Can Erectile Dysfunction Affect a Man's Sex Drive?

In the realm of male sexual health, the intricate interplay between desire and erectile dysfunction (ED) is an interesting relationship. While we often discuss the mechanics of achieving and maintaining an erection, the significance of desire and its impact on the physiological aspects of sexual function is not talked about as much.

"The relationship between libido (desire) and erections is complex," said Deborah Lee, M.B., Ch.B., a sexual and reproductive health specialist at Dr Fox Online Pharmacy, an online doctor and pharmacy service in the United Kingdom.

What are the connections between desire and ED? What are the various factors that intertwine these two crucial components of the male sexual experience?

How does an erection work?

A complex interplay of physiological, psychological and neurological factors causes an erection. The penis is normally semi-flaccid, Lee said, with the penile arteries and veins partially contracted. A man develops an erection when the penile arteries dilate, the veins relax and the chambers of the penis—the corpora cavernosa, which act as two large sponges—fill with blood.

Men don't have to feel desire to get an erection, and men with erectile dysfunction might have a very strong libido.

"The process of getting an erection starts with physical stimulation (touching the genital area), mental stimulation (such as watching erotic movies) or both," Lee said.

Numerous nerve impulses pass from the genital regions to the brain via the spinal cord, and the brain sends back signals to dilate the penile blood vessels and relax the corpora cavernosa.

What causes erectile dysfunction?

ED can have various underlying causes, broadly categorized into physical, psychological and lifestyle factors.

Among the many physical factors that can cause and contribute to ED are the following:

• Reduced blood flow to the penis. This occurs when the penile arteries are clogged with cholesterol deposits, aka atherosclerosis. Risk factors for atherosclerosis include high blood pressure, raised cholesterol, diabetes and smoking.
• Inability to retain blood inside the penis. Referred to as venous leakage, this can happen if the blood circulation to the penis is insufficient. The pressure of blood inside the corpora cavernosa inhibits the venous return, but if the pressure inside the penis never gets high enough, blood continues to leak away and the erection is weakened.
• The nerve supply to and from the penis is disrupted. Anything that damages the nerve supply and function of the penis can result in ED. Parkinson's disease, multiple sclerosis and other neurological conditions are examples.
• Side effects of medication. Some medications can lead to ED, including antidepressants, antihypertensives, antipsychotics, hormonal medications or anti-anxiety medications. It is important to note that not everyone who takes these medications will experience ED.
• Hormones. Low testosterone levels are not uncommon in men, especially as they age. They can be associated with fatigue, loss of muscle strength, depression, irritability, low libido and poor erections.

The emotional factors that can cause or contribute to erectile dysfunction are many and include the following:

• Anxiety, stress and depression. Stress and anxiety cause raised levels of cortisol, which lowers testosterone, and hence can lower libido. Loss of libido is a common symptom of depression.
• Relationship difficulties. This is a relatively common cause of ED. Either partner may feel guilty about this and therefore worsen the problem.
• Cultural or religious issues. Religion can fundamentally affect attitudes and beliefs associated with having sex, especially the issue of sex outside of marriage.
• Performance anxiety. This is one of the most common forms of sexual dysfunction. The fear of failure leads to high cortisol and low testosterone levels. Over time, this can develop into a loss of libido.

Lifestyle factors that lead to ED include a lack of exercise, in addition to the following:

• Alcohol. This affects every aspect of the sexual response. It reduces sexual desire and interrupts the nerve signaling in the brain and the penis, resulting in poor erections.
• Drug use. Chronic use of cannabis and opiates leads to lowered testosterone levels. Cocaine is often associated with reduced libido and delay in ejaculation.

"So your feelings, interest levels, desire and excitement are all very intimately involved with your ability to get an erection," said Michael Werner, M.D., the medical director and founder of Maze Sexual & Reproductive Health, based in New York City and Purchase, New York.

Do men with ED still want to have sex?

