for both clinicians and patients. Talking about sexual health as part of health and wellness could help to normalise sexual health as a key part of overall health, and inspire people to seek help earlier.

While your short term goals for ED might be to be able to get an erection, consider taking a long term perspective on prevention of ED which can have a wide reaching impact on sexual health as well as sleep, mood, cardiovascular health and relationship satisfaction. This is a great investment for your individual health and for the health care system.

References:

https://pmc.ncbi.nlm.nih.gov/articles/PMC12349891/