Erectile dysfunction

Erectile dysfunction (ED) is a common type of male sexual dysfunction. It is when a man has trouble getting or keeping an erection. ED becomes more common as you get older. But it's not a natural part of aging.

Some people have trouble speaking with their doctors about sex. But if you have ED, you should tell your doctor. ED can be a sign of health problems. It may mean your blood vessels are clogged. It may mean you have nerve damage from diabetes. If you don't see your doctor, these problems will go untreated.

Your doctor can offer several new treatments for ED. For many men, the answer is as simple as taking a pill. Getting more exercise, losing weight, or stopping smoking may also help.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Source: MedlinePlus, U.S. National Library of Medicine

Signs and symptoms

ED is characterized by the persistent or recurring inability to achieve or maintain an erection of the penis with sufficient rigidity and duration for satisfactory sexual activity. It is defined as the "persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity for at least 3 months."

Psychological impact

ED often has an impact on the emotional well-being of both males and their partners. Many males do not seek treatment due to feelings of embarrassment. About 75% of diagnosed cases of ED go untreated.

Causes

Causes of or contributors to ED include the following:

Diets high in saturated fat are linked to heart diseases, and males with heart diseases are more likely to experience ED. By contrast, plant-based diets show a lower risk for ED.

Prescription drugs (e.g., SSRIs, beta blockers, antihistamines, alpha-2 adrenergic receptor agonists, thiazides, hormone modulators, and 5α-reductase inhibitors)

Neurogenic disorders (e.g., diabetic neuropathy, temporal lobe epilepsy, multiple sclerosis, Parkinson's disease, multiple system atrophy)

Cavernosal disorders (e.g., Peyronie's disease)

Hyperprolactinemia (e.g., due to a prolactinoma)

Psychological causes: performance anxiety, stress, and mental disorders

Ageing: after age 40 years, ageing itself is a risk factor for ED, although numerous other pathologies that may occur with ageing, such as testosterone deficiency, cardiovascular diseases, or diabetes, among others, appear to have interacting effects

Kidney disease: ED and chronic kidney disease have pathological mechanisms in common, including vascular and hormonal dysfunction, and may share other comorbidities, such as hypertension and diabetes mellitus that can contribute to ED

Lifestyle habits, particularly smoking, which is a key risk factor for ED as it promotes arterial narrowing. Due to its propensity for causing detumescence and erectile dysfunction, some studies have described tobacco as an anaphrodisiacal substance.

COVID-19: preliminary research indicates that COVID-19 viral infection may affect sexual and reproductive health.

Surgical intervention for a number of conditions may remove anatomical structures necessary to erection, damage nerves, or impair blood supply. ED is a common complication of treatments for prostate cancer, including prostatectomy and destruction of the prostate by external beam radiation, although the prostate gland itself is not necessary to achieve an erection. As far as inguinal hernia surgery is concerned, in most cases, and in the absence of postoperative complications, the operative repair can lead to a recovery of the sexual life of people with preoperative sexual dysfunction, while, in most cases, it does not affect people with a preoperative normal sexual life.

ED can also be associated with bicycling due to both neurological and vascular problems due to compression. The increased risk appears to be about 1.7-fold.

Concerns that use of pornography can cause ED have little support in epidemiological studies, according to a 2015 literature review. According to Gunter de Win, a Belgian professor and sex researcher, "Put simply, respondents who watch 60 minutes a week and think they're addicted were more likely to report sexual dysfunction than those who watch a care-free 160 minutes weekly." A 2026 review shows that simple pornography consumption does not cause erectile dysfunction, the relationship between pornography and ED being much more complex.

In seemingly rare cases, medications such as SSRIs, isotretinoin (Accutane) and finasteride (Propecia) are reported to induce long-lasting iatrogenic disorders characterized by sexual dysfunction symptoms, including erectile dysfunction in males; these disorders are known as post-SSRI sexual dysfunction (PSSD), post-retinoid sexual dysfunction/post-Accutane syndrome (PRSD/PAS), and post-finasteride syndrome (PFS). These conditions remain poorly understood and lack effective treatments, although they have been suggested to share a common etiology.

Rarely impotence can be caused by aromatase being active. See Androgen replacement therapy.

Diagnosis

In many cases, the diagnosis can be made based on the person's history of symptoms. In other cases, a physical examination and laboratory investigations are done to rule out more serious causes such as hypogonadism or prolactinoma.

One of the first steps is to distinguish between physiological and psychological ED. Determining whether involuntary erections are present is important in eliminating the possibility of psychogenic causes for ED. Obtaining full erections occasionally, such as nocturnal penile tumescence when asleep (that is, when the mind and psychological issues, if any, are less present), tends to suggest that the physical structures are functionally working. Similarly, performance with manual stimulation, as well as any performance anxiety or acute situational ED, may indicate a psychogenic component to ED.

