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Problems with either the arteries carrying blood to the penis or the veins draining blood from the penis can easily prevent a satisfactory erection. The most common of these problems is blockage of the arteries carrying blood to the penis. The small arteries carrying blood into the penis at the time of an erection must dilate from five to ten times their normal resting diameter. Even as little as 15 % percent occlusion of the small blood vessels is enough blockage to cause a problem.

Such partial arterial blockage is the most common cause of organic impotence and is usually associated with risk factors such as cigarette smoking, diabetes, hypertension (high blood pressure), or even marked elevation of blood cholesterol and fat levels. Other risk factors associated with reduced arterial flow are a history of blunt pelvic trauma or pelvic radiation.

The majority of men who have erection problems as a result of reduced arterial blood flow will also have more generalized cardiovascular problems throughout the body. Frequently, impotent men also have a history of coronary artery occlusive disease with or without a history of prior heart attacks. Some individuals with erection problems also have a history of poor blood circulation to their feet and legs, resulting from arterial occlusive disease. Occasionally, a patient has a focal isolated blockage of one of the arteries carrying blood to the penis. This is usually seen in young patients, in their twenties, who have sustained blunt pelvic trauma such as a past pelvic fracture. Diabetic men can have impotence secondary to both effects on the nerve supply to the penis, as well as the vascular supply. Diabetic men, as well as older men, have an increased amount of scarring, or fibrosis within the walls of the arteries to the penis. Plaque buildup on these different areas further reduces the inside diameter of the arteries.


Patients with hyperlipidemia, or marked elevation of lipid (fat) levels in the blood have a definite well-described risk for arteriosclerosis. The extra lipid builds up in the wall of the artery and eventually causes a significant degree of blockage. High blood pressure (hypertension) is another established risk factor for arteriosclerosis. A recent study reported that in one series of impotent men about 45 percent had a history of hypertension. In patients with hypertension, it is not the increased blood pressure itself that contributes to erection problems. Rather, the associated arterial stenosis found in patients with hypertension is thought to be the cause of the erection problems.

Failure of the mechanism that clamps down on the veins that drain blood from the penis has been proposed as one of the more common causes of vasculogenic impotence. Some men may develop large venous channels that are never quite fully occluded as the arterial blood flows into the penis during the beginning phase of erection. Often, this problem is seen in relatively young patients who have experienced erection problems over their entire life. Such patients may report relatively normal initiation of an erection, but within a few seconds or up to a minute or so lose the erection without ejaculation. These venous leak type problems may be surgically corrected.

In Peyronie's disease, non-elastic scar tissue forms, primarily along the surface of the tunica albuginea, resulting in inadequate compression of the veins below the tunical surface, therefore preventing entrapment of the arterial blood in the normal fashion. On the other hand, if the trabecular smooth muscle and the vascular spaces of the penis are unable to relax sufficiently, the sinusoidal expansion will be inadequate and the subtunical veins will not be compressed enough to maintain an erection. This may occur in the overanxious individual with excessive adrenaline and excitement. Alteration of the neuro receptors in the smooth muscle may give an adverse response and, in effect, impair relaxation of the smooth muscle in response to the usual nitric oxide stimulation.


Interestingly cigarette smoking, in addition to causing generalized arterial blockage, may also cause the cavernous smooth muscle to lose its ability to dilate. Again, the net effect is the same -not enough clamping of the penile penile veins to allow for the heightened intracavernous arterial pressures necessary for an erection.



To initiate and maintain an erection, the penis must fill with blood. Nerve signals stimulate this engorgement. They prompt the blood vessels in the penis to expand so blood can fill it. Meanwhile, other blood vessels constrict, trapping blood inside.

The following factors can cause erectile dysfunction:

Venous Leak

If a leak in the blood vessels in the penis allows blood to escape, an erection may not be attainable, or may not last long. This can be caused by injury or disease.

Neurovascular Function

1. Erection cannot be attained if nerve signals do not prompt blood vessels to expand or if blood flow to the penis is reduced.

2. Nerve dysfunction can also diminish feeling in the penis resulting in impotence.

3. Diabetes can interfere with nerve signals.

4. There may be a complete loss of nighttime erections. 

5. Arteriosclerosis (hardening of the arteries) can cause reduced blood flow. 

6. Peripheral neuropathy , spinal cord injury, and surgery can also damage nerves.

7. Many medications also cause erectile dysfunction. 

Blood Vessels and Nerves of Male Pelvis

Psychological Factors

The brain initiates many of the nerve signals required for a successful erection. Emotional problems may play a role in men who suddenly develop impotence.

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition.

Risk factors include

Age: 65 and older

1. Medical conditions:

a. Diabetes 

b. Arteriosclerosis (hardening of arteries) 

c. Chronic kidney disease

d. Liver failure

e. Peyronie's disease (bending of the penis caused by scar tissue) 

f. Endocrine disorders 

g. Neurological disorders (ie, multiple sclerosis , peripheral neuropathy , stroke )

h. Hypertension 

  • i. Psychiatric disorders (ie, anxiety , depression )

2.Traumatic conditions:

a. Vascular surgery 

2. Pelvic surgeries (particularly for prostate cancer )

3. Spinal cord injury 

3.  Behaviors:

a. Alcohol use 

b. Illegal drug use 

c. Anabolic steroid use 

d. Heavy smoking 

e. Interpersonal conflicts with a sexual partner 

4.  Medications:

a. Antihypertensives 

b. Antihistamines 

c. Antidepressants 

d. Tranquilizers 

e. Antipsychotics 


Symptoms include:

1. A less firm penis 

2. Fewer erections 



The doctor will ask about your symptoms and medical history, and perform a physical exam. Expect questions about the frequency, quality, and duration of your erections. Your answers may help determine if primarily psychological or physical factors are causing your impotence.

The doctor will examine your penis, testes, and rectum. If a physical cause is suspected, the doctor may order laboratory tests. These laboratory tests will include hormone levels such as thyroid function tests, prolactin levels, and testosterone levels.

Nocturnal Penile Tumescence Testing

This test can distinguish psychogenic impotence from those due to neurovascular causes.


Sometimes Doppler imaging may be done to look at the blood flow and to make sure that there is no obstruction in the arteries or veins that supply the penis.


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