Erectile dysfunction
Impotence (ED)
Erectile dysfunction (ED) is the repeated inability to get or keep an erection firm enough for sex. It is very common, especially after 40, and is usually caused by blood vessel, nerve, hormone or psychological problems. It may be an early sign of heart disease or diabetes, and most cases can be treated.
Source: NIDDK (NIH), NHS, Cleveland Clinic
- What is erectile dysfunction?
- Symptoms
- Causes and risk factors
- Types of erectile dysfunction
- Erectile dysfunction and heart health
- Diagnosis
- Treatment options
- Complications
- Prevention and living with erectile dysfunction
- When to see a doctor
- FAQ
- Sources
What is erectile dysfunction?
Erectile dysfunction (ED), still sometimes called impotence, means you repeatedly cannot get an erection, or cannot keep one firm enough and long enough for sex. An occasional failed erection is normal and usually linked to tiredness, stress or alcohol; doctors speak of erectile dysfunction when the problem keeps coming back. MedlinePlus suggests talking to a provider if erections fail more than about 25% of the time. Sex drive is often unaffected, although some men also notice lower desire.
Source: NHS, MedlinePlus, NIDDK (NIH)
Erectile dysfunction is very common. NIDDK estimates that 30 to 50 million men in the United States are affected, and Cleveland Clinic notes it is the sexual problem men most often report to their doctors. It becomes more frequent with age, yet it is not considered an inevitable part of growing older, and most cases can be treated.
Source: NIDDK (NIH), Cleveland Clinic, MedlinePlus
How an erection works
An erection depends on teamwork between the brain, nerves, hormones and blood vessels. Sexual arousal sends nerve signals to the penis, the arteries open, and blood fills the spongy erectile tissue. Valves then close to trap the blood so the penis stays firm. Hormones such as testosterone support this process. A problem at any step, from narrowed arteries to damaged nerves, can lead to erectile dysfunction.
Source: Cleveland Clinic, MedlinePlus
Symptoms
The signs of erectile dysfunction are usually easy to recognize, but they can vary from one man to another:
- Getting an erection sometimes, but not every time you want to have sex
- Getting an erection that does not last long enough for intercourse
- An erection that is not firm enough for penetration
- Being unable to get an erection at all
- In some men, reduced interest in sex
Source: NIDDK (NIH), MedlinePlus, NHS
Many men with erectile dysfunction still wake up with erections. MedlinePlus explains that normal night-time or morning erections suggest the cause is less likely to be physical, while NHS notes you may still have erections at other times even when sex is difficult. Importantly, ED can itself be a symptom of another health problem, so it deserves a medical check rather than silent self-treatment.
Source: MedlinePlus, NHS, NIDDK (NIH)
Causes and risk factors
Most cases of erectile dysfunction have a physical cause, often involving blood vessels, nerves or hormones, and emotional factors frequently add to it. MedlinePlus notes that physical causes are more common in older men, while psychological causes are relatively more common in younger men.
Source: MedlinePlus, NIDDK (NIH)
Medical conditions
- Blood vessel disease: atherosclerosis (clogged arteries), high blood pressure, high cholesterol and stroke
- Diabetes, which can damage both blood vessels and nerves
- Chronic illness: chronic kidney disease, obesity and COPD
- Hormone problems: low testosterone and thyroid imbalance
- Nerve problems: multiple sclerosis, Parkinson disease, spinal cord injury, and nerve damage from pelvic or prostate surgery or radiation
- Penile and prostate conditions: Peyronie’s disease (a curved penis) and an enlarged prostate
Source: NIDDK (NIH), Cleveland Clinic, MedlinePlus
Medicines
Many prescription and over-the-counter drugs list erectile dysfunction as a possible side effect, including some antidepressants, blood pressure medicines (especially beta-blockers) and diuretics, antihistamines, sedatives and sleeping pills, some ulcer medicines, chemotherapy and hormone drugs, digoxin, and pain relievers such as NSAIDs, codeine and oxycodone. Never stop a prescribed medicine on your own; ask your doctor whether a change is possible.
