Erectile dysfunction

Many people AMAB occasionally have difficulty achieving or maintaining an erection. This is a common issue that isn’t necessarily a cause for concern. If the situation continues, however, it may be time to speak with a healthcare provider (HCP) about erectile dysfunction. ED is defined as a persistent inability to get or keep an erection that is firm enough to have sexual intercourse.

Understanding the anatomy of the penis

An erection occurs when blood rushes to the penis, causing it to become hard. This means it grows in length and stands away from the body. Erections are typically responses to excitement or sexual arousal, but they can also occur spontaneously. Understanding the anatomy of the penis can be helpful in making sense of ED.

The penis is the male organ that performs sexual intercourse and urination. It’s made up of several structures:

• Corpora cavernosa: This soft tissue consists of two long chambers that contain a sponge-like bundle of blood vessels. The spaces between these blood vessels are filled with blood during an erection.  
• Urethra: The urethra is the tube that travels underneath the corpora cavernosa and transports semen (male reproductive fluid) and urine to end of the penis where it leaves the body.  
• Shaft: This is the long body of the penis that houses the corpora cavernosa, urethra, nerves, veins, and two main arteries.
• Glans: The head of the penis, located at the end of the shaft, is called the glans.  
• Meatus: This is the small opening at the head of the penis where semen and urine exit.  

In response to mental, visual, or physical stimulation, the brain transmits nerve signals through the body that reach the penis. These messages instruct the muscles of the corpora cavernosa to relax, which allows blood to quickly fill up the spaces in its sponge-like structure. Blood is then temporarily trapped in the corpora cavernosa thanks in part to a surrounding membrane called the tunica albuginea, which help keeps the penis firm. An increase in pressure from blood-filled veins in the penis also helps maintain the erection.

Muscles in the penis contract toward the end of the erection, which pauses the flow of blood to the organ and decreases pressure in veins. This allows the penis to return to a flaccid (soft) state.

Several factors that disrupt the processes involved in achieving and keeping an erection can lead to ED. While it was once believed that ED was strictly a psychological problem, healthcare providers (HCPs) now know that many people with the condition experience physical issues that impact sexual health.   

Back to top

Erectile dysfunction can generally be categorized as primary or secondary.

Primary erectile dysfunction

If someone has never been able to consistently achieve or maintain an erection, the condition is referred to as primary ED. This type of ED is uncommon and usually related to structural problems in the penis or long-standing psychological issues, such as fear of intimacy (genophobia) or depression.

Secondary erectile dysfunction

Secondary ED is the result of another problem in a person who was previously able to achieve and maintain erections. It is the most common type of ED. Many cases of secondary ED are linked to problems with blood flow to the penis or nerve function. Taking certain medications can also contribute to secondary ED, as can psychological issues like performance anxiety (nervousness before or during sex), stress, or depression.

Back to top

Signs and symptoms of erectile dysfunction can include:   

• Frequent difficulty achieving an erection
• Frequent difficulty maintaining an erection
• Low sex drive (libido)  

Some people with ED may be completely unable to achieve an erection. For others, frequent stimulation may be necessary to keep an erection sufficient for sexual intercourse.

Back to top

Several processes are at play during an erection. For instance, in order to achieve and keep an erection, a person AMAB must have:

• Healthy nerve function and blood flow to and from their penis  
• An adequate sex drive
• Sufficient levels of testosterone (the primary male sex hormone)

Anything that affects one or more of these factors can lead to erectile dysfunction. This includes certain medical conditions, medications, psychological issues, and unhealthy habits like illegal drug use. Poor blood supply to the penis is the primary cause of ED in many cases. For some people, a combination of physical and psychological issues leads to ED.

Medical causes of ED

A wide range of medical conditions can cause or contribute to erectile dysfunction.

Blood vessel disorders

Blood vessel disorders that affect blood flow to the penis or disrupt valves are among the most common causes of ED. (Valves are the parts of blood vessels that help keep blood in the penis during an erection.)

One notable blood vessel disorder is atherosclerosis, a type of cardiovascular disease that occurs when plaque buildup in arteries gradually causes them to harden. This can affect arteries in the lower body and hinder blood flow to the penis, causing ED. In fact, ED is an early indicator of cardiovascular disease in as many as 30 percent of people AMAB who see an HCP about their symptoms.

