Erectile Dysfunction

What is Erectile Dysfunction? 

Erectile dysfunction (ED) is as a medical condition in which you regularly have trouble getting or maintaining an erection firm enough for satisfying sexual activity.

One of the most common sexual health challenges, ED affects as many as 30 million men in the United States.

The symptoms of ED can be mild, moderate, or severe. Depending on the severity of your symptoms, you might:

• Not get erections at all

• Get erections that aren’t firm enough for penetration

• Get erections that don't last as long as you want them to

• Get firm erections sometimes, but not others

ED can affect your sex life and relationships. It can also be an early warning sign of health conditions like diabetes and heart disease. Your erectile dysfunction can even be your body’s way of telling you to talk with a doctor.

ED is often a chronic issue, but temporary erectile dysfunction is also a thing. In any case, it’s best to get medical help instead of waiting and hoping it’ll disappear on its own.

When to See a Doctor 

Many men occasionally have difficulty getting an erection. Often, this is situational — like when you’re not particularly aroused or you have one too many drinks at dinner. 

If this sounds like you, and you only have trouble getting an erection every once in a while, it’s not usually cause for concern. But if it happens often, seems to be getting worse, or causes you distress, you may want to turn to a healthcare professional for help.

While urologists are specialists in the field, your primary care provider should also be able to help you manage ED. If going into a doctor’s office to talk about erectile dysfunction doesn’t sound like your cup of tea, there are also telehealth platforms that allow you to connect with a provider from the comfort of your own home. 

A healthcare provider will take your medical history, talk to you about your symptoms, order any necessary tests, and then give you recommendations on the best treatment options for you.

Sometimes, a healthcare provider will further categorize your erectile dysfunction based on the most likely cause. Common types of ED include vascular erectile dysfunction, hormonal erectile dysfunction, neurogenic erectile dysfunction, and psychogenic erectile dysfunction.

Erectile Dysfunction Symptoms

The most common erectile dysfunction symptoms are:

• Having trouble getting an erection

• Having trouble keeping an erection

• Getting erections that aren't as firm as you'd like them to be

Erectile dysfunction can have a few less obvious symptoms. Other symptoms that may come along with ED include:

• Decreased sexual desire

• Loss of confidence

• Changes in your mood

• Stress in your relationships

• Anxiety

A healthcare provider can evaluate your symptoms when diagnosing you with ED and help determine the most appropriate treatment plan for you. So, be sure to tell them all the signs of erectile dysfunction you’re experiencing.

Erectile Dysfunction Causes 

Under ideal circumstances, erections happen naturally when you become aroused. Like breathing and blinking, your body takes care of all the background work without you needing to put much (or any) conscious thought into it.

But if you break it down, the physiology of getting an erection is actually pretty complex.

How Do Erections Work?

Inside the penis, there are two columns of spongy tissue called the corpora cavernosa. There’s also a third, smaller column of spongy tissue called the corpus spongiosum that surrounds your urethra (the tube urine flows through). Most of the time, these tissues are soft and your penis remains in a flaccid state.

When you become sexually aroused, these tissues fill with blood, expand, and get hard. A layer of elastic connective tissue that lines the outside of the spongy tissue, called the tunica albuginea, helps trap blood in your penis until it’s time for your erection to go away.

Types of Erections 

There are actually three different types of erections: 

• Reflexogenic erections. These are the erections stimulated by physical touch. 

• Psychogenic erections. These erections are triggered by arousing thoughts.

• Nocturnal erections. These are erections that occur during sleep. 

All erections depend on a complex interaction between your nerves, blood vessels, physical structures, hormones, and state of mind.

Why do we go into so much detail about the mechanics behind your erections? Because it helps highlight the many ways erectile dysfunction can occur. 

Sometimes, ED is caused by one or more physical problems affecting your blood flow or nerve function. In other cases, it may be due to mental health issues, like stress and anxiety, that are interfering with your self-confidence or sexual arousal.

It’s also possible that multiple factors are at play at the same time. For example, a combination of stress and heart disease could be contributing to your ED.

Physical Causes of Erectile Dysfunction

Since your cardiovascular system, nervous system, and endocrine system are all involved in erectile function, medical conditions affecting these systems can lead to ED.

Physical health issues that may contribute to ED include:

• Atherosclerosis (hardening or blocked arteries)

• Blood vessel disease

• Chronic kidney disease

• Heart disease

• Hypertension (high blood pressure)

• High cholesterol

• Type 2 diabetes

• Low testosterone

• Sleep disorders, like sleep apnea

• Injury from treatments for prostate cancer, including surgery and radiation therapy

• Injury to the genitals, urethra, spinal cord, prostate, bladder or pelvis

• Surgery on the genitals, spinal cord, prostate, bladder or pelvis

• Multiple sclerosis

• Nerve damage

• Parkinson’s disease

• Peyronie’s disease, a condition in which the penis becomes curved, often resulting from scar tissue

These health problems don't automatically cause erection problems. But if you’re experiencing sexual health issues, one or more of the above conditions may be playing a role.