Another factor leading to ED is diabetes mellitus, a well known cause of neuropathy. ED is also related to generally poor physical health, poor dietary habits, obesity, and most specifically cardiovascular disease, such as coronary artery disease and peripheral vascular disease. Screening for cardiovascular risk factors, such as smoking, dyslipidemia, hypertension, and alcoholism, is helpful.

In some cases, the simple search for a previously undetected groin hernia can prove useful since it can affect sexual functions in males and is relatively easily curable.

The current – as of April 2025 – edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) lists Erectile Disorder (ICD-10-CM code: F52.21) as a diagnosis. According to the DSM, it "is the more specific DSM-5 diagnostic category in which erectile dysfunction persists for at least 6 months and causes distress in the individual." The ICD-10, to which the DSM refers regarding Erectile dysfunction, lists it under Failure of genital response (F52.2). The latest edition of the ICD – namely, the ICD-11 – lists the condition as Male erectile dysfunction (HA01.1).

Ultrasonography

Penile ultrasonography with doppler can be used to examine the erect penis. Most cases of ED of organic causes are related to changes in blood flow in the corpora cavernosa, represented by occlusive artery disease (in which less blood is allowed to enter the penis), most often of atherosclerotic origin, or due to failure of the veno-occlusive mechanism (in which too much blood circulates back out of the penis). Before the Doppler sonogram, the penis should be examined in B mode, in order to identify possible tumors, fibrotic plaques, calcifications, or hematomas, and to evaluate the appearance of the cavernous arteries, which can be tortuous or atheromatous.

Erection can be induced by injecting 10–20 μg of prostaglandin E1, with evaluations of the arterial flow every five minutes for 25–30 min (see image). The use of prostaglandin E1 is contraindicated in patients with predisposition to priapism (e.g., those with sickle cell anemia), anatomical deformity of the penis, or penile implants. Phentolamine (2 mg) is often added. Visual and tactile stimulation produces better results. Some authors recommend the use of sildenafil by mouth to replace the injectable drugs in cases of contraindications, although the efficacy of such medication is controversial.

Before the injection of the chosen drug, the flow pattern is monophasic, with low systolic velocities and an absence of diastolic flow. After injection, systolic and diastolic peak velocities should increase, decreasing progressively with vein occlusion and becoming negative when the penis becomes rigid (see image below). The reference values vary across studies, ranging from > 25 cm/s to > 35 cm/s. Values above 35 cm/s indicate the absence of arterial disease, values below 25 cm/s indicate arterial insufficiency, and values of 25–35 cm/s are indeterminate because they are less specific (see image below). The data obtained should be correlated with the degree of erection observed. If the peak systolic velocities are normal, the final diastolic velocities should be evaluated, those above 5 cm/s being associated with venogenic ED.

Other workup methods

Tests such as the bulbocavernosus reflex test are used to ascertain whether there is enough nerve sensation in the penis. The physician squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal. A physician measures the latency between squeeze and contraction by observing the anal sphincter or by feeling it with a gloved finger in the anus.

It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge. A significant proportion of males who have no sexual dysfunction nonetheless do not have regular nocturnal erections.

This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glans and shaft of the penis.

Technique in which fluid is pumped into the penis at a known rate and pressure. It gives a measurement of the vascular pressure in the corpus cavernosum during an erection.

Cavernosography measurement of the vascular pressure in the corpus cavernosum. Saline is infused under pressure into the corpus cavernosum with a butterfly needle, and the flow rate needed to maintain an erection indicates the degree of venous leakage. The leaking veins responsible may be visualized by infusing a mixture of saline and x-ray contrast medium and performing a cavernosogram. In Digital Subtraction Angiography (DSA), the images are acquired digitally.

This is similar to magnetic resonance imaging. Magnetic resonance angiography uses magnetic fields and radio waves to provide detailed images of the blood vessels. The doctor may inject into the patient's bloodstream a contrast agent, which causes vascular tissues to stand out against other tissues, so that information about blood supply and vascular anomalies is easier to gather.

Treatment

Treatment depends on the underlying cause. In general, exercise, particularly of the aerobic type, is effective for preventing ED during midlife. Counseling can be used if the underlying cause is psychological, including how to lower stress or anxiety related to sex. Medications by mouth and vacuum erection devices are first-line treatments, followed by injections of drugs into the penis, as well as penile implants. Vascular reconstructive surgeries are beneficial in certain groups. Treatments, other than surgery, do not fix the underlying physiological problem, but are used as needed before sex.

