Position-dependent erectile dysfunction: causes and treatments

Is your erection strong in some positions but weaker in others? You may be dealing with position-dependent erectile dysfunction (PDED). This type of ED can be frustrating and confusing but it’s surprisingly common. 

And there’s some good news: PDED is very treatable, and understanding why it happens is the most important first step. Here, we’ll break down exactly what’s going on, how to prevent symptoms, and how to treat position-dependent erectile dysfunction. 

Position-dependent erectile dysfunction is a form of ED where a man can get or keep an erection in some positions but not others, according to Justin Houman, MD, a urologist at Cedars-Sinai Medical Center.

Most often, erections stay firm while standing or sitting but weaken when lying on the back or during certain sexual positions. The key feature is the pattern: Erections change predictably with body position.

This typically happens because erections depend on blood flowing into the penis and staying there. When your position shifts, so do pelvic muscles, nerves, and blood vessels, Dr. Houman says. 

If any of those changes affect how blood enters or drains from the penis, rigidity can drop and may not be enough for sexual intercourse.

One common contributor is venous leakage, a condition where the veins in the penis don’t compress tightly enough during an erection, allowing blood to escape too quickly. When that drainage becomes even easier in certain positions, position-dependent ED can show up.

According to Dr. Houman, other potential causes of PDED include:

• Pelvic floor muscle tension. Tight muscles can compress blood vessels or nerves in certain positions.

• Pudendal nerve compression. Pressure on this nerve can alter sensation and erectile response. (FYI, the pundendal nerve provides sensation to the genitals and helps control pelvic floor muscles.)

• Structural or anatomical variations. Small differences in pelvic or penile anatomy can affect blood flow depending on posture.

• Vascular conditions. Issues affecting arteries or veins — like diabetes or cardiovascular disease — can worsen position-specific symptoms.

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What is venous leakage and what causes it?

Venous leakage is a circulation issue where the veins in the penis aren’t compressed effectively enough during an erection. Venous leakage can happen for several reasons, including:

• Vascular changes. Conditions like diabetes, high blood pressure, or cholesterol buildup can weaken the veins and make it harder for them to “hold in” blood during an erection.

• Age-related tissue changes. As tissues naturally lose elasticity over time, the structures that compress penile veins may not work as well as they used to.

• Pelvic or penile injury. Trauma from sports, accidents, or long periods of pressure (such as frequent long-distance cycling) can disrupt the veins or surrounding support tissues.

• Nerve issues. Irritation or injury to the pudendal nerve can affect the signals that help maintain rigidity.

• Hormone shifts. Low testosterone doesn’t directly cause venous leak, but can reduce overall erectile firmness and make existing leakage feel more pronounced.

Venous leakage contributes to ED by allowing blood to escape the penis faster than it can be trapped, making it difficult to achieve or maintain a firm erection. 

“An erection depends on two things: adequate blood inflow and the penis’s ability to trap that blood,” Dr. Houman says. “Venous leakage occurs when the veins in the penis fail to seal properly, allowing blood to drain out too quickly.”

In men with venous leak, erections often start normally but fade quickly — sometimes within seconds of reduced stimulation or a shift in position, Dr. Houman says. 

This problem can become even more noticeable when body posture changes. Certain positions reduce support around the veins or increase pelvic pressure, making it even easier for blood to drain. 

Diagnosing position-dependent ED starts with confirming whether your erections consistently change based on body position.

Typically, a healthcare provider will first ask when your erections feel strongest, when they weaken, and whether certain sexual positions reliably trigger the problem, Dr. Houman says.

Other common signs of position-dependent ED that your provider will look out for include:

• Erections that are firm when standing or sitting but soften when lying on your back

• Losing rigidity almost immediately after changing positions

• Certain sex positions consistently causing weaker erections

• A shaft that feels firm but a glans (head) that feels softer

• Erections improving again when you return to a different position

• Strong morning or nighttime erections despite position-related difficulties

From there, diagnosis typically involves a combination of medical history, physical exam, and tests that help pinpoint how blood flows in and out of the penis. These can include:

• Penile Doppler ultrasound. This is a quick in-office test that shows how well blood flows in and how quickly it drains out — especially helpful for spotting venous leakage.

• At-home position tracking. Paying attention to erection firmness in different positions can reveal patterns that diagnose PDED.

• Nocturnal erection testing (RigiScan). If overnight erections are strong, but position-related ones are not, that can point to a mechanical or venous (vascular) issue rather than a hormonal cause.

• Pelvic and nerve exam. Checks for tight pelvic floor muscles or pudendal nerve irritation, both of which can contribute to position-specific erectile symptoms.

Putting these pieces together helps identify whether venous leakage, pelvic floor issues, nerve compression, or something else is driving your PDED. That way your healthcare provider can tailor your treatment to address the root cause.

Position-dependent ED can be treated with medication, physical therapy, devices, and, in more severe cases, even surgery. In many men, a combination approach works best. 

Below are the most effective, evidence-supported options. 

