Erectile dysfunction, also referred to as ED or impotence, occurs when a man can’t get or keep an erection firm enough for sexual intercourse. Occasional ED isn’t uncommon, particularly during times of stress. In fact, more than half of men over age 40 experience some degree of ED.1
However, frequent ED may be an early sign of more serious health problems, such as disease in the blood vessels elsewhere, including the heart or the brain.
- For some men, ED may be the first symptom of diabetes, even if they have not yet been diagnosed, particularly in men younger than 45.2
- Men with diabetes are three times more likely to experience ED than men without diabetes and it affects them 10 to 15 years earlier in life.1,3
- ED precedes coronary artery disease (CAD) in almost 70 percent of cases. In fact, ED usually comes three or more years before a heart attack, making it a common first sign for men that they have heart disease.4
What are the risk factors for ED?
The most common risk factors for ED are:
- Age over 50
- Cardiovascular disease
- High blood pressure
- High cholesterol
These diseases over a period can lead to a degeneration of the penile blood vessels, leading to restriction of blood flow through the arteries and erectile tissue damage, which allows leakage of blood through the veins during erection.
Abnormally low levels of circulating testosterone may cause ED, although low testosterone is found in a minority of men who develop ED. Low levels of sexual desire, lack of energy, mood disturbances, loss of muscle strength and depression can all be symptoms of low testosterone. A simple blood test can determine if the testosterone level is abnormally low. Low levels of testosterone can be replaced by using a number of different delivery systems (e.g., shots, skin patches, gels, sub-dermal implants).
The choices made in life can lead to degeneration of the erectile tissue and the development of ED. Smoking, drug abuse or alcohol abuse, particularly over periods of time, will compromise the blood vessels of the penis. Lack of exercise and a sedentary lifestyle also contribute to the development of ED. Modifying these risk factors may contribute to overall health and, in some individuals, may correct mild ED.
Patients undergoing surgery or radiation therapy for cancer of the prostate, bladder, colon or rectum are at high risk for the development of ED. Drugs used to treat these risk factors listed above may also lead to or worsen ED.
Another cause of ED is peripheral neuropathy in which the nerves leading to the penis fail to send coordinated signals to the penis. Peripheral neuropathy can be caused by diabetes, human immunodeficiency virus (HIV) infection, certain medications and other less common conditions.
What causes ED?
ED can result from medical, physical or psychological factors. ED may be caused by a combination of factors that could also include medicine, alcohol or drugs. The physical and medical causes of ED include three basic problems:
- Not enough blood flows into the penis. Many conditions can reduce blood flow into the penis, such as heart disease, diabetes, and smoking. The penis cannot store blood during an erection. A man with this problem, which is called venous leak or cavernosal dysfunction, cannot maintain an erection because blood does not remain trapped in the penis. This condition can occur in any man regardless of age.
- Nerve signals from the brain or spinal cord do not reach the penis. Certain diseases, injury or surgery in the pelvic area can damage nerves in the penis. Sexual activity requires the mind and body to work together.
- Psychological, emotional or relationship problems can cause or worsen ED. These include but are not limited to:
- Depression, relationship conflicts, stress at home or work and anxiety about sexual performance
- Many prescription and over-the-counter medications may have side effects that often cause erection difficulties. Using drugs such as marijuana, heroin, cocaine, and alcohol can lead to sexual problems
- If your ED is due to a hormonal problem, such as low testosterone or diabetes, you may be referred to an endocrinologist. Your healthcare provider may also refer you to a mental health professional. These specialists treat psychological or emotional causes of ED. Even if your ED is not caused by these factors, it may contribute to them. It may be helpful to get counseling, alone or with your partner, in addition to medical therapy for ED.
How is ED diagnosed?
ED is diagnosed by a urologist or another medical professional. For most patients, the diagnosis will require a simple medical history, a physical examination, and a few routine blood tests.
The medical history requires healthcare providers to ask about you and your ED experience. Your doctor will also want to know if you have any other conditions that might affect your ED, such as any endocrine problems or depression. They may ask questions about your sexual history and performance, which may be very personal but are necessary to understand the root cause of the problem. The important thing to remember is not to be embarrassed while speaking with your doctor and to be very open to allow for the best treatment options for you. Other questions your doctor is likely to ask include:
- Your current sexual function
- When you started noticing changes
- Any past medical or sexual problems
- Surgery or injury to the pelvic area
- Current and past medication usage lifestyle and personal habits (i.e., smoking, drinking, use of illicit drugs, etc.)