Men don't have to feel desire to get an erection, and men with erectile dysfunction might have a very strong libido. These two things don't always coincide, according to Werner, who gave a few examples:

• The average 17-year-old male can be sitting in homeroom class and get erections even if he's not thinking about sex.
• A 40-year-old man who can physically get and maintain an erection may have difficulties with ED if he's not interested or is even actively disinterested in sex.
• An average 70-year-old man can be very excited and have a good libido and not get a good erection at all.

"For men with ED, it's very common to feel sexual desire and be upset and frustrated at not being able to get a satisfactory erection," Lee said. "If a man has atherosclerosis in his penile arteries but a normal testosterone level, he may well have a good libido but be unable to get a satisfactory erection."

The reverse is also true, Werner said. For example, if your testosterone drops and you lose your libido, that can make you less excited in sexual situations and less likely to initiate something and put in the same amount of stimulation.

"So even with a good functioning of the penis, because the excitement is not there, you may have difficulty getting or maintaining an erection," he said.

'If the ED is successfully treated, libido can return.'

ED is undoubtedly more common in those with low libido, Lee said. In one 2004 study of diabetic men with no obvious erectile difficulties, 40 percent actually had ED upon questioning. Those men with low libido were 18 times more likely to have ED.

"Research has shown that when men try to have sex and fail due to ED, they feel so traumatized that they lose their confidence to try again," Lee said. "Over time, this translates into a general loss of interest in having sex. If the ED is successfully treated, libido can return."

Getting treatment for ED can be crucial.

"Around 40 percent of men have never had a consultation with their doctor about ED," Lee said. "Furthermore, men find it hard to tell the difference between low libido and ED."

Many men have a normal libido but an inability to get a good erection with the frustration and anxiety this causes.

Treatment options for ED

It's important to consult with a healthcare professional to determine the most appropriate treatment option for ED based on your individual circumstances and any underlying health conditions. They can provide personalized recommendations and guide you toward the most effective approach.

Werner said the main treatment options for ED are many.

Treat underlying medical causes

It's essential to be thoroughly evaluated by a medical professional to check for medical problems that might be causing ED, such as heart disease or diabetes. Treating these types of conditions can lead to improvement in ED symptoms. In cases where hormonal imbalances contribute to ED, hormone replacement therapy (e.g., testosterone replacement) might be a treatment option your doctor suggests.

Oral medications

Prescription oral medications such as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanafil (Stendra) are commonly used to treat ED. These medications enhance the effects of nitric oxide, promoting blood flow to the penis and facilitating erections. They are generally effective but require proper medical evaluation and guidance and come with side effects including headaches and priapism—an erection that lasts four hours or more and is a medical emergency.

Penile injections

Medications like alprostadil can be injected directly into the base or side of the penis to induce an erection. This method is effective but may require proper training and guidance. Your healthcare provider can train you to use an auto-injector to make the process easier.

Wearable devices

In this class of ED treatment are vacuum erection devices, mechanical devices that create a vacuum around the penis, drawing blood into the erectile tissues and facilitating an erection. A constriction ring is then applied to the base of the penis to maintain the erection.

One of the newest wearable ED treatments on the market is Eddie®, an FDA-registered Class II medical device designed by urologists to treat erectile dysfunction and improve male sexual performance. It allows blood to flow in but not out, thereby maintaining the erection. Eddie is a safe treatment that does not have the negative side effects of prescription pills, nor does it require a prescription to obtain.

Penile implants

For individuals who do not respond to other treatments or have severe ED, surgical insertion of penile implants may be an option of last resort. These implants provide a rigid or inflatable structure that can be activated to produce an erection.

Lifestyle modifications

Adopting a healthy lifestyle can improve erectile function. This may include regular exercise, maintaining a healthy weight, managing stress, avoiding tobacco use, limiting alcohol consumption and following a balanced diet.

Psychotherapy or counseling

Psychological factors can contribute to ED, and therapy or counseling can help address performance anxiety, relationship issues or underlying emotional concerns that may be impacting sexual function.

"It's important for men to know that although libido and erections are intimately linked, it's a complicated relationship and there are many treatment options to help with erectile dysfunction, whatever the underlying cause," Werner said.