Prescription ED medications 

Medications like sildenafil (Viagra) and tadalafil (Cialis) are known as PDE-5 inhibitors. These drugs increase blood flow into the penis, making it easier to achieve and maintain an erection. 

They’re often the first-line option for ED and can help men with mild position-dependent symptoms, particularly if pelvic tension or nerve sensitivity is involved. However, Dr. Houman says they’re often less effective for true venous leakage because they don’t fix the drainage problem itself — they simply increase inflow. 

Still, they can be worth a try. Speak to your healthcare provider to find out if these ED medications might be appropriate for you. 

Pelvic floor physical therapy

If pelvic floor muscles are tight or not moving properly, they can affect blood flow or put pressure on nerves involved in erections. A pelvic floor physical therapist can teach you relaxation and strengthening techniques tailored to the specific dysfunction, Dr. Houman says. 

Low-intensity shockwave therapy (Li-SWT)

Shockwave therapy uses low-energy acoustic waves to boost the formation of blood vessels and improve blood flow. 

For men with mild venous leakage or reduced vascular function, this treatment may enhance penile blood flow and improve your ability to stay hard in different positions. It’s noninvasive and doesn’t require medication, though multiple sessions are usually required.

While some of the studies on this method were done in men with a history of prostate cancer, it’s worth a try even if you don’t have prostate cancer to see if this method makes a difference for you.

Penile injections

Penile injections deliver medication directly into the erectile tissue, creating a firm, reliable erection regardless of blood-trapping issues. Because they bypass the venous system entirely, injections can be one of the most effective treatments for moderate to severe venous leak. 

Injections can be a good option for people who can’t take ED medications like Cialis or Viagra. That said, they do require learning proper technique and aren’t for everyone. So, talking with a healthcare provider is important before deciding on this type of therapy.

Penile implant surgery

For severe cases — especially when venous leak is the primary cause and other treatments haven’t worked — penile implants may be worth considering. They can offer a permanent, highly reliable solution, Dr. Houman says. 

An implant allows full control over erection firmness and eliminates the role of blood trapping entirely. That said, penile implants require surgery and come with risks such as infection, device malfunction, and the possibility of revision procedures. So, they’re typically reserved for cases where less invasive treatments haven’t been effective.

Preventing position-dependent ED often starts with something simple: If a particular position reliably causes firmness to drop, try avoiding that position or adjusting angles to see if rigidity improves, Dr. Houman says. 

Minor changes to how you sit, lie down, or position your pelvis during sex can also make a noticeable difference.

But if venous leakage, pelvic floor tension, or nerve compression is contributing to PDED, you may need broader strategies. These options support healthy blood flow to the penis and help reduce pressure on the structures involved in erections. 

Here are some of the most effective tactics for addressing erectile dysfunction:

• Support cardiovascular health. Regular exercise, managing blood pressure, and keeping cholesterol and blood sugar in a healthy range can all help protect the blood vessels involved in erections.

• Maintain a balanced pelvic floor. Stretching, diaphragmatic breathing, and avoiding excessive straining can prevent overactive pelvic muscles from interfering with blood flow.

• Limit activities that stress the pudendal nerve (i.e. the main nerve for genital sensation). If you cycle often, Dr. Houman recommends considering a cutout saddle, padded shorts, or shorter rides to reduce nerve pressure.

• Reduce alcohol and quit smoking. Both can impair blood flow and make existing venous issues more noticeable. Stopping these habits can make a big difference in your erectile (and overall) health. 

• Maintain a healthy weight. Excess body fat can affect vascular function and hormone levels. Losing weight can help (and in some cases, may be assisted by medications likeWegovy or Zepbound when medically appropriate).

• Stay within healthy testosterone ranges. Low testosterone doesn’t directly cause venous leak, according to Dr. Houman. But treating low T can improve overall erectile strength and resilience across positions. If you think low testosterone might be an issue, talk to your healthcare provider about exploring further testing.

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Position-dependent erectile dysfunction can feel confusing, but it’s often highly treatable once you understand what’s behind it. Lifestyle changes, medical treatments, and position adjustments can all make a meaningful difference. Here’s what to keep in mind: 

• Position-dependent ED is when your erections change consistently based on specific body positions.

• Venous leakage is a common potential contributor of position-dependent erectile dysfunction, especially if rigidity fades soon after changing positions.

• Other contributors may include pelvic floor muscle tension, pudendal nerve issues, vascular conditions, and anatomical variations.

• Diagnosis typically involves a medical evaluation that can include imaging, specialized testing, pelvic evaluation, and a detailed discussion of how your erection firmness varies by position.  

• Effective treatment options for PDED can include PDE5 inhibitors (e.g. Viagra, Cialis), pelvic floor physical therapy, shockwave therapy, injections, penile implants, and more depending on your discussion with the healthcare provider.

• Prevention of position-dependent ED may focus on supporting heart health, balancing the pelvic floor, reducing nerve pressure, maintaining a healthy weight, and choosing sex positions that optimize your blood flow.