ED Caused by Medications

It's not fair, but sometimes the medications you take to treat other health conditions cause side effects — including ED. Some common culprits include:

• Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs)

• Certain blood pressure medications

• Prescription sleep medications or tranquilizers

• Antiandrogens used for prostate cancer therapy

• Appetite suppressants

• Ulcer medicines

• Narcotic pain medications

Fortunately, once you know which of your medications is contributing to your ED, your healthcare provider can help you figure out how to remedy the situation. 

A quick word of caution: if you develop ED after taking one of these medications, it’s important not to stop taking your meds or change your dose without consulting a healthcare professional. 

Make an appointment to get medical advice — an expert can help you determine a course of action.

Psychological Causes of ED

Your mind is more powerful than you may think. Anxiety can give you stomach cramps, embarrassment can make you blush, and stress can make you sweat. And since you need to be sexually aroused to get erect, your mental state can affect your erectile function.

Some psychological contributors to ED include:

• Anxiety, including sexual performance anxiety

• Depression

• Feelings of guilt about sex

• Low self-esteem

• Relationship issues

• Stress

There’s some evidence to suggest that excessive pornography use could also play a role in erectile dysfunction. More research needs to be done in the area, but the thinking is that excessive pornography can lead to heightened expectations for sex, a lack of sexual satisfaction when those expectations aren’t met, and — as a result — erection problems. 

Lifestyle Causes of Erectile Dysfunction

Certain unhealthy habits can affect erectile function, too. These lifestyle factors might also increase the likelihood of cardiovascular or nervous system issues.

The following are considered risk factors for ED: 

• Drinking too much alcohol

• Not being physically active

• Having overweight or obesity

• Smoking

• Using certain recreational drugs

Changing these habits can have a positive effect on your overall health. But making healthier choices is tough, so many people benefit from a little support. Working with a healthcare professional, physical trainer, or counselor can help you achieve your health goals.

Erectile Dysfunction Risk Factors

In the case of ED, the risk factors and causes are essentially the same. 

If you have any of the medical conditions that can cause ED, take any of the medications that can cause ED, or engage in any of the lifestyle habits that can contribute to ED, your risk of developing erectile dysfunction goes up.

It’s definitely possible to have multiple risk factors for ED at the same time. And in some cases, risk factors come together. 

For example, if you have obesity and your obesity is causing you to have high blood pressure, and then you’re prescribed a blood pressure medication that has ED as a potential side effect — that’s three risk factors right there. 

It's important to be aware of these risk factors because having more than one could potentially increase your risk of more severe ED symptoms.

Erectile Dysfunction Diagnosis

To treat your erectile dysfunction, a medical professional will first have to diagnose the issue.

So, the first thing you need to do is talk with a healthcare provider. You can visit your regular doctor, speak with a urologist, or make an online telehealth appointment with another healthcare professional.

During your visit, your provider may:

• Ask questions about your medical history

• Perform a physical exam

• Ask about your symptoms

There’s also a questionnaire some healthcare providers might use, called the International Index of Erectile Function (IIEF). There’s a 15-question version and a five-question version, both of which can help your provider understand more about your erectile function, state of mind, and sexual satisfaction level.

It can feel awkward sharing these details with a provider, but remember, they hear from men like you all the time. For them, it's business as usual. The more information you share, the better — that way your provider can give you the personalized care you deserve.

Tests for Erectile Dysfunction

Although your healthcare provider might diagnose you with erectile dysfunction based solely on your conversation, they might need you to take one or several erectile dysfunction tests. This will help them determine the possible cause(s) of your ED.

ED tests can include:

• Blood tests to check for underlying medical problems

• An ultrasound scan to observe blood flow

• An intracavernosal injection (aka injection test), which involves injecting the penis with medication to see if it’s possible to get an erection

• A nocturnal erection test, which involves a device that checks for erections during the night

Armed with your test results, your provider can help you identify the most effective form of treatment.

Erectile Dysfunction Treatment

ED is a fact of life for many men, but it's not something you have to live with. There are several treatment options for erectile dysfunction. 

Your treatment plan will depend on the cause(s) of your ED. If multiple factors are causing your ED, you might need a few treatments at the same time. Erectile dysfunction treatments may include:

• Erectile dysfunction medications

• Therapy, like cognitive behavioral therapy or sex therapy

• Healthy lifestyle changes like eating a balanced diet and staying active

• Things like vacuum erection devices and penile implants

In the background, you should also be treating any other conditions you have, such as diabetes, that could contribute to your ED and make it worse.

