Why Men Should Not Ignore Erectile Dysfunction

Erectile dysfunction can be a sign of a more serious health problem, especially in middle-aged men.

Quick facts about erectile dysfunction
  • Erectile dysfunction, or ED, is the difficulty getting and keeping an erection.
  • As many as 1 in 4 men under 40 may experience ED.
  • For some of those men, ED is a harbinger for later heart disease.
  • Men who get to the doctor early find there are effective treatments—and those who learn they are at risk for heart disease will have a chance to prevent it.

The way Matthew Lucarelli saw it, elderly men might develop erectile dysfunction, or ED, but not a guy like himself, a 36-year-old lawyer who lives in Cheshire with his wife, Leah, and their young son. 

Last year, however, the Lucarellis sensed something was wrong. “Things just weren’t the same,” says Leah, an advanced practice registered nurse. “We attributed it to the fact that we are both working parents. We both have stressful jobs and anxieties. It wasn’t until we tried to have a second child that we started to ask, ‘What’s going on here?’ We had been trying for a year and a half.”

Matthew was concerned he might have a medical problem, so Leah encouraged him to get help. Last fall he made an appointment with Charles Walker, MD, a urologist who specializes in ED who was then at Yale Medicine. ED is difficulty getting and keeping an erection. The visit involved an examination as well as some counseling, which surprised Matthew. “I was able to open up and really talk about the issues,” he says.

He left with a prescription for the drug Cialis to treat his ED, a clearer picture of his health in general and new motivation to make lifestyle changes.

“The medication started to work almost instantaneously,” says Leah.

To contact Yale Medicine's reproductive health and sexual medicine specialists, click here.

More young men are seeking help

Persistent or recurring ED is typically a problem of middle or old age, but doctors say it affects an increasing number of younger men. A 2013 study published in the Journal of Sexual Medicine noted that 1 in 4 men under the age of 40 who sought help for ED actually suffered from the condition. Almost half had severe ED.

ED can be devastating to men regardless of their age and should always be taken seriously. The Massachusetts Male Aging Study, widely considered a landmark piece of research, showed ED to be more common than suspected. It is estimated that more than 300 million men globally will suffer from the condition in 2025.

While most ED patients are effectively treated with medication, the Massachusetts study also showed that, for some, the disorder is a harbinger of heart disease. Dr. Walker, who treated patients at the Yale Medicine’s Cardiovascular and Sexual Health Clinic, estimates that ED is a cardiac risk factor in 10 percent to 20 percent of patients who do not have other risk factors for heart disease.

It helps to understand how an erection works. Sexual stimulation delivers extra blood to the penis through the arteries, causing an erection. 

“The arteries in the penis are the smallest, so we can see the beginning of arterial hardening and heart disease in the penis before we see it in the coronary arteries or the heart,” Dr. Walker says. “So if you’re a younger man who is going to have a heart attack in your 50s or 60s, we’re going to see it in the penis first.” 

Stanton Honig, MD, a urologist and director of the Men’s Health Program at Yale Medicine, uses duplex Doppler ultrasound to evaluate penile blood vessels and assess whether a patient has early blood flow problems to the penis.

Analyzing the risks

How can one tell the difference between ED that is psychological or stress-related, and ED that is a heart disease risk? Dr. Walker said he can usually tell from an initial conversation. 

Men in generally good health who use terms such as “performance anxiety” usually suffer from stress-induced or substance-induced ED, which is caused by anxiety, distraction or too much drinking of alcoholic beverages. These patients often respond to such drugs as Cialis, Levitra and Viagra, all of which enhance the effects of nitric oxide, a natural chemical in the body that relaxes the penis muscles and increases blood flow. 

“The drugs work well in these patients because once they get their erectile function back, their confidence improves, their performance anxiety gets better, and they get better,” Dr. Walker says.

When ED is physical, there tend to be weak erections during masturbation or decreased frequency of morning erections. Men may be at higher risk for cardiac issues if their ED medication gradually stops working or if the ED has been a problem for a number of years. Another tipoff is the presence of other cardiac risk factors such as diabetes, obesity or high cholesterol. 

While the risk factors are typically associated with older men, ED is often the only cardiac risk factor in a younger man. “When young men have erectile dysfunction, we can more purely see that as a marker for potential heart problems,” Dr. Walker says.

Social stigma

No matter what type of ED men suffer with, the first step is going to the doctor—the earlier, the better. This can be especially difficult for younger men. 

“The social stigma is stronger,” says Dr. Walker. “Much of their identity is connected to their sexuality, and ED can have a profound effect on their relationships. They must admit to their partner that they have a problem and then they have to seek help. That’s intimidating.” While most partners are understanding, some react with feelings of inadequacy or even distrust. “I’ve had patients with ED say their girlfriend or wife thinks they’re cheating on them.”

When a patient does bring up ED, Dr. Walker considers it “a teachable moment”—an opportunity to talk about lifestyle changes, especially for men suffering from cardiac risk factors. “If the patient is very unhealthy and has not exerted himself, sexual activity can be a risky exertion,” he says. “It’s a level of activity and exercise that causes your heart rate to increase. If you haven’t done that recently, taking the medication and being sexually active can put you at risk.”

While ED medication works for most patients, there are other treatment options. These include external vacuum devices that draw blood into the penis and injections that men administer themselves to dilate the arteries of the penis and allow blood to flow in. Another option is penile implants, which Dr. Walker calls the “gold standard” for men who cannot tolerate the drugs and for whom other treatments fail. Flexible cylinders are embedded in the penis. The man pumps fluid into them from a reservoir when he wants to perform sexually.

Yale Medicine’s Department of Urology has enrolled thousands of patients over the past 20 years in the penile injection program. “The treatment sounds scary, but we spend the time to teach patients the correct techniques so they and their partners are comfortable.” Says Dr. Honig: “We try to involve the partner as much as possible. This relieves much anxiety for the patients and makes for a more personal touch for the couple.”

For Matthew Lucarelli, medication has proved effective in alleviating his ED. Although he learned that he is not at high risk for future heart disease issues, he has made a number of lifestyle changes—working out, eating healthier meals and cutting down on coffee. 

He continues to visit Yale Medicine every six months. He and his wife, Leah, are expecting their second child this fall.