Erectile dysfunction

What is erectile dysfunction?

Erectile dysfunction (ED) is a common medical condition in which a person assigned male at birth (i.e. typically a man) has difficulty achieving or maintaining an erection strong enough for satisfactory sexual activity. Approximately 30 million men in the United States have erectile dysfunction.

ED is more than just not being in the mood or not having an erection. It can be a complex condition that can manifest in different ways, such as being unable to achieve an erection at all, losing an erection too quickly, or only being able to get an erection occasionally. What’s more, it can be influenced by a variety of factors, including physical health, emotional wellbeing, and relationship dynamics, making ED a multifaceted issue that requires a personalized approach when it comes to addressing symptoms (which can range in severity) and overall treatment.

Erectile dysfunction causes

Getting an erection requires a complex interplay between different systems in your body, including (but not limited to) your brain, nerves, and blood vessels. When you’re turned on, your brain sends arousal signals to the body through the spinal cord and nerves. Then, cGMP, a messenger (i.e. chemical), causes the smooth muscles in the penis to relax, allowing blood to rush in and fill the sponge-like tissues in the penis. Meanwhile, the veins that drain blood from the penis become smaller and prevent as much blood from leaving. This helps trap the blood, thereby resulting in an erection. To simplify the process, an erection ends when the phosphodiesterase type 5 (PDE5) enzyme breaks down cGMP, causing blood to flow back out of the penis.  

If there’s a problem with any part of the system, it can make it more difficult to get and ultimately keep an erection. The causes of ED can stem from a variety of physical, psychological, or lifestyle-related factors, each affecting how the body responds to sexual arousal. 

Physical causes of erection dysfunction

As mentioned above, a healthy erection is the product of some pretty impressive teamwork between your cardiovascular, nervous, and endocrine systems. So, issues getting or maintaining an erection can be related to medical conditions as well as other physical ailments that impair these systems. These include: 

• Heart disease

• High cholesterol

• High blood pressure (hypertension)

• Atherosclerosis (clogged arteries)

• Diabetes

• Obesity

• Metabolic syndrome

• Sleep disorders (e.g. sleep apnea) 

• Multiple sclerosis

• Parkinson's disease

• Trauma (e.g. pelvic fractures, spinal cord injuries)

• Hypogonadism (low testosterone levels) 

• Peyronie's disease

Medications that cause erectile dysfunction

While the point of medications is to yield a positive outcome (i.e. treatment of other conditions), they can also cause side effects. And depending on the drug, these side effects may include erectile dysfunction. In fact, prescription medications are thought to cause up to 1/4 of all cases of ED. But some over-the-counter (OTC) options can also be to blame. Here, medications that are often linked to this issue: 

• Antidepressants (particularly SSRIs, or selective serotonin reuptake inhibitors)

• Stimulants (including Adderall)

• High blood pressure medication (e.g. beta-blockers, some diuretics)

• Opioids

• Antihistamines (used to treat the symptoms of allergies or acid reflux)

• Antipsychotics

• Anti-epilepsy drugs

• Hair loss drugs (e.g. finasteride, brand name Propecia)

If you're experiencing ED and think it may be linked to a medication you’re taking, have an open and honest conversation with your healthcare provider. It’s important to never stop or change your medication without consulting your provider first, as doing so can be dangerous. There are many simple steps you can take with your provider to address ED due to your medication. A healthy sex life is an important part of overall health, and treating a medical condition doesn’t have to mean sacrificing satisfying sexual relationships. 

Psychological causes of erectile dysfunction

Many, if not most, people who experience erectile dysfunction have an underlying physical condition. But some men may deal with ED due to psychological causes—after all, sexual function is just as much about the mental as it is about the physical. Think of it this way: The more unsettled or overwhelmed your mental or emotional state, be it because of situational stress or a longer-term mental health issue, the harder it can be to get aroused, to perform, and to experience sexual satisfaction. Common psychological causes of ED include: 

• Depression

• Anxiety (including sexual performance anxiety)

• Low self-esteem 

• Stress

• Relationship issues 

• Shame 

While watching pornography isn’t inherently detrimental, there’s some evidence to suggest that excessive use of pornography can contribute to ED. Frequent exposure to porn may desensitize you to the real thing and create unrealistic expectations—both of which can result in sexual difficulty or dysfunction, though more research is needed.

Generally, erectile dysfunction can create strain on relationships as well as for the individual. And even when the underlying source of ED is another medical cause, emotional and mental health struggles may often follow in consequence. In fact, it’s normal to experience feelings of shame, embarrassment, low self-esteem, anxiety, or depression as a result of ED, though people’s individual responses may vary. It’s important to remember how common and treatable this condition is—and to be patient and kind to yourself in the meantime.

Lifestyle causes of erectile dysfunction

In some ways, lifestyle factors can be the simplest causes of ED—though not necessarily the easiest to change. If you know you’re not getting enough exercise, eating mostly processed foods, or abusing drugs or alcohol, the “fix” is pretty simple. Of course, making changes to your lifestyle is never easy, but it’s often worth the effort for your health and sexual function. 

• Lack of physical activity

• Obesity

• Poor diet 

• Alcohol abuse or overuse (e.g. whiskey dick)

• Smoking

• Drug use

Erectile dysfunction treatment

Since its accidental discovery in 1996, Viagra (sildenafil), famously known as the “little blue pill,” has probably become the most well-known treatment for erectile dysfunction. Despite its popularity, however, Viagra is just one of many treatment options for the condition. 

Erectile dysfunction medications

Phosphodiesterase type 5 inhibitors, or PDE5 inhibitors such as Viagra, are a class of medications proven to be safe and effective at treating ED. In fact, they’re commonly used as first-line treatment for the condition. 

PDE5 inhibitors work in part by widening the blood vessels in the penis, allowing for increased blood flow in order to make it easier to get an erection. More specifically, these drugs block the PDE5 enzyme, which prevents the breakdown of cGMP. This allows the blood vessels to become and stay more relaxed and dilated, allowing an increase in blood flow to the penis with sexual stimulation and encouraging harder, longer-lasting erections. But it’s not automatic—you need to be aroused for the oral medication to work.

These are the most common PDE5 inhibitors for ED—all of which require a prescription from a healthcare provider and are approved by the US Food and Drug Administration (FDA) to treat ED:

• Viagra (sildenafil)

• Cialis (tadalafil)

• Vardenafil (formerly available as brand name Levitra) 

• Stendra (avanafil)

Some PDE5 inhibitors can also be found in alternative formulations. Take, for example, Ro Sparks, a sublingual treatment that contains both sildenafil and tadalafil (the active ingredients in Viagra and Cialis, respectively) and dissolves under your tongue for fast-acting effects. Another pill-free option that can make taking ED meds more enjoyable? Ro’s Daily Rise Gummies, which are fruit-flavored, once-daily gummies with 7 mg of tadalafil in each gummy to deliver long-lasting benefits. 

For those who may not respond to PDE5 inhibitors or prefer alternative treatments, alprostadil can be another effective option for managing erectile dysfunction. The FDA-approved medication works as a vasodilator, helping to relax blood vessels in the penis to promote increased blood flow. Alprostadil is available as an injectable sold under brand names like Caverject and Edex. Other medications are commonly used for injections into the penis to induce an erection, such as phentolamine and papaverine, with or without alprostadil, such as Trimix. 

Whether it’s the little blue pill, a compounded formulation, or an injection, erectile dysfunction medications—just like any other medication—can come with the risk of side effects. It’s important to discuss your full medical history with your healthcare provider before starting any ED medication to ensure it's safe for you, especially if you have underlying conditions, such as heart disease or take certain medications (e.g. nitrates). If you experience side effects or the treatment isn’t working as expected, be sure to consult your healthcare provider to address any symptoms and explore alternative options.

Surgical options and medical devices

Although popular and frequently effective, ED medications aren’t necessarily a fit for all patients. Some people may be allergic to an ingredient in the drugs or ED medications may not be effective enough for them. There also may be side effects from the medications or a health condition that makes ED medications unsafe. In these cases, injections are often considered (if a patient is willing to do self-injections), or a healthcare provider might discuss using a device such as a vacuum constriction device (VCD, also known as a penis pump) or—in severe cases—a surgically placed penis implant.

• VCD or penis pump is used by placing a hollow tube over the flaccid penis and applying gentle vacuum pressure, which draws blood into the penis and causes it to become firm. Then you will place a snug band over the base of the penis to temporarily “trap” the firmness, enabling you to have sex. Men who experience ED as a result of prostate surgery or benign prostatic hypertrophy (BPH) may find this solution especially effective.

• Penile implant is surgically inserted into the penis, where it remains permanently. Two types are available: malleable (which can be externally manipulated into an erect position) and inflatable (which are inflated to firmness using a small pump in the scrotum). This approach is typically only after other less invasive measures haven't been helpful. 

Testosterone replacement therapy 

Your healthcare provider can help determine if your ED is related to low testosterone. In addition to erectile dysfunction, symptoms of low T include fatigue, low sex drive, loss of body hair and muscle mass, and weight gain. If this is the case, testosterone replacement therapy (TRT) can help by increasing your hormone levels via an injection, oral pills or nose sprays used several times a day, or a gel applied to the skin. Be careful to avoid taking testosterone unless your testosterone level is truly abnormal, as excessively high testosterone levels can have unwanted consequences for your health, such as increasing your risk of blood clots.

Lifestyle changes 

Improving your overall health is one of the best and lowest risk ways to immediately improve your sexual health. Making lifestyle changes such as getting regular exercise, eating a healthy diet, quitting smoking, sleeping better, and limiting your alcohol consumption might be enough to ameliorate ED. If not, there are medical approaches that can help resolve ED, too (remember, they will be most effective if started alongside lifestyle improvements).

• Exercising regularly. Getting a moderate amount of exercise is not only great for your overall health, but it can also do wonders for your sexual function and wellbeing. In fact, addressing ED by increasing physical activity can improve erectile function from so many perspectives, such as improving cardiac and endothelial function, increasing testosterone, decreasing depression, improving stamina, reducing anxiety, improving body image, and more. Some studies have shown that it has the strongest relationship between treatment and improvement of ED. Furthermore, boosting physical activity can have a synergistic effect on medication taken for ED, meaning it can amplify the drug and make it more effective.

• Eating a healthy, balanced diet. Following a nutritious eating pattern can reduce various risk factors for ED, including type 2 diabetes, high blood pressure, high cholesterol, and obesity. One of the best diets for heart and erection health is the Mediterranean diet, which emphasizes fruits and vegetables, fish and other lean proteins, whole grains, and olive oil. According to research published in the American Journal of Medicine, eating a Mediterranean diet might even help prevent ED from happening in the first place. 

• Losing weight. Obesity is closely associated with erection problems, so diet and exercise are especially helpful for losing weight, but using medications to lose weight can be very effective as well.

• Getting more sleep. Research shows that regularly sleeping less than 6 hours per night may increase the likelihood of developing erectile dysfunction. Lack of sleep is also linked to conditions such as obesity, high blood pressure, heart disease, and diabetes—all of which can restrict blood flow and elevate the risk of ED. To reduce this risk, try to get 7-9 hours of restful shut-eye nightly by enhancing your sleep routine and adjusting your bedtime.

Mental health care and treatments 

Taking care of your mental health is another crucial aspect of treating erectile dysfunction, as psychological factors such as stress, anxiety, and depression can significantly impact sexual performance. Addressing mental health through techniques, such as mindfulness, meditation, and deep breathing exercises, can help reduce anxiety and other mental health challenges, and ameliorate sexual function. 

If these strategies aren’t sufficient, or if you need additional support, consulting a mental health professional (e.g. therapist) can prove helpful. Such an expert can help identify underlying psychological factors that might be contributing to ED and provide tailored treatments, such as cognitive-behavioral therapy (CBT) or sex therapy, to address those issues. These therapies can help break the cycle of stress and performance anxiety, which often worsen erectile dysfunction. In some cases, couples counseling may also be beneficial to address relationship concerns that could be affecting sexual function. By working with a professional, you can gain new coping strategies and emotional support, improving both mental and sexual wellbeing.