Let’s Talk About Erectile Dysfunction
We’ve got the doctor-approved scoop on ED causes, symptoms, treatments, and other facts and tips that can make life with ED easier.by Matt McMillen Health Writer
Ask most any guy and if he’s honest, he’ll likely tell you that he’s had trouble rising to the occasion in the bedroom from time to time. It’s normal, and many factors—including stress, too much booze, and even over-the-counter meds—can mess with mojo. But persistent trouble is likely erectile dysfunction (ED). Take it seriously and see a doctor, especially since ED can signal other, potentially serious health concerns. Also, keep in mind that ED is definitely treatable. It’s true: You really can get your groove back.
Our Pro Panel
We tapped some of the best experts in the field of ED for the most scientific and up-to-date information possible.
Miguel A. Pineda, M.D.
Director of Male Sexual Dysfunction and Urologic Prosthetics
Staten Island University Hospital
Staten Island, NY
Bob Berookhim, M.D.
Director of Male Fertility and Microsurgery
Lenox Hill Hospital
New York, NY
Jamin Brahmbhatt, M.D.
Remember, it’s ok to have an off night every now and then. That’s normal. But if erection difficulties become a regular occurrence to the point of causing anxiety and get in the way of enjoying sex, pick up the phone and schedule an appointment with your doctor.
Not necessarily. Your primary care doctor should be able to treat erectile dysfunction and may refer you to a specialist, such as a urologist who focuses on male sexual health, if you require more complex care. You may also be referred to a psychologist or other mental health professional if your ED appears to be caused by emotional issues, like anxiety or depression.
That depends. If the causes are emotional, such as depression or anxiety, successfully treating the root cause should clear up the ED. However, if ED results from damage to the arteries in the penis from diabetes or heart disease, that damage is permanent and will likely get worse over time. But don’t despair! Effective treatments exist to help you.
It’s not always clear what these pills contain, so you can’t know if they’re safe or will interact dangerously with a prescription medicine you take. Let your doctor guide you to the right treatment.
What Exactly Is Erectile Dysfuncton (ED)?
Erectile dysfunction can happen for many reasons but the effect is the same: regularly having trouble getting and/or maintaining an erection to have sex.
In 1995, an estimated 152 million men worldwide experienced ED. By 2025, that number is expected to hit 322 million, according to Johns Hopkins Medicine. Despite what some might think, ED isn’t just the scourge of the older crowd—roughly 5% of men under age 40 contend with complete erectile dysfunction. ED may actually be much more common than the statistics show, because many men are embarrassed to admit the issue.
The Physiology Behind an Erection
To understand ED, it helps to understand how erections happen in the first place. Many processes working inside your body make your erection possible, including the endocrine system, which regulates hormones like testosterone, and the vascular system, made up of blood vessels. But erections actually begin in your brain. Here’s how it goes:
When you’re sexually aroused, either by mental stimulation (through your imagination, seeing something sensual, or watching an erotic movie, for example) or physical stimulation (being touched down there), signals from your brain spur the release of a chemical called nitric oxide in the arteries that supply blood to your penis.
The flood of nitric oxide causes those arteries to relax, which increases blood flow to two spongy chambers in your penis, called the corpora cavernosa.
Once those chambers have filled with blood, there’s an erection.
Ideally, the blood will remain trapped there until you have an orgasm and ejaculate.
Along the way, plenty of things can go wrong—any of which can impede getting adequate blood flow to your penis, causing the whole magical process to, uh, fall flat.
What Causes Erectile Dysfunction?
Without sufficient blood flow to the penis, there’s no action—and several factors can muck with the flow. Let’s explore the most common causes of ED, keeping in mind that for some men, there may be more than one.
As a wise man from New Jersey once sang, you can’t start a fire without a spark. The brain is that spark, playing a critical role in erections. Once the brain gets the whole process going by sending out signals that travel down the spinal cord and to the nerves in the penis, chemicals are released that prep the penis to fill with blood and become hard. But those brain signals can get disrupted—usually by one of these issues:
Anxiety, depression, and/or stress. These challenges, whether they’re ongoing or the result of a temporary event, may run interference and prevent you from getting or maintaining an erection. They also can curb libido (a.k.a. sex drive), making you less interested in getting busy between the sheets. And if you’re not turned on, good luck getting a sufficient erection for sex.
