What Is Erectile Dysfunction?

Erectile dysfunction (ED) is a common sexual disorder reported among assigned males at birth, characterized by an inability to achieve or maintain an erection. Though you can be affected at any age, ED risk rises with older age, and it can be the result of certain diseases, medication side effects, mental health issues, as well as lifestyle factors. It’s currently estimated that 12 million in the U.S. experience this condition.

You may have ED if you are unable to achieve an erection when you want to have sex, are unable to maintain one long enough to complete the act, or are never able to have an erection. This issue can be short-term or long-term. Treatment options vary based on the individual case and can include everything from lifestyle changes to medications. Fortunately, ED can mostly be effectively managed with medical help.

Erectile Dysfunction Symptoms 

ED most often arises as a symptom of other conditions or diseases, due to certain individual behaviors, or as a side-effect of medications. An issue that can be more short-term or chronic, there’s no established duration of time that defines ED. That said, some physicians consider you to have it if the symptoms persist for at least six months.

This condition can range significantly in severity, and you are considered to have it when:

• You are entirely unable to ever achieve an erection.
• You can achieve an erection but are unable to sustain it long enough to have sex.
• You are sometimes or always unable to achieve an erection when you are sexually aroused.
• You have “soft” erections, in which the penis can only partially become erect.

Because ED is a type of sexual dysfunction, it can also cause emotional distress and relationship problems, both for the person experiencing it and their partner(s). As such, it’s also associated with anxiety and depression.

What Causes Erectile Dysfunction? 

Physiologically, erections occur when cavernous smooth muscle found in a fibrous envelope that surrounds spongy tissue in the penis (known as the tunica albuginea) relaxes. This allows blood to flow into this tissue, giving the penis rigidity. This is regulated by an interaction of central nervous system function and local stimulation. ED occurs when there’s dysfunction of this process.

ED is considered a “multifactorial” disease, meaning it can have a variety of causes, which sometimes work together. Disorders of the vascular system (the heart, arteries, and vessels), nervous system (brain and nerves), and endocrine system (hormones and glands) can all be at the root of the condition.

Risk Factors

As noted above, there are many conditions associated with ED, which raise the risk of developing the condition. These include:

• Depression and anxiety
• Type 2 diabetes
• Cardiovascular diseases, such as coronary artery and heart disease, among others
• Kidney disease
• Multiple sclerosis
• Cancer, or the side-effects of cancer treatment
• Medication side-effects, including drugs for blood pressure, antidepressants, sedatives, and others
• Smoking and/or excessive alcohol and illicit drug use
• Being overweight or clinically obese
• Sedentary lifestyle
• Older age

How Is Erectile Dysfunction Diagnosed?  

To diagnose ED, you’ll need to talk to your healthcare provider about the frequency and scope of the issue, any medical or psychological issues you have, medications you’re taking, and lifestyle factors, such as smoking, alcohol, or illicit drug use. Questionnaires, such as the International Index of Erectile Function (IIEF), help healthcare providers assess the severity of the condition.  

In addition, the provider may perform additional tests to isolate potential causes of ED:

• Physical exam: Alongside tests of blood pressure and pulse, the provider may observe your penis for signs of certain diseases, palpate (touch) it to assess sensitivity to touch, and look for signs of breast enlargement or excess hair, which are signs of hormonal dysfunction.
• Mental health exam: Since psychological factors can cause ED, you may also undergo a mental health evaluation to talk about the impact of the condition and screen for depression and anxiety.
• Lab tests: To screen for the presence of diabetes, kidney disease, hormonal imbalances, or certain other diseases, you may need a laboratory evaluation of blood or urine samples.
• Imaging: Typically using a technique called Doppler ultrasound, imaging may be performed to assess blood flow into the penis.
• Nocturnal erection test: When you sleep, you have an average of three to five erections; this test involves wearing a plastic ring on your penis overnight to see if are physically capable of achieving an erection. Sometimes, healthcare providers just ask you whether you experience nocturnal erections.
• Injection test: In the provider’s office, they inject a medicine that causes erections into your penis and assess how engorged it becomes as well as how long the erection lasts.  