Medications

The PDE5 inhibitors sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) are prescription drugs which are taken by mouth. As of 2018, sildenafil is available in the UK without a prescription. Additionally, a cream combining alprostadil with the permeation enhancer DDAIP has been approved in Canada as a first line treatment for ED. Penile injections, on the other hand, can involve one of the following medications: papaverine, phentolamine, and prostaglandin E1, also known as alprostadil. In addition to injections, there is an alprostadil suppository that can be inserted into the urethra. Once inserted, an erection can begin within 10 minutes and last up to an hour. Medications to treat ED may cause a side effect called priapism.

Prevalence of medical diagnosis

In a study published in 2016, based on US health insurance claims data, out of 19,833,939 US males aged ≥18 years, only 1,108,842 (5.6%), were medically diagnosed with erectile dysfunction or on a PDE5I prescription (μ age 55.2 years, σ 11.2 years). Prevalence of diagnosis or prescription was the highest for age group 60–69 at 11.5%, lowest for age group 18–29 at 0.4%, and 2.1% for 30–39, 5.7% for 40–49, 10% for 50–59, 11% for 70–79, 4.6% for 80–89, 0.9% for ≥90, respectively.

Focused shockwave therapy

Focused shockwave therapy involves passing short, high frequency acoustic pulses through the skin and into the penis. These waves break down any plaques within the blood vessels, encourage the formation of new vessels, and stimulate repair and tissue regeneration.

Focused shockwave therapy appears to work best for males with vasculogenic ED, which is a blood vessel disorder that affects blood flow to tissue in the penis. The treatment is painless and has no known side effects. Treatment with shockwave therapy can lead to a significant improvement of the IIEF (International Index of Erectile Function).

Testosterone

Men with low levels of testosterone can experience ED. Taking testosterone may help maintain an erection. Males with type 2 diabetes are twice as likely to have lower levels of testosterone, and are three times more likely to experience ED than non-diabetic men.

Pumps

A vacuum erection device helps draw blood into the penis by applying negative pressure. This type of device is sometimes referred to as penis pump and may be used just prior to sexual intercourse. Several types of FDA approved vacuum therapy devices are available under prescription. When pharmacological methods fail, a purpose-designed external vacuum pump can be used to attain erection, with a separate compression ring fitted to the base of the penis to maintain it. These pumps should be distinguished from other penis pumps (supplied without compression rings) which, rather than being used for temporary treatment of impotence, are claimed to increase penis length if used frequently, or vibrate as an aid to masturbation. More drastically, inflatable or rigid penile implants may be fitted surgically.

Vibrators

The vibrator was invented in the late 19th century as a medical instrument for pain relief and the treatment of various ailments. Sometimes described as a massager, the vibrator is used on the body to produce sexual stimulation. Several clinical studies have found vibrators to be an effective solution for Erectile Dysfunction. Examples of FDA registered vibrators for erectile dysfunction include MV.Health's Tenuto and Reflexonic's Viberect.

Surgery

Often, as a last resort, if other treatments have failed, the most common procedure is prosthetic implants which involves the insertion of artificial rods into the penis. Some sources show that vascular reconstructive surgeries are viable options for some people.

Topical Gel

In June 2023, The U.S. Food and Drug Administration (FDA) authorized for marketing Eroxon, an over-the-counter non-medicated hydro-alcoholic gel indicated for treatment of erectile dysfunction. In the clinical trial, erection was achieved by most men within ten minutes after applying the gel.

The gel is manufactured by Futura Medical, a British medical company. The gel is regulated as a medical device and not as a drug, because its mode of action is a physical one and it doesn't have an active pharmaceutical ingredient.

Eroxon is the first topical ED treatment sold over the counter in the United States. The gel had been on sale in Europe under a CE mark since 2023, and it reached American shops in October 2024.

As of 2026, the gel is sold in the United States, United Kingdom, Europe, and several countries in Latin America and the Middle East.

Alternative medicine

The Food and Drug Administration (FDA) does not recommend alternative therapies to treat sexual dysfunction. Many products are advertised as "herbal viagra" or "natural" sexual enhancement products, but no clinical trials or scientific studies support the effectiveness of these products for the treatment of ED, and synthetic chemical compounds similar to sildenafil have been found as adulterants in many of these products. The FDA has warned consumers that any sexual enhancement product that claims to work as well as prescription products is likely to contain such a contaminant. A 2021 review indicated that ginseng had "only trivial effects on erectile function or satisfaction with intercourse compared to placebo".

Source: Wikipedia, The Free Encyclopedia · CC BY-SA 4.0