Erectile Dysfunction

Erectile dysfunction is a common condition that affects millions of men, particularly those over 40, but it doesn’t have to be a permanent part of aging. Understanding its causes and available treatments can help restore both physical intimacy and confidence.

Table of contents

• What Is Erectile Dysfunction?
• Other Names for This Condition
• How Common Is Erectile Dysfunction?
• Signs and Symptoms
• Types of Erectile Dysfunction
• What Causes Erectile Dysfunction?
• Possible Complications
• How Doctors Diagnose Erectile Dysfunction
• Treatment Options
• Lifestyle Changes That Can Help
• Managing ED in Relationships

What Is Erectile Dysfunction?

Erectile dysfunction, also known as ED, is a condition that prevents you from getting or keeping an erection that is firm enough for sexual intercourse^[1]. It means you have difficulty either achieving an erection or maintaining it long enough to have sex^[2].

Your feelings play a major role in getting and maintaining an erection. Feeling relaxed, confident, and aroused is essential. However, it’s normal to sometimes have erection issues. Erection problems can occur if you feel nervous, anxious, frustrated, or tired. Drinking alcohol or using substances can also have an effect^[2].

Experiencing difficulty with erections from time to time is usually no cause for concern. Most men occasionally fail to get or keep an erection, which is usually caused by stress, tiredness, or drinking too much alcohol^[1][4]. But ongoing issues can cause stress, affect self-confidence, and contribute to relationship problems^[1].

impotence, impotency

Other Names for This Condition

Erectile dysfunction is sometimes called impotence, though this term is not used as much now^[3]. Other names include impotency^[2].

How Common Is Erectile Dysfunction?

Erectile dysfunction is very common, particularly in men over 40^[4]. It is the most common sex-related condition that males report to healthcare providers, especially as they age and develop other health issues^[2].

Research suggests that between 30 million and 50 million men in the United States have ED^[3]. ED is more common as people get older. At age 40, about 40% of men are affected, while 70% report having ED by age 70^[3]. More than half of men between the ages of 40 and 70 experience some form of ED^[1].

Medical researchers estimate that erectile dysfunction affects over 50% of males between the ages of 40 and 70. Those numbers may be higher because many don’t seek help for the condition due to embarrassment or shame^[2].

Signs and Symptoms

Erectile dysfunction symptoms include^[2]:

• Only sometimes being able to get an erection before sexual intercourse
• Being able to get an erection before sexual intercourse but not being able to maintain it during sexual intercourse
• Complete inability to get an erection
• Requiring a lot of stimulation to maintain an erection

Depending on the cause, you may still be able to get an erection at other times, such as when you wake up. Sometimes you might also have low sex drive, which is called loss of libido^[4].

Types of Erectile Dysfunction

Healthcare providers separate ED into several categories based on the underlying cause^[2]:

Vascular erectile dysfunction is the most common type of ED. It includes causes that affect the blood vessels that send blood to the tissues in your penis that allow you to get and maintain an erection, or the valves in the penis that normally hold blood inside^[2].

Neurogenic erectile dysfunction occurs as a result of nerve problems, which prevent signals from traveling from your brain to your penis to create an erection. This can happen because of trauma, pelvic surgery, radiation therapy, or neurologic conditions like stroke, spinal stenosis, and multiple sclerosis^[2].

Hormonal erectile dysfunction refers to ED that happens as a result of testosterone deficiency, or in some cases as a result of thyroid issues^[2].

Psychogenic erectile dysfunction involves psychological conditions—conditions that affect your thoughts, feelings, or behavior—that can cause ED^[2].

What Causes Erectile Dysfunction?

ED can be caused by physical or psychological issues. Sexual arousal is a complicated process. It involves your brain, your hormones, your nerves, your muscles, and your blood vessels. A hiccup in any of these can cause a problem^[1].

Most of the time, ED is caused by problems with blood flow to your penis or problems with the nerves to your penis^[5]. Your penis needs adequate blood flow to become erect and maintain an erection^[2]. Often, the culprit behind ED is insufficient blood supply to the penis because of clogged arteries, a condition called atherosclerosis^[13].

There are many possible causes of ED. Common conditions related to ED include^[6]:

• Diabetes mellitus
• High blood pressure or high cholesterol
• Heart disease
• Obesity
• Depression or anxiety
• Hormone problems, including testosterone deficiency
• Prostate cancer treatment, such as surgery, radiation, or hormone therapy

ED may also result from vascular disease, neurological disease, or prostate-related treatments or surgeries^[13]. In up to 30% of men who see their doctors about ED, the condition is the first hint that they have cardiovascular disease^[13].

Performance anxiety and relationship issues are common psychological causes^[6]. Job stress, relationship problems, or depression can also contribute to ED^[13].

Many medications cause or exacerbate ED. Antidepressants are a common cause, especially the selective serotonin reuptake inhibitors^[6]. It can also be a side effect of some medicines, particularly medicines for high blood pressure or depression^[4].

Tobacco use is also a significant risk factor. Current smoking is significantly associated with ED, and smoking cessation has a beneficial effect on the restoration of erectile function^[6].

Possible Complications

Complications of ED may include^[3]:

• An unfulfilled sex life
• Loss of intimacy between you and your partner
• Mental health or emotional issues, such as depression, anxiety, and low self-esteem
• Being unable to get a partner pregnant

The emotional impact the condition can have on a man and their partner can be just as difficult as the physical toll. It is common for men with ED to feel anger, frustration, sadness, or lack confidence^[21].

In many cases, ED can be the first symptom of another underlying problem, including heart disease. It’s important to talk to a healthcare provider if you have problems getting and maintaining an erection^[2]. Sometimes ED may indicate an underlying condition^[1].