Treatments for Erectile Dysfunction  

While ED can be distressing, it’s highly treatable. Most cases of the condition can be effectively managed, with the typical approaches including lifestyle modifications and oral medications. In more difficult cases, specialized injections and pump devices may be attempted.

Lifestyle Modifications

Since ED is often linked to health factors like obesity or being overweight, diabetes, smoking, alcohol, and illicit drug use, lifestyle changes are considered a first-line approach to the condition. You’ll be advised to:

• Quit smoking
• Limit or stop alcohol use
• Change your diet and/or incorporate physical fitness to manage weight
• Stop using illicit drugs
• Changing medications

Prescription Medications

Medications that help you achieve and maintain an erection may also be indicated for ED. A class of drug called phosphodiesterase 5 (PDE 5) inhibitors is prescribed for this issue. Taken orally, these include:

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

Injection

In more difficult and treatment-resistant cases, an injectable drug, alprostadil (Caverject), may be indicated. The injection, self-applied and targeted on one side of the penis, produces an erection prior to sexual contact. You’ll be trained on proper use in your healthcare provider’s office. That said, some doctors have reported that repeated injections have damaged tissue at the site of the injection, and can be uncomfortable to use.

Vacuum Erection Device   

An approach that doesn’t involve medications, using a vacuum erection device (VED) is well-tolerated and has high rates of user satisfaction. Available over-the-counter (OTC) or with a prescription, this tube-shaped device creates a vacuum to stimulate blood flow to the penis. Talk to your provider about this approach and ask for recommendations of safe devices to use.

How to Prevent Erectile Dysfunction

Primarily, the prevention strategies for ED are the types of lifestyle changes that are recommended as a frontline approach to treatment. These include:

• Quitting smoking: Researchers have found smokers to be 1.5 to 3.1 times as likely to experience ED, so quitting the habit can help.
• Limiting alcohol: Heavy alcohol use is another common risk factor for ED since it’s thought this can damage the cavernous smooth muscle and surrounding nerves, severely restricting or stopping drinking significantly improves ED.
• Managing high blood pressure: Between 30% and 50% of people assigned males at birth have been found to have ED. Reducing salt intake, improving diet, and exercising alongside medications, may help prevent the condition.
• Managing weight: People with obesity are 50% more likely to have ED than those of healthy weight. Physical exercise and modifying diet to shed extra pounds are recommended for prevention.
• Stopping illicit drug use: Using illicit drugs, such as opioids (heroin, morphine), cocaine, and amphetamines, is associated with ED, especially over the long-term. Therefore, taking steps to stop use has proven benefit.
• Treating depression: Among assigned males with depression, 40% experience ED. Therapy, medications, and other means of treating the condition can help.

Comorbid Conditions

People with ED are more likely to have certain cardiovascular and psychological conditions. These comorbidities include:

• Hypertension: Researchers have found those with high blood pressure (hypertension) nearly twice as likely to report ED.
• High cholesterol: High cholesterol is associated with obesity and other risk factors for ED, and is also about twice as prevalent in those with the condition.
• Anxiety: Having an uncontrollable amount of worry or stress, or anxiety disorder, is more common among those with ED, likely due to concerns about sexual performance and social stigmatization.
• Diabetes: Diabetes has been found to occur in nearly 16% of people with ED, compared to about 6% of people assigned males at birth without.
• Depression: A condition that can both lead to ED and be caused by it, clinical depression is defined by depressed move, lack of energy, and loss of interest in daily activities.

Living With Erectile Dysfunction  

Living with ED can have a significant impact on mental health. Those with it—and their partners—are more likely to feel depressed, anxious, and feel stress around sex. However, treatments and lifestyle changes are highly successful in managing this condition. Therapy and counseling are often effective when there are psychological causes, and medications and other treatments have high success rates.

In addition, there are several strategies to help you cope, including:

• Keeping lines of communication open and clear with your partner
• Seeking out medical attention and asking for suggestions for coping from your medical provider
• Having counseling sessions with a therapist or mental health professional
• Seeking support online from social media groups or message boards
• Sharing and talking to others in support groups