Source: NIDDK (NIH), MedlinePlus, NIDDK (NIH)
Lifestyle and emotional factors
Smoking, heavy drinking, recreational drugs such as cocaine, lack of physical activity and carrying extra weight all raise the risk. Anxiety, depression, stress, relationship conflict, low self-esteem and performance worries can cause erectile dysfunction or make an existing problem worse. NHS also suggests that men who cycle more than three hours a week may consider cutting back.
Source: NIDDK (NIH), NHS, MedlinePlus, Cleveland Clinic
Types of erectile dysfunction
Doctors often group erectile dysfunction by its main underlying mechanism. Cleveland Clinic describes four broad types, and many men have more than one at the same time:
- Vasculogenic (vascular): the most common type, caused by problems with the arteries that bring blood in or the valves that keep it there.
- Neurogenic: nerve signals between the brain and penis are disrupted, for example after trauma, pelvic surgery, radiation, stroke, spinal stenosis or multiple sclerosis.
- Hormonal: usually low testosterone, and sometimes thyroid disease.
- Psychogenic: driven by depression, anxiety, stress, fear of intimacy or low self-esteem.
Source: Cleveland Clinic
Erectile dysfunction and heart health
Because the arteries of the penis are small, the same narrowing that later affects the heart may cause erection problems first. Cleveland Clinic and MedlinePlus both point out that erectile dysfunction can be an early sign of heart disease or diabetes. A systematic review in the American Journal of Men’s Health found that erectile dysfunction and cardiovascular disease share risk factors and a common mechanism, damage to the lining of blood vessels (endothelial dysfunction), and reported studies in which ED appeared on average three to five years before a heart event.
Source: Cleveland Clinic, MedlinePlus, American Journal of Men’s Health (PMC)
The same review stresses that this evidence is limited and that guidelines disagree on how much ED should count in formal heart-risk scores. Still, it supports asking every man with erectile dysfunction about cardiovascular risk, especially younger men without diabetes. In practice this means having your blood pressure, blood sugar and cholesterol checked when you seek help for ED.
Source: American Journal of Men’s Health (PMC)
Diagnosis
Diagnosing erectile dysfunction usually starts with a conversation, not a test. Your doctor will ask about your medical history, medicines and supplements, alcohol and drug use, mood, stress and relationships, and about desire, erection, ejaculation and orgasm. With your permission, they may also talk to your partner. A physical exam checks blood pressure, the genitals and signs of blood vessel, nerve or hormone problems; men with urinary symptoms may also have a prostate (rectal) exam.
Source: NIDDK (NIH), NHS, MedlinePlus
Tests that may be used
- Blood and urine tests for diabetes, cholesterol, heart risk, thyroid function, prostate health and testosterone levels
- Penile Doppler ultrasound to show blood flow in the penis
- Nocturnal (night-time) erection test, at home or in a sleep lab, to help tell physical from psychological causes
- Injection test: a medicine injected into the penis in the clinic to see how firm the erection becomes and how long it lasts
- Less often, nerve sensitivity tests, magnetic resonance angiography (MRA) or psychological questionnaires
Source: NIDDK (NIH), Cleveland Clinic, MedlinePlus
Treatment options
Treatment of erectile dysfunction begins with finding and treating the cause. Cleveland Clinic notes that ED is unlikely to go away without lifestyle change or treatment, but the outlook is good because so many options exist. Doctors usually start with the least invasive choices.
Source: Cleveland Clinic, NIDDK (NIH)
Lifestyle changes and counseling
Stopping smoking, limiting alcohol (NHS advises no more than 14 units a week), losing excess weight, eating well, sleeping enough and exercising regularly can all help. Cleveland Clinic cites vigorous aerobic exercise for at least 45 minutes three times a week as helpful for mild ED. When stress, anxiety or relationship issues play a role, counseling or sex therapy, sometimes with your partner, can be very effective. Your doctor may also review and adjust medicines that could be contributing.
Source: NHS, Cleveland Clinic, NIDDK (NIH), MedlinePlus
PDE5 inhibitor tablets
For many men, the first medical treatment is a pill from the PDE5 inhibitor group: sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanafil (Spedra). They increase blood flow to the penis but only work with sexual arousal. Sildenafil is usually taken about an hour before sex; a heavy meal can delay its effect. Common side effects include headache, flushing, a stuffy nose, indigestion, dizziness and temporary blurred vision.
