Erectile dysfunction (ED, impotence) is a common condition in older men, but is also a common sexual health problem in younger men today. Many people see erectile dysfunction in the elderly as a natural consequence of aging. However, with a healthy life, a normal sexual life at the age of 70-80 is possible. According to studies, the causes of ED seen in young men are mostly related to smoking, alcohol and drug use, unlike the elderly.

In this article, I will explain the erection problem in young men, its causes and treatment. I will describe a general literature review on the subject and my own experiences.

What is erectile dysfunction?

Erectile dysfunction is defined as the inability to achieve or maintain an erection necessary for a normal sexual intercourse. Erectile dysfunction can be of varying degrees. It can be severe in some people, while it can be mild in others. Erection problems in young men respond better to treatment than older people.

How common is erectile dysfunction in young men?

Erectile dysfunction, which is generally known as the problem of older men, is actually common in young people. Contrary to popular belief, this situation seen in young men is higher. When we review the literature on this subject;

• In a study conducted in Brazil, the incidence of ED in young people aged 18-25 was 36.5%; It has been reported as 30.7% in young men aged 26-40 years.
• In a study conducted among men under the age of 40 in the USA, ED was seen at a rate of 26%, and it was reported that the problem was serious in more than 50% of them.
• In another study conducted in the USA, it was reported that 11.3% of men aged 18-31 had mild erection problems and 2.9% had moderate-to-severe erection problems.
• According to the results of a study in which relevant articles published in international medical journals were reviewed: It was shown that 21.48% of men aged 18-35 years had ED.
• In a study conducted by the University of Wisconsin, approximately 50% of men in their 50s and 60% of those in their 60s have varying degrees of erectile dysfunction.
• In a study conducted among 28000 men, it was shown that there are varying degrees of erectile dysfunction at the rate of 11% in the 30s and 8% in the 20s.
• According to a study published in the journal J. Sexual Medicine in 2013, erection problems are seen at higher rates in young people than in previous years.

What are the causes of ED in teenagers?

In young men with erection problems, as in the elderly, there is no need to investigate detailed anatomical causes, detailed anamnesis gives sufficient information. The causes of erectile dysfunction in young men are similar to those in the elderly. These reasons are mainly 2 groups; including psychological and organic causes.

Psychological reasons: Psychological reasons also cause erection problems in young men by negatively affecting libido, that is, sexual desire. Stress and anxiety increase the production of epinephrine, as a result of this increased sympathetic activity, contraction in the cavernous tissue increases, relaxation does not occur, and as a result, erectile dysfunction develops. Failure to develop a full erection causes performance anxiety in the person, and this situation continues in the form of a vicious circle.

• Anxiety: Anxiety is the most common cause of erectile dysfunction in men. Fear that the partner will become pregnant, erection ending while wearing a condom, sexual performance anxiety are the conditions that cause erectile dysfunction in young people.
• Stress: Stress in the work or family environment affects sexual life and causes erection problems.
• Depression: Depression negatively affects sexual desire. As a result, erection and sexual intercourse are negatively affected.

Organic causes: The organic causes of erectile dysfunction in young men are similar to older men. These reasons can be listed as follows:

• Narrowing of the vessels carrying blood to the penis: As a result of the narrowing of the vessels carrying blood to the penis, the flow of clean blood (arterial blood) to the penis decreases and eventually erectile dysfunction develops. This is a general situation. In other words, there is not only a narrowing in the penile arteries, but a narrowing in the entire vascular system in the body. Conditions that cause constriction of penile blood vessels in young men are similar to those in adults. These:
  • High blood pressure
  • High cholesterol
  • Excessive use of alcohol and cigarettes
  • Diabetes
  • A sedentary life
  • Obesity (overweight).
• Hormonal reasons: The use of steroid group drugs is common, especially in young men who do sports, in order to ensure excessive muscle growth. Erection problems can be seen in those who take such drugs excessively for the purpose of bodybuilding. High or low thyroid hormones (hyperthyroidism or hypothyroidism), high prolactin hormone secreted from the pituitary gland (hyperprolactinemia) also cause erection problems. Another hormonal cause is the deficiency of the hormone estosterone. Testosterone deficiency is one of the most common hormonal causes. Other rare hormonal causes such as Klinefelter syndrome, congenital hypogonadotropic hypogonadism, subsequent hypogonadotropoic hypogonadism, atrophic testis may also cause erection problems in young men.
• Some drugs used: Psychiatric drugs, cholesterol and blood pressure lowering drugs, some drugs used in the treatment of heart diseases cause erectile dysfunction. Erectile dysfunction problems occur especially when illegal drugs are used for a long time and in high doses.
• Anatomical causes: Some diseases in the penis cause erection problems due to anatomical causes. Penile anatomical causes such as Peyronie’s disease, congenital penile curvature, phimosis (adhesion of the foreskin in uncircumcised men), and incomplete development of the penis are associated with erectile dysfunction at varying degrees in men.
• Neurogenic (nervous) related anatomical causes: Neurological diseases that cause ED of nervous origin: nerve traumas involving the genital area, spinal cord injuries, neurological diseases such as multiple sclerosis, epilepsy.