Certain conditions can contribute to atherosclerosis and subsequently to ED, including:

• High blood pressure (also known as hypertension)
• High cholesterol, known as hyperlipidemia. (Around 42 percent of people with ED also have high cholesterol.)
• Diabetes

Other blood vessel disorders that may cause ED are veno-occlusive dysfunction and endothelial dysfunction. Veno-occlusive dysfunction occurs when blood exits veins in the penis too quickly and interferes with the ability to achieve or keep an erection. Endothelial dysfunction is a disease that makes it difficult for vessels to widen and increase blood flow to the penis.

Nerve disorders  

The brain sends messages to the penis via nerves to initiate an erection. If these nerves are damaged or function improperly, ED can result.

Several issues can affect nerves that serve the penis and lead to ED, including:  

• Diabetes and diabetic neuropathy
• Spinal cord injury
• Stroke
• Multiple sclerosis
• Epilepsy

Another common nerve-related cause of ED is injury from prostate surgery. Nerves that supply the penis run along the prostate, which is a small gland that sits just below the bladder. Prostate surgeries (such as those performed to treat prostate cancer or an enlarged prostate) can sometimes damage these nerves and cause ED.

Other medical conditions

A variety of other medical conditions may disrupt a person’s ability to get or keep an erection. These include:

• Chronic kidney disease   
• Structural disorders of the penis, such as Peyronie’s disease (a buildup of scar tissue in the penis)
• Penile fractures
• Injuries that affect the bladder, prostate, or pelvic bones
• Injuries caused by bladder, colon, or rectal surgery 
• Hormonal conditions (such as hypogonadism) that reduce testosterone levels  
• Priapism (painful, prolonged erections that can damage erectile tissue over time)  
• Sleep apnea  
• Liver disease

Medication-related causes of ED

Prescription medications are believed to cause around 25 percent of erectile dysfunction cases. Many prescription and over-the-counter (OTC) medications list ED as a potential side effect. These drugs include, but are not limited to:  

• Antidepressants such as amitriptyline, diazepam, fluoxetine, and sertraline
• Antihistamines such as dimenhydrinate, diphenhydramine, and ranitidine
• Antiarrhythmics such as amiodarone and disopyramide
• Blood pressure medications such as thiazide diuretics and beta blockers 
• Parkinson’s disease medications such as benztropine, levodopa, and trihexyphenidyl
• Chemotherapy drugs such as cyclophosphamide, luteinizing hormone-releasing hormone (LHRH) agonists, and LHRH antagonists
• Opiate analgesic painkillers such as codeine, methadone, and morphine 

Various other medications may also cause or contribute to ED. These include antiseizure drugs, sedatives, muscle relaxers, and cholesterol-lowering drugs. If you’re concerned that a medication you’re taking is affecting your sexual health, speak with your HCP. They may adjust your dosage, recommend a different drug or treatment option, or suggest ways to help counteract the side effects of these drugs. (Remember, always check with your HCP before stopping a medication or adjusting how much you take.)

Psychological causes of ED

Emotions and mental health problems can play a central role in the development of erectile dysfunction or make the problem worse. In fact, some experts believe that as many as 20 percent of ED cases are related to psychological factors such as:

• Stress  
• Poor self-esteem
• Anxiety
• Guilt
• Fear of intimacy
• Fear of sexual failure  
• Depression

People AMAB with depression are more than 40 percent more likely to develop ED than people AMAB without depression, according to a 2018 study published in The Journal of Sexual Medicine.

Routine problems like illness, fatigue, and relationship issues can also interfere with sexual performance. ED may be situational for some people, meaning it occurs with a certain partner or at a specific place or time.