Source: NHS, NHS, MedlinePlus, Cleveland Clinic
These tablets must not be combined with nitrate medicines such as nitroglycerin (GTN) for chest pain, or with recreational “poppers”, because blood pressure can fall dangerously. They may also be unsuitable after a recent heart attack or stroke, with severe heart disease, very low or uncontrolled blood pressure, or certain liver, kidney, blood or eye conditions. Buy them only through a registered doctor or pharmacy: NHS warns that many websites sell fake or unregulated pills.
Source: NHS, MedlinePlus, NHS
Other medical options
- Penile injections such as alprostadil, papaverine or phentolamine, which Cleveland Clinic says work within about 10 minutes; you are taught to inject yourself
- Urethral suppositories: a small pellet of medicine inserted into the tip of the penis
- Testosterone therapy for men with proven low testosterone, sometimes together with a PDE5 inhibitor
- Vacuum erection devices: a tube and pump draw blood into the penis and a ring holds it there; side effects include coldness, numbness, painless bruising and weaker ejaculation
Source: NIDDK (NIH), Cleveland Clinic, NHS
Shockwave therapy for ED
Low-intensity shockwave therapy uses sound waves applied to the penis to try to improve blood flow, with any benefit taking about two months to appear. A 2024 review in the World Journal of Men’s Health found it low-risk, with trials generally showing modest improvement over sham treatment, but judged much of the evidence to be of low quality, found no agreed treatment protocol, and noted that only about half of men kept the benefit after two years. Professional guidelines differ, from treating it as experimental to listing it as a possible option for mild-to-moderate vascular ED.
Source: Cleveland Clinic, World Journal of Men’s Health (PMC)
Penile implant and surgery
Most men never need surgery. When other treatments fail or are not acceptable, a penile implant (prosthesis) can be placed inside the penis. Inflatable implants use a small pump in the scrotum, while semi-rigid implants use bendable rods. Cleveland Clinic reports that more than 90% of people are satisfied with the result and that the implant does not affect sensation, urination or orgasm, although infection, mechanical failure and erosion are possible. Repairing the penile arteries is a rare option that works best in some younger men.
Source: Cleveland Clinic, Cleveland Clinic, NIDDK (NIH)
Herbal products and supplements sold for erections are not proven to work and may interact with other medicines, so check with a doctor before using them. Men who want an assessment by a specialist andrology team can also consult dedicated centers such as Male Hospital in Istanbul, which focuses on men’s sexual health.
Source: MedlinePlus, NIDDK (NIH)
Complications
Untreated erectile dysfunction rarely harms the body directly, but it can affect quality of life in important ways:
- An unsatisfying sex life and loss of intimacy with a partner
- Stress, anxiety, depression or low self-esteem
- Relationship strain
- Difficulty getting a partner pregnant
- Missed diagnosis of an underlying condition such as diabetes or heart disease
Source: NIDDK (NIH), MedlinePlus
Treatments carry their own risks. The most important is priapism, a painful erection lasting four hours or more, which is an emergency because it can permanently damage the penis. Sudden loss of vision or hearing after taking an ED tablet also needs urgent care.
Source: NIDDK (NIH), Cleveland Clinic, NHS
Prevention and living with erectile dysfunction
Many cases of erectile dysfunction are linked to the same habits that protect the heart. Not smoking, staying active, keeping a healthy weight, eating a diet low in saturated fat, sleeping well, controlling cholesterol, blood pressure and blood sugar, and drinking little or no alcohol all lower the risk. Managing stress and seeking help early for depression or anxiety matter too.
Source: Cleveland Clinic, NHS, NIDDK (NIH)
Living with erectile dysfunction is easier when you talk about it openly with your partner and doctor. MedlinePlus notes that sex is usually safe for men with heart disease, so fear of heart problems should be discussed rather than avoided. Counseling can ease the pressure on a relationship even when the physical problem cannot be fully cured.
Source: MedlinePlus
When to see a doctor
See a doctor or a sexual health clinic if erection problems keep happening, if they begin after an injury or prostate surgery, if you think a medicine is responsible, or if they come with other symptoms such as low back pain, abdominal pain or changes in urination. Because erectile dysfunction may be the first sign of diabetes or heart disease, a check-up is worthwhile even if the problem seems mild.