Performance anxiety. When worries over getting hard make it hard to get hard, that’s what is called performance anxiety. This means you’re so nervous you won’t be able to get it up (and get it on) that fear further inhibits the ability to perform in the bedroom. That, in turn, can lead to more stress, anxiety and/or depression. A vicious cycle.
It’s useful to note that when emotional causes are the culprit, ED usually comes on suddenly (whereas ED gradually worsens over time when the cause is physical). And while emotional problems can develop in men at any age, they’re more commonly a primary cause of ED in younger men. For men 60 and older, the chronic conditions that often accompany aging are more often to blame. We’ll discuss those next.
Getting older does not solely contribute to erectile dysfunction. However, older men are more susceptible to ED because they’re more likely to have health conditions that can impede erections. They’re also more likely to take the medications used to treat those conditions, with side effects that may let them down, too. Struggling to get and maintain an erection can in itself cause additional stress, depression, and anxiety, making erections even more difficult to achieve.
The most common physical conditions that can lead to ED include:
Damaged heart arteries. Damage to the arteries in the heart usually occurs over a long period of time, often due to bad habits such as poor diet, lack of exercise, and smoking, and from high blood pressure and diabetes, both chronic and common illnesses that can wreak havoc on blood vessels. Over time, this damage can evolve into heart disease, which occurs when those arteries slowly starve the heart of blood and the oxygen it carries. That can lead to a potentially fatal heart attack.
How does ED factor in here? ED may in fact be a warning sign of heart disease: The same habits that can harm the heart’s system of arteries will also harm those arteries that supply blood to the penis. In fact, because the arteries in the penis are so small and delicate, they tend to become damaged well before those in the heart. By some scientific estimates, symptoms of ED precede full-blown heart disease by about five to seven years. If your doctor determines that ED can be traced to damaged arteries, be sure to see a cardiologist to check your heart health. It just might save your life.
Atherosclerosis. Sometimes referred to as hardening of the arteries, this condition involves the buildup of fat, cholesterol, and other substances (together known as plaque) on the walls of the arteries, or the blood vessels that carry blood away from the heart to the rest of the body. Why atherosclerosis starts is not entirely clear, but damage to arteries can trigger it. Such damage may be caused by:
High blood pressure (HBP)
High triglycerides, a type of fat found in the blood
Chronic inflammation, caused by lupus, rheumatoid arthritis, and other causes
Atherosclerosis is usually slow-moving, with damage building up over many years. Eventually, it causes arteries to become less flexible and elastic, as well as narrower, all of which prevents blood from flowing normally. A type of heart disease, atherosclerosis contributes to heart attacks, angina (chest pain), kidney disease, and more. It can occur in arteries throughout the body, including those that supply the penis with blood. Those arteries are, as we know, particularly fragile and can become damaged early on in the course of developing heart disease, making it difficult for blood to flow into the penis when you’re aroused. The result: ED.
Diabetes. Both type 1 and especially type 2 diabetes can limit your ability to get or maintain an erection. How? Diabetes, when it’s not effectively managed, causes blood glucose levels to go up. That means you have more sugar in the blood than is good for you, and over time, that elevated sugar can damage arteries, including the arteries in your penis. Diabetes also can cause neuropathy, or nerve damage, impacting the nerves that control erections. Having diabetes triples the risk of ED, according to the Centers for Disease Control (CDC).
Nerve damage. Diabetes is just one of many ways that the nerves involved in erections can be damaged. Other things that can impair nerves include:
Spinal injuries and diseases, which can affect the nerves
Traumatic brain injuries, which can damage parts of the brain involved in sexual function
Parkinson’s disease, which can lower the sex drive as well as the ability to achieve an erection, and cause nerve problems that interfere with erections
Hormonal imbalance. The hormone testosterone plays a pivotal role in a man’s life. It contributes to muscle-building and strength, helps put hair on your chest during puberty, and aids in sperm production. It also fuels your sex drive. Men with low testosterone may have less interest in sex, and that may make erections more difficult. However, low testosterone on its own is rarely the primary cause of ED.