Erectile Dysfunction Medications 

Erectile dysfunction is usually treated with oral medications called phosphodiesterase type 5 inhibitors, or PDE5 inhibitors. 

This class of medication works by increasing blood flow to the penis, making it easier to get an erection when you're sexually stimulated. They don’t impact your libido or make you more aroused, but they do help everything work properly when you are.

The U.S. Food and Drug Administration (FDA) has approved four prescription PDE5 inhibitors for the treatment of erectile dysfunction. Common erectile dysfunction medications include:

• Sildenafil, the active ingredient in Viagra®

• Tadalafil, also sold under the brand name Cialis®

• Vardenafil, the active ingredient in Levitra® and Staxyn®

• Avanafil, currently only available as the brand name Stendra®

In some cases, these medications can come in a different form, either independently or compounded together. These other forms — such as Hard Mints by Hims — can make the experience of taking medication more enjoyable (and more discreet, if that’s something you’re interested in).

While PDE5 inhibitors are generally considered safe and effective, they can cause side effects. Additionally, PDE5 inhibitors may not be appropriate for people with certain health conditions.

Beyond the PDE5 inhibitors, there are other medications that can be used for ED. Alprostadil (Caverject®) is an injection that’s FDA-approved to treat erectile dysfunction. It may also be available as a suppository that’s meant to be inserted into the urethra.

Other medical options include BiMix®, TriMix®, and QuadMix®. These are injectable medications that combine ingredients such as alprostadil, papaverine, phentolamine, and atropine in different combinations. Like the PDE5 inhibitors, these medications help increase blood flow to the penis through different mechanisms.

A healthcare professional can suggest the best ED medication for your specific needs. If one medication doesn’t work, they may change your dose or have you try a different drug.

Treatment for Psychological Erectile Dysfunction 

If your mental health is affecting your erectile function — or, conversely, if ED is weighing on you emotionally — it's a good idea to get mental health support. 

You may benefit from different types of therapy, such as:

• Sex therapy (by yourself or with a partner)

• Couples counseling

• Individual therapy

Many therapists are specifically trained to address men’s health issues, which can include sexual health issues. Often, counseling and therapy are combined with ED medications to help restore confidence and sexual satisfaction more quickly.

Healthy Lifestyle Changes 

Healthy choices can help prevent erectile dysfunction. If you already have ED, making positive changes to your lifestyle could improve your symptoms and prevent the condition from getting worse.

You can reduce your risk of erectile dysfunction by:

• Eating a balanced, nutrient-rich diet

• Limiting consumption of alcohol 

• Avoiding recreational drugs

• Quitting smoking

• Staying physically active and maintaining a healthy weight

• Managing stress in a healthy way 

If this list seems a bit overwhelming, try one or two healthy habits at a time and slowly work toward improving your lifestyle.

The best thing about these techniques is that they can benefit you beyond the bedroom by supporting your overall mental and physical well-being.

Want to learn more? Our guide to naturally protecting your erection shares other techniques you can use for the management of erectile dysfunction.

Other ED Treatments

If PDE5 inhibitors, other medications, lifestyle changes, or therapy don’t work for you — or if you need a little something extra — you might want to explore other treatment options for ED. 

These include:

• Vacuum erection devices (VEDs). These work by pulling blood into the tissues inside your penis. You’ll typically need to use a vacuum erection device with a cock ring to maintain an erection during sex.

• Penile implants. Also known as a penile prosthesis, these implants include bendable rods or inflatables that help the penis maintain an erect position.

• Eroxon® Stingel. Recently authorized by the FDA for erectile dysfunction, this is a non-prescription, non-medicated gel that’s applied to the penis and stimulates the nerves to promote an erection.

• Testosterone replacement therapy. If your ED is caused by low testosterone levels, you might consider testosterone replacement therapy (TRT) or an alternative, like off-label clomiphene (Clomid®).

Although these approaches aren’t generally first-line treatments for ED, your healthcare team may suggest trying them if necessary.

Erectile Dysfunction Prevention Tips

You may have already guessed it, but tips to prevent erectile dysfunction are related to managing all of the potential causes and risk factors we've talked about.

There are some things you can’t change — like your age. While having erectile dysfunction when you’re older isn’t a foregone conclusion, having ED is more likely with advancing age. This is because many of the conditions that cause ED become more common or more severe the older you get. 

The Massachusetts Male Aging Study — a large survey of men ages 40 to 70 that was done in the 1980s but still stands as essential research — found that 40 percent of 40-year-old men have ED, while 70 percent of 70-year-old men have ED. 

(Just an FYI, younger men experience erectile dysfunction, too. A study from 2013 found that 26 percent of men seeking help for ED for the first time were under the age of 40.)

But other things you can change — or at least try to manage. Work with your healthcare provider to treat any chronic conditions you may have to improve both your overall health and your sexual health.