- Relationship with current and past partners
Your doctor will check your overall health and physical condition, looking for signs of problems with your circulatory, nervous and endocrine systems. This includes checking your blood pressure, penis and testicles, and possibly a rectal exam to check the prostate. These tests are not painful and may provide valuable information about the cause of ED. Most patients do not require extensive testing before beginning treatment.
The choice of testing and treatment depends on the goals of the individual. If erection returns with simple treatment such as oral medication and the patient is satisfied, no further diagnosis and treatment are necessary. If the initial treatment response is inadequate or the patient is not satisfied, then further steps may be taken. In general, as more invasive treatment options are chosen, testing may become more complex.
What are the treatments options for ED?
For ED, there are several treatment options, with varying degrees of success and reliability,5 including medications and surgical procedures. Because each option offers unique features, potential risks and benefits, men should talk to their doctor about which treatment option best meets their individual needs and the problems they are experiencing.
Most men try medications like Viagra™, Cialis™ or Levitra™6-8 for their erectile dysfunction. However, up to 50 percent of men with ED do not respond adequately to pills and require a different option.6-8 Men with diabetes and heart disease are more likely to pursue ED treatment beyond medications.
- In a recent study, nearly 20,000 men with ED and diabetes were 1.5 to 2 times more likely to move on to other treatments, such as pumps and penile implants than men without diabetes.9
- Men taking nitrates for heart disease are generally not candidates for oral ED medications and those taking alpha-blocking agents for blood pressure may need to be closely monitored by their doctor.6
A needle is used to inject medication directly into the penis. The medication allows blood to flow into the penis, creating an erection.
Vacuum Erection Devices
A plastic cylinder is placed over the penis, and a pump (manual or battery operated) creates a vacuum suction within it, drawing blood into the penis to create an erection. A stretchable tension band placed at the base of the penis helps maintain the erection.
An applicator containing a small pellet is inserted into the urethra and the pellet is released. The pellet dissolves and increases blood flow to the penis, creating an erection.
A medical device is implanted in the penis, contained entirely within the body. The patient activates the device to achieve an erection and can choose when to return to a flaccid state.
Frequently Asked Questions
Are ED treatments covered by insurance?
Most insurers cover the diagnosis and medical treatment of ED, and Medicare has a national coverage policy for ED, which includes penile implants. Coverage may vary by geography and insurance plan.
How do I know my ED is not just in my head?
We do not know this for sure. It is impossible to prove that there is no psychological component to a man’s ED. Many years ago, doctors thought that most men with ED had psychological problems. We now realize that most men have an underlying physical cause and that the cause of ED is often a combination of physical and psychological factors.
If I worry about my ability to get an erection, can I make a bad condition worse?
Nothing happens in the body without the brain. Worrying about your ability to get an erection can interfere with the process. This condition is called performance anxiety and can be overcome with education and treatment.
I was fine until I began taking a new medication - what should I do?
Many drugs can cause ED, but some cannot be changed because the benefits outweigh the adverse effects. If you are certain that a specific drug has caused the problem, discuss the possibility of a medication change with your doctor. If you must remain on the specific medication causing the problem, the treatment options outlined above can still be used in most cases.
Can I combine treatment options?
This is often done but, because of the risk of prolonged erections with drug therapy, it should only be performed under physician supervision. Ask your doctor for proper instructions.
1. Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol. 1994 Jan;151(1):54-61.
2. National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes and Sexual and Urologic Problems. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/sexual-urologic-problems. Accessed May 3, 2017.
3. Malavige LS, Levy JC. Erectile dysfunction in diabetes mellitus. J Sex Med. 2009 May;6(5):1232-47.
4. Gandaglia G, Briganti A, Jackson G, et al. A systematic review of the association between erectile dysfunction and cardiovascular disease. Eur Urol. 2014 May;65(5):968-78.
5. Erectile dysfunction (ED). www.auanet.org/content/education-and-meetings/med-stu-curriculum/ed.pdf. American Urological Association Web site. Accessed January 21, 2013.
6. VIAGRA™ Prescribing Information. Pfizer Inc. Revised January 2010:8-9.
7. CIALIS™ Prescribing Information. Lilly USA, LLC. Revised 2011:18-20.
8. LEVITRA™ Prescribing Information. Bayer HealthCare Pharmaceuticals Inc. 2011:19-20.
9. Walsh TJ, Hotaling JM, Smith A, et al. Men with diabetes may require more aggressive treatment for erectile dysfunction. Int J Impot Res. 2014 May-June;26(3):112-5.