Obesity. Carrying a lot of excess weight increases the odds of having several ED risk factors, including:
High blood pressure (HBP), which can damage the arteries in the penis
Low testosterone, which can put the brakes on the libido
Type 2 diabetes, which can damage the arteries and nerves in the penis
Chronic inflammation, which can damage the arteries in the penis
Cancer treatment. Surgery for prostate cancer and other cancers located near the pelvis, such as bladder, colon, and rectal cancers, can reduce your ability to have an erection. You may become permanently unable to have an erection without the assistance of an implant, a very effective treatment that we’ll discuss in the next section. The reason: Cancer may require the removal of the nerves that control erections, or those nerves may be damaged during surgery.
Radiation therapy for cancers around the pelvis may damage the arteries that deliver blood to the penis. It also can harm the nerves involved in erections. You may not experience erection problems for a few years after radiation therapy, however, the effects of surgery to remove the cancer are immediate. In the long term, both treatments have an equal impact on erections, according to the American Cancer Society.
Hormone therapy for prostate cancer can reduce sex drive as well as the ability to get an erection. For approximately half of the men who require hormone therapy, ED is permanent.
Peyronie’s disease. This condition, thought to be caused by injuries to the penis that might occur during sex or sports, leads to scarring on the penis. The result: curved and painful erections that can make it difficult to maintain hardness.
Medications. There’s a long list of both Rx and over-the-counter treatments that may hamper the ability to get and maintain an erection. Here are just a few:
Blood pressure medications. These include:
Hydrodiuril (hydrochlorothiazide), a diuretic
Antidepressants and anti-anxiety drugs. These include:
Other drugs. Additional medications that sometimes lead to ED include:
Digox (digoxin), used to treat atrial fibrillation (a type of abnormal heart rhythm)
Proscar (finasteride), used to treat benign (non-cancerous) prostate growth
Benadryl (diphenhydramine) and other OTC antihistamines, used to treat common allergies
How Do Doctors Diagnose Erectile Dysfunction?
If you are regularly unable to get an erection when you want one, or you regularly can’t maintain an erection long enough to have sex, you have ED. While you may feel embarrassed to bring the subject up, it’s worth discussing with your doctor, since erections serve as an important gauge for other aspects of your health. Remember, ED is a medical condition not a personal failing, and it’s one that your doctor has likely discussed with many other men—and will have a slew of options that will help you get back in business. Here’s how that doc visit will likely go down.
Detailed Health History
Your visit will likely start with a discussion about ED, including the following questions:
How long has ED been happening?
What was happening in your life when you first noticed it?
Did it begin gradually or suddenly?
Does it happen all the time?
Has your interest in sex diminished?
When you do have erections, how long do they last?
Do you still get nighttime/morning erections?
Are there other problems at home aside from ED, such as marital stress, work stress, etc?
Have you had symptoms of depression, anxiety, or other psychological problems?
These questions are personal, but it’s important that you answer them as honestly as possible. Your answers will provide clues that will help your doctor identify a possible cause and everything you tell your doctor remains between you two.
You and your doctor will discuss lifestyle issues that can play a role in ED. A poor diet, lack of exercise, and smoking can all contribute to blood flow problems, for example. How much alcohol you drink will be another topic of discussion, as overdoing it affects both blood flow and the nerves involved in erections. Too much booze can also lead to a drop in your testosterone levels.
Another critical topic: medications. Many commonly prescribed meds can cause ED. Your doctor will review the drugs you take to determine if any of them may be the culprit.
A thorough physical exam will allow your doctor to determine if underlying health conditions may be to blame. Blood and urine tests, for example, can reveal the presence of diabetes, HBP, and/or high cholesterol, all of which can damage the arteries that deliver blood to the penis. Your doctor likely will measure your testosterone level as well as your kidney and liver function.
