Erectile Dysfunction: Sorting the Evidence From the Noise

Key takeaways

• Common underlying causes: heart and blood vessel disease, diabetes, medicines, low mood
• Cardiovascular significance: can come years before other symptoms
• Most useful single change: See your doctor rather than buying online; the cause matters more than the symptom.
• Commonest mistake: Buying medicines or "natural" sexual enhancement products from unregulated websites, which may contain hidden drugs.
• See a doctor if any of the signs under "When to speak to a doctor" below apply to you.

What it is

Ongoing difficulty getting or keeping an erection firm enough for sex. It sits within Mens Health. What follows are the published numbers, not the ones that get passed around.

The numbers, in one place

What helps

What follows is the practical part: the things guidance actually asks of you.

• See your doctor rather than buying online; the cause matters more than the symptom
• Ask for blood pressure, cholesterol and diabetes checks at the same time
• Review your medicines, several of which can contribute
• Address smoking, alcohol, weight and activity, all of which are relevant

What to avoid

What to steer clear of, and why it catches people out.

• Buying medicines or "natural" sexual enhancement products from unregulated websites, which may contain hidden drugs
• Taking PDE5 inhibitors with nitrates, which can cause a dangerous drop in blood pressure
• Treating it as only a sexual issue

In depth

An erection depends on several systems working together. Sexual arousal sends nerve signals to the penis, which release nitric oxide. That relaxes smooth muscle in the arteries and in the spongy tissue of the penis, letting blood flow in, while the expanded tissue compresses the veins so blood stays in. Problems with blood vessels, nerves, hormones, medicines or mental state can interrupt any part of that chain. Often more than one factor is involved at the same time.

The arteries of the penis are small, so they are often affected by the same narrowing and stiffening that later causes heart attacks and strokes. That is why erectile dysfunction can appear several years before heart disease is diagnosed, and why it is treated as a reason to check blood pressure, cholesterol and blood sugar, not just as a sexual concern. A man with new erectile dysfunction and no known heart disease has a good reason to have his cardiovascular risk assessed.

Occasional trouble with erections is normal, especially when tired, stressed or after drinking. Erectile dysfunction refers to a problem that is ongoing. It becomes more common with age but is not an inevitable part of aging. Physical and psychological causes often overlap, because a physical problem can lead to performance anxiety, which then makes things worse. Treating both the physical and the psychological sides often works best, and recognizing that the problem is common can take some of the pressure off.

Signs and symptoms

• Trouble getting an erection when you want one
• Erections that are not firm enough for sex
• Losing an erection before or during sex
• Fewer morning or nighttime erections than before
• Reduced interest in sex alongside erection problems, which can suggest a hormonal cause
• A curved or painful erection, which may point to Peyronie's disease

Causes and risk factors

• Narrowed blood vessels from heart disease, high blood pressure or high cholesterol
• Diabetes, which damages blood vessels and nerves
• Smoking, heavy drinking and drug use
• Medicines, including some for blood pressure, depression and prostate conditions
• Depression, anxiety, stress and relationship difficulties
• Low testosterone, prostate surgery or nerve conditions such as multiple sclerosis

How it is checked

Your doctor will ask about when the problem started, whether you still have erections at night or in the morning, your sex drive, your medicines, alcohol and drug use, and your mood and relationships. Having erections at other times, but not with a partner, can point toward a psychological component, while a gradual loss across all situations suggests a physical cause.

A physical exam usually includes your blood pressure, pulse, weight, and an exam of the genitals. Blood tests often check blood sugar, cholesterol and sometimes morning testosterone and thyroid function. Specialized tests, such as an ultrasound of penile blood flow, are only needed in some cases, usually when first-line treatments have not worked or surgery is being considered.

Treatment and support options

Lifestyle changes

Quitting smoking, increasing physical activity, losing weight if needed, and cutting back on alcohol can improve erections and lower cardiovascular risk at the same time. These changes work slowly but help the underlying cause, and they can make medicines work better. Treating sleep apnea and controlling diabetes also helps. They also improve energy, sleep and long-term heart health, so the benefits reach well beyond the bedroom.

PDE5 inhibitor medicines

Medicines such as sildenafil and tadalafil enhance the natural response to arousal by keeping blood flowing in. They do not cause an erection without sexual stimulation. They take time to work and may need several tries at different times before judging them. Side effects can include headache, flushing and a stuffy nose. Your doctor will check they are safe with your heart and other medicines.

Talking therapies

Counseling or sex therapy can help when anxiety, depression, stress or relationship issues contribute, even alongside a physical cause. Including your partner often helps. Reducing pressure around sex and focusing on other forms of intimacy can break the cycle of performance anxiety. A therapist can also help couples talk about sex more openly, which many find reduces tension. Ask your doctor for a referral to a certified sex therapist if you would like specialist help.

Other treatments

If tablets do not work or are not suitable, a urologist can discuss vacuum devices, medicines injected into the penis or placed in the urethra, and penile implants. These are effective for many men. If low testosterone is confirmed, treating it may help, though testosterone alone does not usually fix erectile dysfunction. A urologist can explain the success rates and side effects of each option.