Source: NHS, MedlinePlus, Cleveland Clinic
- You have an erection lasting more than 4 hours, or a painful erection after using ED medicine (priapism)
- You suddenly lose vision or hearing after taking an ED tablet
- You have chest pain, fainting, a fast or irregular heartbeat, or signs of a severe allergic reaction after taking an ED tablet
Source: NIDDK (NIH), MedlinePlus, NHS, Cleveland Clinic
Related treatments
Further reading
Erectile dysfunction: frequently asked questions
What is the main cause of erectile dysfunction?
Most cases have a physical cause, most often reduced blood flow from conditions such as atherosclerosis, high blood pressure or diabetes. Nerve damage, low testosterone, medicines and psychological factors can also cause it, and several causes often combine.
Source: Cleveland Clinic, MedlinePlus
Can erectile dysfunction be cured?
Sometimes. ED caused by a medicine, a hormone problem, stress or lifestyle can improve or resolve once the cause is treated. When the cause cannot be reversed, treatments such as tablets, injections, vacuum devices or a penile implant can still allow satisfying sex.
Source: Cleveland Clinic, MedlinePlus
At what age does erectile dysfunction start?
It can happen at any adult age, but it becomes more common with age. NIDDK reports that about 40% of men are affected by age 40 and about 70% by age 70, yet it is not a normal part of aging.
Source: NIDDK (NIH)
Is erectile dysfunction a sign of heart disease?
It can be. ED and heart disease share risk factors and blood vessel damage, and research suggests ED may appear a few years before a heart event in some men. Anyone with ED should have their heart risk checked.
Source: Cleveland Clinic, American Journal of Men's Health (PMC)
How quickly do ED pills work?
PDE5 inhibitors usually start working within about an hour, and MedlinePlus says many work within 15 to 45 minutes. They need sexual arousal to work, and a heavy meal can delay them.
Source: Cleveland Clinic, MedlinePlus, NHS
Who should not take Viagra or other ED tablets?
Men taking nitrate medicines for chest pain, and those with a recent heart attack or stroke, severe heart disease, or very low or uncontrolled blood pressure, may not be able to use them. Ask a doctor before starting.
Source: MedlinePlus, NHS
Can anxiety cause erectile dysfunction?
Yes. Anxiety, stress, depression and relationship problems can cause ED or make it worse, and psychological causes are relatively more common in younger men. Counseling or sex therapy can help.
Source: NIDDK (NIH), MedlinePlus
Does shockwave therapy work for erectile dysfunction?
Low-intensity shockwave therapy appears safe and may give modest improvement, mostly in mild-to-moderate vascular ED, but evidence quality is low, protocols vary and benefit may fade over time.
Source: World Journal of Men's Health (PMC), Cleveland Clinic
Is a penile implant noticeable?
Cleveland Clinic reports that partners generally cannot tell the difference during intercourse and that more than 90% of people are satisfied with their implant.
Source: Cleveland Clinic
Talk to a men's health specialist about erectile dysfunction
Sources
- NHS — Erection problems (erectile dysfunction)
- NHS — Sildenafil (Viagra)
- NIDDK (NIH) — Definition & Facts for Erectile Dysfunction
- NIDDK (NIH) — Symptoms & Causes of Erectile Dysfunction
- NIDDK (NIH) — Diagnosis of Erectile Dysfunction
- NIDDK (NIH) — Treatment for Erectile Dysfunction
- Cleveland Clinic — Erectile Dysfunction (ED)
- Cleveland Clinic — Penile Implants
- MedlinePlus — Erection problems
- MedlinePlus — Erectile Dysfunction
- American Journal of Men's Health (PMC) — The Association of Erectile Dysfunction and Cardiovascular Disease: A Systematic Critical Review (Raheem et al.)
- World Journal of Men's Health (PMC) — Variations in Low Intensity Shockwave Treatment Protocols for Erectile Dysfunction: A Review of the Literature
This page is part of the Morepital medical reference. It is for general health education and does not replace a consultation with a qualified doctor. Last reviewed: October 2026.