Your doctor may order an ultrasound. This painless, non-invasive exam uses sound waves to create an image of what’s going on inside your penis. It can reveal blood flow problems, for example those caused by atherosclerosis.
How Is Erectile Dysfunction Treated?
ED can be effectively treated in most men. Infinitely reassuring, right? It may take some time to find the treatment that helps, and the best treatment for you now may not always work, requiring you to try something different down the line. These are a few options to explore:
Achieving and maintaining a healthy weight, eating a nutritious diet, and getting regular exercise can help improve ED for some men. Together, all may help prevent or slow the progression of chronic illnesses like heart disease and diabetes that are major culprits in the development of ED. Improving your lifestyle can’t reverse the damage that already may have been done to the arteries in your penis, but it may help keep that damage from getting worse.
Talking about your problems with a psychologist, social worker, or other counselor trained in sex therapy can help with the emotional components of ED, such as stress, anxiety, and depression. Your mental health professional will address any relationship difficulties you may be having, which may contribute to and result from your troubles in the bedroom. The doctor treating your ED can refer you to a specialist, so speak up and ask.
By now, you’ve probably heard of Viagra (sildenafil) and other similar drugs that also work to treat ED, including:
All four drugs belong to a class of medication called PDE5 inhibitors. They work by increasing blood flow into the penis so that you are able to become erect. They also help prevent that blood from flowing back out of the penis prematurely, allowing you to maintain an erection during sex.
PDE5 inhibitors, which only work if you become sexually aroused, do their job quite well for about 70% of men with ED, but they come with limitations and risks. Sex must be planned ahead because you will have to wait for them to take effect, and how long depends on which drug you’re prescribed. Viagra, for example, takes about an hour and remains effective for about four hours. Cialis, on the other hand, keeps working for up to 36 hours, meaning you’ll be capable of having erections when you’re aroused during that time period.
Like with any drug, side effects may occur while taking PDE5 inhibitors. Among the most common:
These side effects are usually mild and short-lived. However, if you take nitrates for heart disease, you’ll want to avoid PDE5 inhibitors entirely. Combined, the two drugs can cause a dangerous drop in blood pressure and you could lose consciousness.
Injections and Pellets
Men who don’t find PDE5 inhibitors effective, or who simply can’t take them, likely will benefit from Caverject Impulse or Muse, both forms of the drug alprostadil. The former is a self-administered injection—you jab the penis with a very small syringe—while the latter is a pellet that you insert into the head of the penis.
Like PDE5 inhibitors, injections boost blood flow to the penis so you’re able to achieve an erection. The injections, which your doctor will teach you how to do, are effective for most men. Nearly nine out of 10 men get an erection firm enough for sex. One advantage an injection has over pills: it works quickly. You will likely have an erection in about 15 minutes, which will last up to about 30 minutes or until you have an orgasm.
Injections do come with a few drawbacks, such as pain and scarring at the injection site. There’s also a chance that an erection won’t go away without medical help. If you have an erection that lasts more than two hours, you have what’s called priapism. This is a medical emergency because prolonged erections can damage the penis in ways that can make ED permanent and untreatable. Go to the emergency room. You’ll receive an injection that relaxes the penis.
If the notion of needles makes you wince, you can try the drug in pellet form. You push a tiny pellet into the head of the penis, where it dissolves in the urethra (the tube that carries urine from the bladder). It takes a little longer to work than injections, and the most common side effect you may experience is a burning sensation in the penis. Like with injections, there’s a risk of priapism.
Vacuum Erection Device (a.k.a. the Penis Pump)
These devices don’t involve medication or any invasive procedures. Instead, when you want to have sex, you place your penis inside the tube-shaped pump, which is powered either by hand or with batteries and seals in place at the base of the penis. The pumping action creates a vacuum inside the tube, and this pulls blood into the penis. Once erect, you slip an elastic ring onto the base of the penis and remove the pump. The ring prevents blood from flowing out of the penis, allowing you to have sex. About three-quarters of men who use a pump find them effective, according to the American Urological Association. While you can get these online without a prescription, talk to a doctor first, and make sure it’s the right device for you.