Is ED seen in the 20s, what are the causes?

Erection problems can also be seen in men in their 20s. These show similarities to diseases that cause general erectile dysfunction. Common causes of erectile dysfunction or sudden onset erectile dysfunction in young men in their 20s include:

• Hypertension (high blood pressure)
• Obesity (overweight)
• Diabetes
• Excessive alcohol use
• Excessive smoking
• A still life
• Drug use
• Sexual performance anxiety
• Watching pornographic movies

What are the complications of erectile dysfunction?

Erectile dysfunction negatively affects people’s normal lives, and serious problems arise in their work and family lives. We can list some of the complications that can cause erection problem as follows;

• Stress, anxiety
• Decreased self-confidence of the person
• Mental problems
• Problems in partner relations
• Problems in daily life and business life

Can erectile dysfunction be reversed in young men?

Some of the erection problems seen in young men are reversible compared to the elderly. Erectile dysfunction, especially due to psychological reasons, can be reversed in young people if appropriate counseling is received and the causes can be eliminated. Likewise, the causes of erectile dysfunction due to reasons such as alcohol, cigarette, and drug use can return to normal by quitting these habits, especially in short-term cases.

Erectile dysfunction due to organic causes is a little more difficult and time-consuming to return to normal. If these organic causes are not long-term, they will not cause permanent damage to the penis, so they have the chance to return with appropriate treatment. In patients with ED due to long-term organic causes, the chance of recovery is less and has a slower course.

A strict diet and regular physical activity play an important role in preventing the negative effects of diabetes on the penis.

How is the treatment of erectile dysfunction in young men?

Treatment of ED in young people is generally similar to that in older men. In young men, mainly psychological reasons are at the forefront, so more attention should be paid to this issue in treatment. Another important issue in terms of treatment in young people is the need for less invasive treatments (such as penile prosthesis) in young people. Treatment principles in patients with erectile dysfunction at a young age are as outlined below;

• Lifestyle changes: Lifestyle changes are more important in younger men with erectile dysfunction than in the elderly. With lifestyle changes, better results are obtained for erectile dysfunction treatment in young people. These changes are:
  • Cessation of smoking if any
  • Alcohol cessation in those who use excessive alcohol
  • Have a healthy, ideal weight
  • Exercising regularly
  • Eating healthy
  • A regular sleep
• Psychological support: If patients have psychological problems, they can receive support regarding these issues. In this way, as a result of supportive treatments performed by experts in the field, anxiety, depression and stress situations disappear, and sexual life returns to normal. People become happier and more productive in their work and family life.
• Oral erectile dysfunction drugs: Oral medications used in the treatment of ED by the urology specialist are recommended as the first-line drug therapy in the treatment of these patients. Young patients generally respond well to this group of drugs. If the desired response to these oral drugs is not obtained, further organic causes should be investigated. These drugs are;
  • Sildenafil
  • Tadalafil
  • Vardanafil
  • Avanafil
• Hormonal therapy: If there is an endocrine problem that may cause erectile dysfunction, it should be treated. The endocrine cause that we often encounter is the lack of Testosterone hormone. In such cases, the urologist prescribes testosterone replacement therapy.
• Vacuum device: Vacuum device applied to the penis in the treatment of erection is a non-invasive treatment method. It has no serious side effects and complications. With this treatment, the patient is educated and their use can be beneficial.
• Supportive treatment: Supportive treatments can be given to these patients in line with the recommendation of the urologist. Although the effects of these are controversial, vitamins and minerals that can help a healthy diet can be effective.
• Penile injection therapy: Penile injection applications are made 10-20 minutes before intercourse. These patients should be advised to consult a urology specialist if the erection lasts for 4-5 hours. Priapism and permanent penile damage can be seen in prolonged erections.
• Urethral gel: Erection gels can be squeezed into the urethra. They should not be used more than twice a day.
• Penile ESWT application: Studies have shown that erection problems seen in young men are treated more effectively with ESWT treatment (ESWT-shock wave therapy) applied to the penis. ESWT has a higher success rate, especially in young people with mild to moderate arterial problems. Our observations are also in this direction. Therefore, we recommend penile ESWT treatment in young male patients with erectile dysfunction.
• Penile PRP (p-shot) application: PRP application to the penis is still in the experimental stage. It is not among the routine treatment options with proven effectiveness.
• Combined treatments: For some patients, combined treatments may be recommended for better results.
• Penile prosthesis surgery: Penile prosthesis insertion is the last option in the treatment of erectile dysfunction in both elderly and young patients. Penile prosthesis surgery is performed as the last option in patients who do not respond to all treatments. There are different reasons for prostheses. Three-piece inflatable prostheses should be preferred for young patients.

In summary; Erection problem is not only the problem of the elderly, but also a problem that can be seen in young men. The causes of erectile dysfunction in young people, unlike the elderly, are due to smoking, alcohol and drug use, and obesity. Erection problems in teenagers can sometimes be a symptom of an underlying disease. In this respect, those who have such problems should definitely consult a Urologist. Unlike the elderly, ED in young people is a condition that can be corrected more easily with lifestyle changes and other appropriate treatments.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY