Erectile dysfunction (ED): everything you want to know

Erectile dysfunction (ED), also known as impotence, can be frustrating, and the taboo around talking about sexual health can make it difficult to seek treatment. Most people experience occasional difficulty getting or maintaining an erection, but if it happens frequently, there are treatment options available that can help. ED can be taxing on your relationship and self-confidence, and can also be a sign of other, sometimes serious, underlying conditions. Your healthcare provider can help.

Simply put, erectile dysfunction is the inability to get or keep an erection long enough for satisfying sex. But ED comes in all shapes and sizes. For some people it’s sporadic, happening only occasionally. For others, it’s constant. It can appear at any age. Sometimes, there’s no known underlying cause at all, while in other cases, other health conditions or medications can contribute.

Getting an erection requires a complex interplay between different systems in your body, including your brain, your nerves, and your blood vessels. To get an erection, your brain needs to tell the blood vessels that carry blood into your penis to open up and let blood in. That blood fills sponge-like tissues in the penis, making your penis swell and get hard. If there’s a problem with any part of the system, it can make it more difficult to get an erection.

Erectile dysfunction can happen for a wide range of reasons, including certain medical conditions, medications, hormonal imbalances, and even stress. Some things that can contribute to erectile dysfunction include: 

• Diabetes

• Heart disease

• Smoking

• Depression

• Certain medications (like those used to treat high blood pressure and depression)

• Parkinson’s disease

• Atherosclerosis (blocked blood vessels)

• Smoking

• Anxiety

• Low testosterone

• Spinal cord injuries

• History of prostate cancer treatment

• Alcohol use

• Thyroid disease

• Kidney disease

• Obstructive sleep apnea (a condition where a person’s breathing patterns are disturbed while they sleep)

Erectile dysfunction and age

Overall, erectile dysfunction, and other sexual issues like decreased libido, tend to become more common with age. By age 40, about 40% of men experience reduced sexual function, and that number increases by about 10% every decade (Feldman, 1994). This may be because testosterone levels start declining around the age of 30, or due to the increase in blood vessel blockages and heart disease as we get older.

ED isn’t "just a part of getting older," though. Many people experience ED when they’re young, too. And regardless of age, ED can be treated.

ED at a young age

Even though ED is often associated with age, research shows that about a quarter of all people who experience it are actually under the age of 40. ED in younger men is often caused by (Capogrosso, 2013):

• Conditions like diabetes and obesity, which are prevalent in young people in the US. Obesity is associated with low testosterone levels, which may contribute to ED. Studies show that people with obesity and erectile dysfunction who lose weight see an improvement in their erectile function (Diaz-Arjonilla, 2009).

• Alcohol use, drug use, and smoking. Many people have found that with more than a few drinks in their system, they can have a difficult time getting an erection. But the problem can be more consistent among people who drink a lot regularly. Tobacco use is also associated with ED (Arackal, 2007).

• Mental health also plays a big role in our ability to get an erection. A huge component of your ability to get an erection is related to how you’re feeling. For example, anxiety and depression can activate a set of processes in our bodies that are meant to help us when we’re facing a threat. That fight-or-flight response can then interfere with your ability to get or maintain an erection. 

It’s also common to stress about sex, particularly if you’re with a new partner. Many people worry that they won’t be able to get an erection or that they’ll ejaculate too quickly. They can be concerned about whether their partner or partners are enjoying themselves. Other people find that it can be difficult to maintain an erection when they use a condom. All that stress can make it harder to get and stay hard.

COVID and erectile dysfunction

Since the pandemic began, we learn more and more every day about the coronavirus, the symptoms of COVID-19, and what sort of long-lasting effects the disease can have. There has even been some research into whether the coronavirus might contribute to erectile dysfunction.  

Overall, there are a lot of theories about how the virus might cause ED, but not enough evidence to say that it does for certain. One very small study showed that erectile dysfunction was significantly more common among people who had COVID than those that didn’t, and it developed after their infection. Some theorize that the same damage to the delicate cells that line our blood vessels that increases the chance of blood clots and other problems in people with severe COVID might also affect the blood vessels in the penis, making it more difficult to achieve an erection (Sansone, 2021).

Can porn cause erectile dysfunction?

While watching pornography isn’t inherently detrimental and can actually be a good thing for some people, there’s a lot of evidence that excessive use of pornography can contribute to ED by desensitizing a person to the real thing (Dwulit, 2019). There’s also evidence that increased porn consumption can create an aversion to sex, a condition known as sexual anorexia. This may, in turn, cause erectile dysfunction (Park, 2016). 

Luckily, with rising levels of awareness around this condition, more and more treatment options are available. Taking a break from pornography can help, as can speaking with a mental healthcare provider.

Diabetes and erectile dysfunction

There’s no doubt that diabetes can contribute to the development of erectile dysfunction. While about 20% of men in the general population experiences ED, the numbers soar to around 50% among people with diabetes (Kouidrat, 2017).

Diabetes is a condition where your cells can’t use the sugar in your bloodstream for energy the way they should be able to. Because that sugar stays in your blood where it’s not supposed to be, it can cause damage to the sensitive nerves and blood vessels in your body, causing a wide range of problems including kidney damage and non-healing wounds.

That damage can extend to the machinery responsible for initiating and maintaining an erection, and when that damage to the blood vessels and nerves in the penis occurs, it can be permanent.

Since its accidental discovery in 1996, Viagra (generic name sildenafil), famously known as the “little blue pill,” has probably become the most well-known treatment for erectile dysfunction. But there are other treatments available too, and we’ve covered everything you need to know to learn which treatment might be right for you. 

Erectile dysfunction drugs

The drugs currently available for the treatment of erectile dysfunction are all PDE5 inhibitors. These drugs work by widening the blood vessels in the penis, allowing for increased blood flow in order to make it easier to get an erection. But it’s not automatic, you need to be aroused for the pills to work. 

These are the pills that are prescribed for the treatment of ED: 

• Sildenafil (brand name Viagra)

• Vardenafil (brand names Levitra and Staxyn)

• Tadalafil (Cialis)

• Avanafil (Stendra)

Which erectile dysfunction drug is best?

That really depends on your situation and needs. 

While Viagra is a good choice for some people, some people find it difficult to plan around their sex lives and prefer the option for more spontaneity. In these cases, daily tadalafil might be a good option. Also, daily tadalafil has been found to be a good option for people who have complete ED (which is when a person never gets an erection satisfying enough for sex) (Shabsigh, 2013). 

Another benefit of tadalafil is that it can help treat some of the symptoms of benign prostatic hyperplasia (like difficulty urinating or incontinence), so for people with both BPH and ED, tadalafil might be a good choice. 

If you have sex between one and three times per week, taking medication on an as-needed basis is probably a good idea. Spontaneity is still an option, especially if you pick a pill that works quickly, like Avanafil. 

And no matter which medication you start with, if you try it on multiple occasions and find that it’s not working for you, or that the side effects are intolerable, speak with your healthcare provider about adjusting your dose or trying a different medication. 

Erectile dysfunction drugs over-the-counter

In 2017, sildenafil became available over-the-counter in the UK—not so in the US. These medications still require a prescription from a healthcare provider. 

You may have noticed other pills, typically available online or in gas stations, claiming to be over-the-counter Viagra, but your best bet is to steer clear of these. That’s because Viagra is one of the most counterfeited drugs in the world. In 2011, Pfizer, the manufacturer of Viagra, tested the contents of some of these fake pills and found them to contain everything from blue printer ink, drywall, antibiotics, and amphetamines (“speed”). Many of them contained sildenafil as well, but in dangerously high doses (Jones, 2019). 

Luckily, getting a legitimate prescription from a healthcare professional who can assess if the treatment is right for you is easier than ever. Viagra is available both in-person and online from a range of licensed providers.

Erectile dysfunction pump

In addition to medications, there are other treatment options available for ED. Since erections require that blood enter the penis and stay there, using a manual or battery-operated pump can help bring blood into the penis, giving you a harder erection. Research around their effectiveness became less popular once ED medication became the standard treatment, but scientists found these ED pumps effective (Witherington, 1989). Other claims that these devices permanently increase the size of your penis haven’t been backed up though.

Shockwave therapy for erectile dysfunction

Another popular alternative to ED medications is acoustic (shockwave) therapy for ED. This treatment uses low-intensity sound waves to improve blood flow in the penis. Whether or not it works is still up for debate, though. While some small trials have shown that the treatment can make it easier to get an erection, blinded studies (where participants didn’t know if they were getting the real treatment or placebo) haven’t backed that up.

Treating underlying causes of ED

If you are experiencing ED as a result of an underlying medical condition, treating that medical condition can sometimes make it easier to get and keep an erection. For example, if you have diabetes, obesity, or Peyronie’s disease, treatment can improve ED as well. 

If your ED is caused by a medication you’re taking, sometimes there are alternative treatment options for your condition that don’t cause ED. It’s important that you consult with a healthcare provider and that you don’t stop taking your medication without professional guidance as stopping certain medications abruptly can be detrimental to your health. 

Medications that can contribute to ED include: 

• Blood pressure medications (e.g., beta blockers, thiazide diuretics)

• Antidepressants (e.g., selective serotonin reuptake inhibitors, or SSRIs)

• Antihistamines

• Opioids

• Some drugs for acid reflux

• Cancer treatment (e.g., chemotherapy, radiation)

• Parkinson’s disease medications

Some people prefer to try natural remedies for their ED like herbs and supplements. Some of these have more research backing them than others. Stay away from products claiming to be "over-the-counter Viagra" or the like.

CBD oil for erectile dysfunction

CBD, a non-psychogenic component of the cannabis plant, won’t get you high, but there’s also no evidence that CBD can treat erectile dysfunction. There is evidence, however, that CBD may be helpful for anxiety, and for some people, anxiety can be a significant contributor to ED. 

While CBD may help your anxiety, smoking marijuana probably isn’t the answer to your erectile woes. In fact, there is quite a bit of research that regular cannabis use can contribute to ED (du Plessis, 2015). 

Supplements for ED

There’s a wide range of vitamins and supplements that people claim can help with ED, but do any of these claims hold any water? Horny goat weed, yohimbe (yohimbine), and Korean red ginseng all have some promising studies, but none of them have the kind of rigorous clinical trials needed for scientists to recommend these at this point. More research is needed on these and other so-called ED supplements. 

Depending on the underlying cause, regular physical exercise may help ED. Since ED can be the first symptom many people experience of conditions like heart disease, diabetes, and high blood pressure, treating these conditions can often improve your ED symptoms at the same time. Exercise is one primary factor in treating these conditions. 

Pelvic floor exercises (like Kegels) and cardio (like running or swimming) have been shown to improve symptoms of erectile dysfunction. 

Kegel exercises may be most well-known for their role in improving pelvic floor strength in women who are pregnant or who recently had a baby. But it turns out that practicing pelvic floor exercises can help with erectile dysfunction too. Research shows that men who did Kegels regularly over the course of six months saw greater improvement in symptoms than those who did not. In fact, 40% of men who did pelvic floor muscle exercises regularly regained normal erectile function, and an additional 36% saw an overall improvement in their erections (Dorey, 2005).

And it’s not just Kegels that help. Research has shown that regular cardio (think: swimming, jogging, biking) can also help improve blood flow and improve the symptoms of ED for some people. They saw that moderate to intense exercise improved overall erectile function.

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Current version

March 25, 2022

Written by

Health Guide Team

Fact checked by

Yael Cooperman, MD

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About the medical reviewer

Yael Cooperman, MD, Ro

Yael Cooperman is a physician and works as a Senior Manager, Medical Content & Education at Ro.