What are the drawbacks? Aside from being cumbersome, potentially uncomfortable, and putting a wrench in spontaneity, there are several other potential side effects:
The penis may feel numb or cold and may take on a bluish tint while the constriction band is in place.
If not used properly, you may experience pain or bruising.
You may feel pain when ejaculating or feel that semen has gotten stuck inside your penis. (Some devices feature adjustments to counter this effect; ask your doctor to recommend one.)
If nothing else works, you might consider a surgical implant; these devices are very effective. They enable you to get an erection at a moment’s notice, and you can remain erect as long as you want. Plus, sex will feel just as good as it did when you were able to get erections unassisted.
The most common type of implant comes in three parts. During surgery, two inflatable cylinders will be implanted in the penis. These cylinders are attached via a tube to a fluid-filled pouch that will be permanently placed near the bladder. The third part, a small pump, fits inside the scrotum and is attached to the pouch.
When you want to have sex, you squeeze the pump. This triggers the fluid to travel from the pouch into the implanted cylinders. Once they fill up, you have an erection. You’ll remain hard until you release the fluid back into the pouch so the penis can relax. There’s also a two-piece implant that works similarly, but the erections it enables are not as firm as those you’ll achieve with a three-piece.
What’s Life Like With Erectile Dysfunction?
ED can be caused by anxiety, depression, and stress and can also make people more prone to those emotional difficulties. After all, erections and the ability to have sex are, for many men, defining features of masculinity. ED can ruin self-esteem and simply worrying about whether it will happen may lead to avoiding sex altogether. Depression, meanwhile, often dampens interest in sex. Troubles in the bedroom also can lead to (and as stem from) difficulties in relationships with a partner. In short, ED can become as much a mental health issue as a physical one, and addressing the roots of it can get messy.
Some men find it hard to talk about sex with either their doctor or their partner, but ED may only get worse over time if it continues unaddressed. Remember: While it may be hard to speak frankly with your physician, doing so is the first step towards fixing the problem. Many men who find the courage to do so eventually look back after treatment and wonder why they waited so long. The best time to get help is now.
- The Basics of Erectile Dysfunction: Nature Reviews Disease Primers. (2016). “Erectile Dysfunction.” ncbi.nlm.nih.gov/pmc/articles/PMC5027992/
- How Erections Work: American Urological Association. (n.d.). “Erectile Dysfunction (ED).” urologyhealth.org/urology-a-z/e/erectile-dysfunction-(ed)
- Erectile Dysfunction and the Brain: Boston University School of Medicine. (n.d.) “The Central Mechanisms of Sexual Function.” bumc.bu.edu/sexualmedicine/publications/the-central-mechanisms-of-sexual-function/
- Erectile Dysfunction and Heart Disease: Cleveland Clinic. (2019). “Heart Disease & Erectile Dysfunction.” my.clevelandclinic.org/health/diseases/15029-heart-disease--erectile-dysfunction
- Erectile Dysfunction and Heart Disease: Cleveland Clinic. (2019). “Heart Disease & Erectile Dysfunction.” my.clevelandclinic.org/health/diseases/15029-heart-disease--erectile-dysfunction
- Erectile Dysfunction and Diabetes: Centers for Disease Control and Prevention (CDC). (2019). “Diabetes and Men.” cdc.gov/diabetes/library/features/diabetes-and-men.html
- Erectile Dysfunction and Diabetes: Mayo Clinic. (2018). “Erectile dysfunction and diabetes: Take control today.” mayoclinic.org/diseases-conditions/erectile-dysfunction/in-depth/erectile-dysfunction/art-20043927
- Erectile Dysfunction and Cancer Treatment: American Cancer Society. (2020). “How Cancer Can Affect Erections.” cancer.org/treatment/treatments-and-side-effects/physical-side-effects/fertility-and-sexual-side-effects/sexuality-for-men-with-cancer/erections-and-treatment.html