Other causes of ED

Several other factors may contribute to erectile dysfunction, including:

• Radiation therapy given for cancer or another medical issue
• Drugs like cocaine, heroin, marijuana, barbiturates, and amphetamines  
• Cigarette smoking
• Persistent pressure around the buttocks and genital areas, which may occur during long bicycle rides 
• Heavy alcohol consumption  

The Centers for Disease Control and Prevention (CDC) advises people AMAB to consume no more than two alcoholic drinks per day. A “drink” is defined as:

• 1.5 ounces of distilled spirits, such as whiskey, vodka, gin, tequila, and rum
• 5 ounces of wine
• 8 ounces of malt liquor beverages, such as hard seltzers
• 12 ounces of beer  

People assigned female at birth (AFAB) should limit their alcohol consumption to one drink per day, according to the CDC.

Back to top

Erectile dysfunction is a common issue that can affect any person AMAB. That said, certain factors may make you more likely to experience this condition than others. Some prevalent risk factors for ED include:

• Being 40 or older
• Smoking cigarettes  
• Being overweight or obese
• Living a sedentary lifestyle   
• Receiving radiation therapy or prostate surgery
• Drinking alcohol in excess
• Using illegal drugs 
• Experiencing acute or chronic (long-term) stress, depression, or anxiety  
• Taking certain medications, such as antihistamines, antidepressants, or drugs used to treat high blood pressure  
• Having certain medical conditions, such as diabetes, high blood pressure, or prostate problems 

Back to top

Erectile dysfunction itself isn’t a life-threatening issue, but it can have a negative effect on self-esteem and relationships. It’s worth speaking with an HCP if you’re experiencing signs of ED or other issues related to sexual performance. Because ED is so common, many HCPs have experience evaluating and treating the condition.  

ED is sometimes caused by an underlying health issue such as diabetes or atherosclerosis, so having trouble getting or keeping an erection could be a sign that something is wrong with your overall health. If symptoms of ED persist, be sure to visit your HCP. It’s especially important to seek medical care if your ED symptoms include: 

• Intense cramping in leg muscles that worsens during physical activity but improves with rest
• Numbness around the buttocks or genital area. This is a possible sign of spinal cord damage—seek medical care right away.
• Complete absence of erections overnight or when waking up in the morning  

Call 911 or go to the nearest emergency department (ED) if you develop signs of priapism—a very painful erection that lasts longer than four hours.

If your HCP thinks you could benefit from consulting with a medical specialist, they may refer you to a urologist or an endocrinologist. A urologist is a medical doctor who focuses on issues of the kidneys, bladder, and male reproductive organs. An endocrinologist is a medical doctor who specializes in issues related to hormones.

Many people also find it helpful to speak with a licensed mental https://www.sharecare.com/mental-health-behavior/how-to-find-right-therapisthealth provider, such as a psychologist, if their ED is related to psychological factors.

What questions should you ask your healthcare provider?

You may not be eager to discuss certain bodily functions with your HCP, but it’s important to be candid about your sexual health concerns and voice any questions you might have. If you suspect you have erectile dysfunction or have recently been diagnosed, keeping a running list of questions to ask your HCP can help you learn more about your condition and make confident decisions about your health.

A few basic questions to get you started include:

• What do you think caused my ED? Are there any other possible causes?
• Can my ED be treated? Is it acute (short-term) or chronic?
• What are my ED treatment options? Can you explain the risks and benefits of each?  
• What alternative treatment options can I try in addition to medical treatment? 
• What activities or habits should I avoid? Do I need to follow any dietary or activity restrictions?
• What’s the best way to manage ED with my other health conditions? 
• Are there generic alternatives to ED medications? 
• Should I see an ED specialist?
• Would I benefit from speaking with a licensed mental health provider?

Back to top

If your HCP believes you have erectile dysfunction, they’ll likely start by:

• Evaluating your overall health  
• Screening you for depression
• Assessing your testosterone levels

Your HCP will ask you questions about your medical history, such as any injuries, conditions, or medical procedures you’ve had. You’ll also be asked about any current health concerns you’re experiencing and what (if any) medications or supplements you’re taking. They may then perform a physical exam to examine your penis and testicles, check nerve function around the genital area, and look for signs of hormonal and blood vessel disorders.

Your HCP may also ask questions about your sexual health, sex drive, and satisfaction with your sexual relationships. Sexual topics may feel uncomfortable to discuss, but this information is important in determining what’s causing your symptoms and what ED treatments may be best for your needs.

Because depression sometimes plays a role in ED, you can expect your HCP to ask about your emotions, thoughts, and any difficult situations you’re facing. You may be experiencing depression if you consistently feel:

• Sad, hopeless, or empty
• Anxious or restless
• Irritable or frustrated
• Fatigued
• Guilty or ashamed  
• Worthless

Other signs of depression include trouble sleeping or sleeping too much, difficulty focusing or remembering things, changes in appetite, and thoughts of self-harm or suicide. If you or someone you know needs immediate assistance for depression, contact the 988 Suicide and Crisis Lifeline by calling or texting 988. The service is free, confidential, and available 24/7 in the United States.

Tests for erectile dysfunction  

Your HCP might recommend a series of tests to determine what’s at the root of your erectile dysfunction and to rule out any urgent medical issues. These tests may include the following:

• Blood tests may be used to check testosterone and cholesterol levels and to screen for evidence of underlying conditions, such as diabetes and cardiovascular disease.
• Urine tests can screen for signs of kidney disease, diabetes, and other conditions that may cause or contribute to ED.
• Ultrasound imaging can evaluate how blood flows in the veins and arteries that serve the penis. During this imaging test, an HCP may inject the penis with a drug that triggers an erection, then use a device called a transducer to create images using sound waves of blood vessels in the penis.

Back to top

If your erectile dysfunction is caused by an underlying medical condition, ED treatment usually focuses on addressing that condition. ED related to medication side effects may be treated by adjusting the dosage or type of medication you’re taking. If ED persists despite these measures, other treatments may be used to help improve sexual function.

Depending on what’s causing your ED, your treatment plan may include a combination of:

Medication

Medication is an effective treatment option for many people with erectile dysfunction. There are a few types of medication you may be prescribed if you have ED:  

Oral phosphodiesterase inhibitors

Oral phosphodiesterase inhibitors like avanafil, tadalafil, vardenafil, and sildenafil help people achieve and sustain erections by maximizing the effects of nitric oxide. Nitric oxide is a naturally occurring chemical in the body that boosts blood flow to the penis by relaxing muscles.

Oral phosphodiesterase inhibitors aren’t aphrodisiacs (substances that increase sexual desire) and they don’t instantly trigger erections. Instead, they work by enhancing the effectiveness of nitric oxide, which is released by nerves in the penis in response to sexual stimulation. This stimulation is still necessary for oral phosphodiesterase inhibitors to be effective.  

Some oral phosphodiesterase inhibitors (vardenafil and sildenafil) should be taken on an empty stomach no sooner than one hour before sexual intercourse. Depending on the dosage, avanafil can be taken 15 to 30 minutes before sexual intercourse, while tadalafil may be taken once daily or as needed (usually around 30 minutes before sexual intercourse).

Oral phosphodiesterase inhibitors may not be appropriate for people who have low blood pressure or heart disease or those who take nitrate drugs for conditions such as chest pain. Common side effects of these medications include temporary changes in vision, reduced blood pressure, headache, and facial skin reddening or discoloration. Rarely, priapism (an abnormal, prolonged erection) may occur.

Alprostadil

When taken around 10 minutes before sexual intercourse, alprostadil can help some people achieve and maintain an erection for up to one hour. Alprostadil can be given as an injection into the side of the penis or as a small suppository pill that’s inserted into the urethra through the opening (meatus) at the end of the penis. This drug is sometimes combined with other medications (such as papaverine, phentolamine, or phosphodiesterase inhibitors) to achieve desired results.

If your HCP recommends you try the injection form of alprostadil, they’ll show you how to administer the shot in their office so you can do it yourself at home. The needle used to inject alprostadil is very thin and typically only causes mild discomfort, if any.

The suppository form of alprostadil is administered into the urethra using a small applicator that resembles a straw. Your HCP can teach you how to administer this medication at home. 

Possible side effects of alprostadil include priapism, mild bleeding in the urethra, penile pain or burning, and growth of fibrous tissue in the penis.  

Testosterone replacement therapy 

Your HCP may recommend testosterone replacement therapy if your ED is related to low testosterone levels. Supplemental testosterone may be given as a cream, gel, skin patch, or under-the-skin implant. If your testosterone levels are severely low, your HCP may suggest twice-monthly testosterone injections.

Psychological treatment

Erectile dysfunction has a psychological component for many people. Issues like depression, anxiety, stress, and relationship difficulties can be a direct cause of ED or make symptoms worse.

Consider speaking with a mental health provider if you believe psychological issues are impacting your sex life. You might consult with a counselor, psychologist, or sex therapist, which is a licensed mental health provider with specialized training in sexual issues. Your HCP can refer you to a provider if you’re unsure where to turn.

ED can cause emotional strain or tension for both people in a relationship. Depending on your situation, it may be a good idea for you and your partner to attend counseling together. A mental health provider can help you improve communication skills, reduce performance anxiety, and work through relationship issues that may contribute to or result from ED.

Lifestyle changes

Relatively small lifestyle changes can make a big difference for many people with erectile dysfunction. For example, you may be able to improve sexual function and boost your overall health by:

• Quitting smoking  
• Drinking less alcohol
• Losing excess weight
• Exercising regularly

A 2018 review of studies published in Sexual Medicine found that doing 40 minutes of moderate- to vigorous-intensity aerobic exercise four times per week for six months can decrease erectile problems in people AMAB. Positive results were shown in people whose ED was caused by obesity, high blood pressure, physical inactivity, metabolic syndrome (a precursor for diabetes), and/or heart disease.

Examples of moderate aerobic exercises include brisk walking, mowing the lawn, and swimming at a relaxed pace. Vigorous exercises include hiking, jogging, interval training, and playing basketball or singles tennis. Your HCP can provide exercise recommendations based on your age and overall health.

A less-conventional type of exercise has also been shown to be effective for some people with ED. Pelvic floor muscle training helps strengthen the muscles of the pelvic floor, which run from the pubic bone at the front of the body to the tailbone and between both hip bones. Having strong pelvic floor muscles can provide stronger erections and help keep blood in the penis during sexual activity.

Your HCP may be able to recommend exercises that bolster weak pelvic floor muscles,or they can refer you to a pelvic floor physical therapist for specialized care. Many of these exercises focus on repeatedly tightening specific muscles in the genital area, including those that may be used if you were trying to “lift” your testicles upwards or stop your flow of pee.

Devices and procedures

Your HCP may recommend other treatments if approaches like medication, therapy, and lifestyle changes aren’t enough to improve your ED. Two such treatments are penis pumps and penile implants.

Penis pumps  

Also called a vacuum erection device, a penis pump is a hollow tube that’s placed over the penis. A gentle, hand- or battery-powered vacuum pulls air out of the tube, which draws blood into the penis to produce an erection.  

Once an erection is achieved, the pump is removed and a tension ring (also called a constriction ring) is slipped onto the base of the penis to hold blood in the organ and maintain the erection. A tension ring may also be used without a penis pump in people who can naturally get an erection but have difficulty keeping it.

Following sexual intercourse, the tension ring is removed and the penis returns to a flaccid state. Potential drawbacks of the penis pump approach include bruising, coldness at the end of the penis, and restricted ejaculation.   

Penile implants  

Penile implants are another treatment option for people with ED. Although uncommon, penile implant surgery can be effective for some cases of ED that don’t improve with nonsurgical approaches.  

Penile implant surgery involves placing bendable or inflatable rod-shaped implants on either side of the penis. Bendable silicone implants keep the penis firm but flexible, while the inflatable, hydraulically operated implants give the person control over when and how long they have an erection.  

As is the case with any medical procedure, penile implant surgery comes with some measure of risk. Possible complications of surgery include infection, issues related to anesthesia, and implant malfunction.   

Supplements

There’s little evidence that dietary supplements are effective in treating erectile dysfunction. In fact, some supplements can cause unpleasant side effects or interact negatively with prescription medications. 

A few supplements have shown positive results for some people with ED and are generally considered safe when used under the guidance of an HCP. These include:

• Ginseng
• Dehydroepiandrosterone (DHEA), in low doses
• Propionyl-L-carnitine (when combined with sildenafil)
• L-arginine (which should not be combined with sildenafil)

Check with your HCP about whether these may be appropriate for you.

Clinical trials  

Various clinical trials are underway to improve treatment options for people with erectile dysfunction. A clinical trial is a research study that involves human participation to test the effectiveness of new treatments. To learn if you’re a candidate for an ED clinical trial, speak with your HCP. 

Back to top

Erectile dysfunction itself is a potential complication of various medical conditions, such as diabetes, depression, and cardiovascular disease. Still, ED can cause complications of its own, especially if it’s left untreated. Some people with ED experience:

• Relationship issues
• Difficulty getting their partner pregnant (if that is a goal of the relationship)
• Embarrassment or poor self-esteem
• Depression
• An unfulfilling sex life 
• Anxiety surrounding sexual issues

If you’re experiencing emotional or interpersonal complications of ED, reach out to your HCP or a mental health provider.

Back to top

Erectile dysfunction is very common, but it’s not an inevitable part of aging. There are several steps you can take to help lower your risk of ED, including:

• Maintain a healthy weight. A person AMAB with a 32-inch waist is 50 percent less likely to have ED than one with a 42-inch waist. (Depending on one’s overall size, a larger waist circumference is associated with greater amounts of belly fat.) Being overweight or obese increases the risk of major ED causes (like diabetes and cardiovascular disease) and can interfere with testosterone levels.
• Get on the move. Staying physically active can help you maintain a healthy weight and avoid issues that can lead to ED, such as high blood pressure, diabetes, and cardiovascular disease. Aerobic exercises like brisk walking, hiking, and jogging have shown to be especially helpful in reducing the risk of ED.
• Try to keep stress in check. Some simple stress management techniques include deep breathing exercises, meditation, journaling, or yoga.
• Make healthy lifestyle choices. This includes avoiding or quitting smoking, avoiding illegal drug use, and drinking alcohol in moderation (if at all). People AMAB should limit their alcohol consumption to no more than two drinks per day.   
• Eat a heart-healthy diet. Fill your plate with fruits, vegetables, whole grains, and lean proteins like fish. Cut back on foods high in saturated fat, such as red meat, processed meat, full-fat dairy products, butter, and baked goods like biscuits and cake. Because ED is in many cases a vascular condition (meaning it involves the blood vessels), taking steps to improve your overall heart health can benefit your sexual function, as well.
• Seek help for mental health concerns. Issues like depression and anxiety can lead to ED, but speaking with a mental health provider such as a counselor, psychiatrist, or psychologist can help you feel better and avoid complications.
• Stay on top of your overall health. Common conditions like high blood pressure, high cholesterol, diabetes, and atherosclerosis are major risk factors for ED. To successfully manage or stay clear of these problems and lower your risk of ED, it’s important to make healthy lifestyle choices and visit your HCP for all recommended health screenings and checkups.

Back to top

Finding the right ED treatment for your needs may take some trial and error, but there’s plenty of reasons for optimism. The outlook for most people with erectile dysfunction is good. Many causes of ED can effectively be addressed. Even ED related to chronic (long-term) conditions like diabetes or cardiovascular disease can be significantly improved with appropriate treatment.  

Some cases of ED related to nerve damage or injuries can be permanent. This is uncommon, though, and it may still be possible for some people with these issues to experience improvements in sexual function.

Back to top

Erectile dysfunction presents distinct challenges. ED may trigger feelings of embarrassment, anxiety, or frustration, or it may cause or add to problems in sexual partnerships. Remember, you’re not alone. ED is not a reflection of your worth as a person or the value you bring to a relationship. Rather, it’s an extremely common condition and is treatable in the majority of cases.   

ED is sometimes called a “couple’s disease.” Not only can this condition affect your well-being, it may also leave your partner feeling frustrated or unwanted. If you are navigating ED and working to improve intimacy, it’s important to prioritize clear and open communication.

A mental health provider can teach you and your partner ways to improve communication skills and to sort through relationship issues caused or exacerbated by ED. You may also find it helpful to access online or in-person support groups to speak with other people who are living with ED.

To learn more about erectile dysfunction, its many treatment options, and healthy ways you can cope, speak with your HCP.

Back to top

• Should You Take Medication for Erectile Dysfunction?
• Take a Walk to Help Prevent Erectile Dysfunction   
• 7 Surprising Facts About the Penis