Prevention

• Do not smoke
• Stay active most days of the week
• Keep blood pressure, cholesterol and blood sugar in healthy ranges
• Keep alcohol within moderate limits
• Get help early for stress, anxiety or depression

Day to day

Erectile dysfunction can affect confidence and relationships, and many men avoid intimacy to avoid the problem. Talking openly with your partner, ideally outside the bedroom, usually helps more than silence. Partners often worry they are the cause, so explaining that it is a health issue can ease tension on both sides.

Treatment is often a process of trying approaches and adjusting. Keep your doctor informed about what has and has not worked, and do not give up after one attempt with a medicine. Remember that the visit for erectile dysfunction is also an opportunity to protect your heart, which is a significant benefit in itself.

For specific groups

Men with diabetes

Erectile dysfunction is more common and often starts earlier in men with diabetes because high blood sugar damages both blood vessels and nerves. Good blood sugar control helps prevent it from getting worse, and standard treatments work for many men with diabetes.

Men with heart disease

Sex is generally safe for most men with stable heart disease, but check with your doctor. PDE5 inhibitors must never be taken with nitrates, including nitroglycerin for chest pain. If you develop chest pain after taking one, tell emergency staff, because it changes the treatment they can give.

Young men

Erectile problems in younger men are more often linked to anxiety, stress, alcohol, drugs or pornography habits, but physical causes still need to be ruled out. Anabolic steroid use is a recognized cause. A frank conversation with your doctor is the best starting point.

Questions to ask your doctor

• What do you think is causing my erectile dysfunction?
• Should I have my heart health, blood sugar and cholesterol checked?
• Could any of my medicines be contributing?
• Is a PDE5 inhibitor safe for me, and how should I take it?
• Would testing my testosterone be useful?
• Would counseling or sex therapy help?

More questions, answered

Is erectile dysfunction always physical?

No. Psychological factors such as anxiety, depression, stress and relationship problems are common causes, particularly in younger men. In older men, physical causes are more common, but the two often overlap. Your doctor can help sort out which factors are involved. Both deserve attention.

Why should I not buy ED pills online?

The FDA has found many products sold online or as natural supplements contain hidden prescription drugs, wrong doses or contaminants. These can interact dangerously with heart medicines. Licensed telehealth services and pharmacies are safe options, but a check with your doctor matters because of the link with heart disease.

Can alcohol cause erectile dysfunction?

Yes. Heavy drinking can make erections harder in the short term, and long-term heavy drinking can damage nerves, lower testosterone and affect the liver. Cutting back often improves erections, along with sleep and overall health. Limiting drinking before sex can make a noticeable difference in the short term.

Do PDE5 inhibitors increase sex drive?

No. They help the body respond to arousal but do not increase desire. If low sex drive is a main problem, it is worth discussing separately, because it can be linked to hormones, mood, medicines or relationship factors. Your doctor can help.

Can cycling cause erectile problems?

Long periods of pressure on the perineum from a narrow saddle can cause numbness and may affect erections in some riders. Adjusting the saddle, using a wider or cut-out seat, and standing periodically can help. The overall benefits of exercise usually outweigh this risk.

Is erectile dysfunction reversible?

Often, yes, or at least manageable. When it is linked to smoking, weight, alcohol, medicines or mental health, addressing those can improve it. Even when the cause cannot be reversed, treatments allow most men to have satisfying sex. Ask your doctor about all options.

Related topics

• What the Guidance Really Says About Sexual Function (Sexual Health)
• What the Guidance Really Says About Fatty Liver Disease (Liver Health)
• What the Guidance Really Says About Mental Health and Long-Term Illness (Long-Term Conditions)
• Smoking and the Heart: What Published Guidance Supports (Heart Health)

Where to go next

• Erectile Dysfunction: Separating Myth From Guidance
• Erectile Dysfunction: A Beginner-Friendly Start
• Erectile Dysfunction — the reference entry
• Men's Health: The Complete Guide
• What the Guidance Really Says About Male Fertility
• What the Guidance Really Says About Men and Health Services

When to speak to a doctor

Never take sildenafil or similar medicines with nitrate drugs such as nitroglycerin: the combination can cause a dangerous fall in blood pressure. Go to the emergency room for an erection lasting more than four hours, which can cause permanent damage. See your doctor promptly for new erectile dysfunction, and call 911 for chest pain.

Where this comes from

• National Institute of Diabetes and Digestive and Kidney Diseases — Erectile Dysfunction (ED)
• FDA — Tainted Sexual Enhancement Products

How this page was put together

Every figure, recommendation and warning above is taken from the guidance named in Where this comes from. Nothing on this page is inferred, summarized or generalized beyond what those bodies publish: where they give a number, it is their number, and where they are silent, so are we. Pages are rebuilt whenever the underlying record changes. Sign-off by a named clinician, where it has happened, is shown at the top of the page along with the date.

Medical disclaimer

This article is general information, not medical advice. It cannot account for your own history, medication or circumstances. Always speak to your doctor, pharmacist or another qualified health professional before making changes that affect your treatment, and never delay seeking medical advice because of something you have read here. In an emergency, call 911.