Erectile Dysfunction: A Penis Problem That Is Rarely a Penis Issue

If you have noticed problems with your sexual function or performance that weren't evident previously, such as not being able to get or maintain an erection, you could have a form of erectile dysfunction (ED). The possible causes of ED are many, but very rarely is an actual physical issue with the penis to blame.

ED may feel like a physical penis problem, but it's usually caused by another, more systemic medical issue.

"We like to say that the penis is like the canary in the coal mine," said Miguel A. Pineda, M.D., the director of male sexual dysfunction of urology at Staten Island University Hospital in New York. "When the penis starts having dysfunction, it might be an early sign that other parts of the body, like the heart, could also start having dysfunction in the near future."

It is important that people understand ED is often just the tip of the iceberg. It could be a sign to look deeper for other health problems.

Why ED can mean bigger problems

ED is often one of the first signs a male might have a systemic health issue. Why? Because in order for an erection to occur, there's actually a great deal of "behind the scenes" work that has to happen, explained Kevin Chu, M.D., a urologist and men's health specialist at Advanced Urology in Los Angeles and a co-host of the podcast "Man Up: A Doctor's Guide to Men's Health."

"There are many systems within your body that work in concordance and are required for the penis to get an erection," he said. "This includes adequate blood circulation, nerves and hormone levels. Additionally, emotional status and psychological well-being are very important. These systems act on a systematic level, so it just happens that many times the first sign there could be an issue is in the penis with erectile dysfunction."

In other words, a successful erection requires a lot of different systems to be working properly in the body. And if there is a breakdown in any of those systems, it could manifest as ED.

Beyond the penis

Erections rely on penile tissue filling up with blood, so any circulatory system issue can impact a person's ability to achieve an erection. Even a seemingly minor issue without other obvious symptoms could cause blood vessel damage over time that could lead to ED.

"Most of the time, [ED] is related to decreased blood flow to the penis," Pineda explained. "When this problem with blood flow happens, it's rarely ever just to the penis."

Blood flow to the penis can decrease naturally as people get older, but some medical conditions accelerate the problem. These include diabetes, high blood pressure and high cholesterol.

"Usually, the blood flow is decreased throughout the body, including a decreased blood flow to the heart, which is obviously most important," Pineda noted.

Lifestyle factors such as smoking, excessive alcohol consumption, drug use and lack of exercise are contributors, Chu added. Obesity, too, could eventually result in lower testosterone levels, which can also contribute to erectile dysfunction.

ED isn't just about a physical medical problem; mental health conditions can also have a direct impact on a person's sexual function. Chu said anxiety, depression and stress are psychological ailments that can contribute to ED.

Even if a psychological issue is not a contributing factor, research suggests some sort of psychological consequence will occur once ED has manifested. ED can often lead to feelings of shame, isolation and anxiety, so it's important to treat both the physical and emotional aspects of the condition.

In some instances, ED can be directly attributed to a physical malfunction of the penis. For instance, prostate surgery or trauma to the penis or pelvic area can have an impact on localized blood circulation or nerves that could negatively affect erectile function. Scar formation from such injuries can contribute, too.

What doctors will want to know

If you are having erectile difficulties and haven't spoken to a doctor about your symptoms, it might be time for a checkup. A physician will most likely start with some basic bloodwork, including checking your testosterone levels, Chu said.

"It really is specialized to the assessment of the patient from the first visit," he said. "In certain instances, I may utilize duplex ultrasounds, which evaluate penile blood flow."

Let your doctor know what medications you are taking, what conditions you might have, what surgeries you have had and what kind of stressors you are experiencing. They all factor into an erectile dysfunction diagnosis.

Your doctor will also want to know about any significant family history, including if there's a history of ED. The systemic issues behind the condition are often hereditary, so you may be screened for those medical conditions.

A history of coronary artery disease (CAD) is significant because it is strongly associated with ED, according to Pineda, since both are due to decreased blood flow through the arteries.

Inform your doctor if you or any first-degree relatives have other diseases that can affect the flow of blood through arteries. These include diabetes, high blood pressure and high cholesterol, which will predispose you to ED.

The assessment will also include a physical examination and a detailed medical, sexual and psychosocial history. It might sound strange, but looking beyond physical symptoms is important in both assessing and treating ED.

For instance, Chu stressed what he calls the "biopsychosocial" approach.

"All three aspects—biological, psychological and social-environmental factors—are interconnected and required for an adequate erection to be achieved," he explained. "A lot of times, the focus is on the biological aspect, and that is what most patients only want to be forthcoming about. The psychological and social-environmental factors are just as important and should be mentioned to the doctor."

Pineda encourages anyone who is having symptoms of ED to be honest with their doctor because treatment for ED is often available.

In addition, mentioning to your doctor that you have ED will open up the evaluation for other diseases that are related.

One of the newest ED treatments on the market is Eddie®, an FDA-registered Class II medical device designed to treat erectile dysfunction and improve male sexual performance. In 2021 clinical trials, Eddie proved effective in treating men with physically, psychologically and pharmacologically induced ED. Its penis-specific shape optimizes blood flow as it puts pressure on the veins of the penis but not the arteries. Blood can get in and is kept there.