How Doctors Diagnose Erectile Dysfunction

If you see someone about erectile dysfunction, the doctor or nurse may^[4]:

• Ask about your lifestyle and relationships, and any problems you might be having
• Do some basic health checks, such as taking your blood pressure
• Examine your genitals to rule out any obvious physical cause

If you have symptoms like needing to pee more often than usual, you may also have an examination of your prostate, which is called a rectal examination^[4].

Your doctor will test your blood to measure the level of testosterone and check for diabetes or other disorders. Sometimes, they may do ultrasound to check the blood flow to your penis^[5].

Treatment Options

Treatment can usually help improve erectile dysfunction^[4]. The condition can be treated, and choosing an ED treatment is a personal decision. If you have a partner, you may want to talk together about treatments that work for you as a couple^[8].

First, doctors treat any health problems you have that might be causing ED and consider changing any medicine you’re taking that’s causing ED^[5]. There are also treatments for some of the causes of erectile dysfunction. For example, your doctor may switch you to a different medicine if it’s causing your erectile dysfunction, or high blood pressure, high cholesterol, and hormone problems may be treated with medicine^[4].

Medicines for Erectile Dysfunction

The main treatments are medicines that increase the blood flow to your penis, called PDE-5 inhibitors^[4]. Oral phosphodiesterase-5 inhibitors are the first-line treatments for ED^[6]. These include^[4]:

• Sildenafil (Viagra)
• Tadalafil (Cialis)
• Vardenafil (Levitra)
• Avanafil (Spedra)

You can get sildenafil on prescription or you can buy it from a pharmacy. You need a prescription for the other types^[4]. Pills like sildenafil are called phosphodiesterase inhibitors. You shouldn’t take these pills if you also take a certain type of heart medicine called nitrates. Nitrates such as nitroglycerin are medicines for chest pain^[5].

If you can’t take phosphodiesterase inhibitors, your doctor may prescribe medicine that you inject into your penis before sex or prescribe medicine that you put into the opening of your penis before sex^[5].

Other Treatment Options

Vacuum pumps encourage blood to flow to the penis, causing an erection. They work for most men and can be used if medicine is not suitable or does not work^[4]. A vacuum device is a round plastic tube that you place over your penis. It has a hand pump you use to pull out the air. This gives you an erection. After the erection, you’ll place a ring or band around the base of your penis to maintain your erection when you take the pump off^[5].

If you have severe ED and none of these treatments work, doctors may do surgery to put a device in your penis. The device may be a solid silicone rod that keeps your penis stiff all the time, or it may be an inflatable device that you pump up to give yourself an erection^[5]. Surgically implanted penile prostheses are an option when other treatments have been ineffective^[6].

Counseling and Therapy

Counseling and therapy can help if your erection problems are linked to emotional or mental health problems, but there can be a long wait for these services on the National Health Service^[4]. Counseling is recommended for men with psychogenic ED^[6]. For some couples, sex therapy may be necessary to help you and your partner cope^[21].

Lifestyle Changes That Can Help

Your health care professional may suggest lifestyle changes to help improve your ED symptoms^[8]. Healthy lifestyle changes can sometimes help with erectile dysfunction^[4]. Your doctor may also advise you to^[5]:

• Lose weight if you’re overweight
• Stop smoking
• Eat a healthy diet
• Exercise daily
• Try to reduce stress and anxiety
• Drink less alcohol

Obesity, sedentary lifestyle, and smoking greatly increase the risk of ED^[6]. Tobacco cessation, regular exercise, weight loss, and improved control of diabetes, hypertension, and hyperlipidemia are recommended initial lifestyle interventions^[6].

Just 30 minutes of walking a day was linked with a 41% drop in risk for ED. Other research suggests that moderate exercise can help restore sexual performance in obese middle-aged men with ED^[13].

Eating a diet rich in natural foods like fruit, vegetables, whole grains, and fish—with less red and processed meat and refined grains—decreased the likelihood of ED^[13]. A trim waistline is one good defense. A man with a 42-inch waist is 50% more likely to have ED than one with a 32-inch waist^[13].

You should not drink more than 14 units of alcohol a week and should not cycle for a while if you cycle for more than 3 hours a week^[4]. There is no evidence that mild or even moderate alcohol consumption is bad for erectile function, but chronic heavy drinking can cause liver damage, nerve damage, and other conditions that can lead to ED. Binge drinking may impact the ability to have an erection^[6].

A strong pelvic floor enhances rigidity during erections and helps keep blood from leaving the penis by pressing on a key vein. Three months of twice-daily sets of Kegel exercises, which strengthen these muscles, combined with advice on lifestyle changes—quitting smoking, losing weight, limiting alcohol—worked far better than just advice on lifestyle changes^[13].

Managing ED in Relationships

The first step in addressing your concerns about ED is to be honest with yourself, your partner, and your doctor. Once ED has been brought out into the open, coping with it as you go through treatment will be easier and less stressful. Communication is essential to a successful diagnosis and treatment, as well as helping your partner understand your feelings^[21].

Communication is essential for a satisfying sex life, especially when coping with ED. Partners should talk openly about desires and fears, and reassure each other while remaining supportive^[20]. ED doesn’t have to signal the end of your sex life. You and your partners can still enjoy physical intimacy and a satisfying sexual life^[20].

While you are being treated for ED, it is important to be patient with your progress and keep in mind that everybody is different and that a treatment that might work for one person may not work or be appropriate for you. It is also important to know that the treatment you choose may not work the first time or may not work every time^[21].