Erectile Dysfunction Causes to Know—And Ways to Treat the Condition

The cause of erectile dysfunction can be physical, psychological, or a combination of both.

Every man has an "off" night occasionally. While maybe frustrating, it usually isn't any cause for concern. But what if someone, time and time again, is having trouble getting and keeping it up? Known as erectile dysfunction (ED), that continued inability to perform may not only be stressful, but it may also be a sign of an underlying health condition.

Here's what to know about ED, including its symptoms, causes, and treatment, as well as how to prevent it and talk to your partner about it.

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What is erectile dysfunction?

ED is the inability to get and maintain an erection adequate for penetrative sex. "While it's not uncommon for a man to have trouble from time to time, men diagnosed with ED have persistent problems for three months or more," Tobias Kohler, MD, professor of urology at the Mayo Clinic and secretary of the Sexual Medicine Society of North America (SMSNA), tells Health.

ED affects as many as 30 million men in the US, making it the most commonly reported sex problem for men, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), which points out that even though it's common, ED is not a normal part of aging.

What are the symptoms of erectile dysfunction?

Every man has that occasional time when they just can't get the job done. But according to the Mayo Clinic and the NIDDK, any of the following symptoms might be a sign of ED:

  • being able to get an erection sometimes, but not every time you want to have sex
  • being able to get an erection, but not having it last long enough for penetrative sex
  • never being able to get an erection
  • Reduced sex drive

What causes erectile dysfunction?

"Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles, and blood vessels," per the Mayo Clinic. "Erectile dysfunction can result from a problem with any of these. Likewise, stress and mental health concerns can cause or worsen erectile dysfunction."

That means the cause of ED can be physical, psychological, or a combination of both.

Physical causes of erectile dysfunction

Often, ED is a symptom of another health problem or health-related factor, as the NIDDK points out. So even though many men might find it embarrassing to approach their doctor with concerns, doing so can potentially help doctors find out about a more serious underlying condition.

There are a lot of factors affecting your different systems that can be behind ED:

Vascular system

"The most common cause for ED is not getting enough blood flow into the penis, which could be due to atherosclerotic disease of the cavernosal arteries responsible for supplying blood to the penis," Darshan Patel, MD, assistant professor of urology at UC San Diego Health, tells Health. "Because the arteries of the penis are half the size of the arteries to the heart, they can clog about three to five years sooner and are a warning sign of a future heart attack or stroke."

High blood pressure and high cholesterol also contribute to the narrowing of the arteries that allow blood into the penis, leading to ED, according to Dr. Kohler. On the other hand, medications used to treat these conditions, like beta-blockers and thiazides, decrease blood flow to the penis, making erections more difficult.

Nervous system

Trauma or damage to the nerves that feed into the penis also causes problems with erections, according to the SMNSA. Spinal cord injuries and conditions like multiple sclerosis, Parkinson's, and spina bifida affect these nerves, making it more challenging to sustain intercourse.

Diabetes is another condition that can lead to nerve damage. Known as diabetic neuropathy, the nerve damage can affect the genitals and urinary tract, according to the NIDDK. In fact, men who have diabetes are two to three times more likely to develop ED than men who do not have diabetes, the NIDDK reports.

Other physical causes

The NIDDK and Mayo Clinic list these as just some of the other potential causes of ED:

  • Injury from treatments for prostate cancer, including radiation therapy and prostate surgery
  • Sleep disorders
  • Chronic kidney disease
  • Peyronie's disease (which is the development of scar tissue inside the penis)
  • Certain prescription medications
  • Lifestyle factors like drinking too much alcohol, using recreational drugs, and smoking

Something that could be the cause but likely isn't? Low testosterone. "Most of the time, your testosterone must be very low to affect the penis," says Dr. Kohler. "With low testosterone, you'll lose interest in sex and have low energy, but treating low testosterone doesn't fix the penis as much as it does other vascular causes. You're much more likely to be disappointed with testosterone replacement alone to fix ED."

Psychological causes of erectile dysfunction

Worrying about your sexual performance or psyching yourself out makes the situation worse. "If a guy has a bad night, he may start freaking out that something is wrong, and he gets scared. Fear causes your body to release adrenaline, and then its light's out. Nothing's going to work," says Dr. Kohler. Adrenaline sends blood to your heart, brain, and lungs and away from organs like the penis as part of the fight-or-flight response. Besides fear of sexual failure and anxiety about sexual performance, guilt about certain sexual activities, as well as low self-esteem, are other psychological/emotional factors that can lead to or worsen ED.

Depression, anxiety, and stress also lead to lower sex drive, less energy, and problems with erections. Unfortunately, medications to treat those conditions come with side effects that can exacerbate the issue. Talk to your doctor if this is the case.

Are there risk factors for erectile dysfunction?

Yes. "The most common risk factors for ED are linked to lifestyle choices that can disrupt blood flow and circulation, like smoking, excessive alcohol use, poor diet, stress, and lack of exercise," says Dr. Patel.

Age is another important risk factor. With each decade of life, a higher percentage of men report experiencing symptoms of ED. "As you get older, the blood vessels themselves are not as robust, and you're more at risk for other medical problems," says Dr. Kohler.

The Mayo Clinic also mentions the following risk factors:

  • Injury, particularly if it damages the nerves or arteries that control erections
  • Medications, like those for blood pressure and depression
  • Certain medical treatment, such as prostate surgery or radiation treatment for cancer
  • Psychological conditions, like stress, anxiety, and depression

How do you treat erectile dysfunction?

If you've dealt with symptoms of ED for several months, it's important to see your primary care doctor or a urologist. They'll complete a physical exam and ask you to provide a thorough medical history. "Typically, that's all that's needed to diagnose ED, but if your doctor suspects an underlying medical complication, you might need further testing or be referred to a specialist," says Dr. Kohler.

When it comes to treating ED, both Dr. Kohler and Dr. Patel say patients get the biggest bang for their buck by improving their overall health first. Things like losing weight, getting regular exercise, eating a healthy diet, and quitting smoking lead to the most lasting improvements. And sometimes, treating an underlying condition is enough to reverse ED, the Mayo Clinic reports.

Beyond lifestyle changes and treating the underlying cause, there are many other safe and effective ED treatments available, including medications. According to the Mayo Clinic, a class of drugs called phosphodiesterase 5 (PDE5) inhibitors enhance the effects of nitric oxide—"a natural chemical your body produces that relaxes muscles in the penis. This increases blood flow and allows you to get an erection in response to sexual stimulation." These medications are used just before sexual activity or, in some cases, daily. Examples of PDE5 inhibitors include:

  • avanafil (Stendra)
  • sildenafil (Viagra)
  • tadalafil (Cialis)
  • vardenafil (Levitra, Staxyn)

Besides medication, someone might also get treated for ED with:

  • Penile injection therapy: Patients are taught to self-inject a drug through a small needle at the base of the penis five to 10 minutes before sexual activity.
  • Vacuum erection devices: A clear plastic cylinder with an opening at one end is placed over the penis. A pump then connects to the cylinder, drawing out air and creating a vacuum. Once the penis is erect, the user places an elastic ring at the base of the penis, reducing blood flow out.
  • Penile implant surgery: A penile implant or prosthesis is surgically inserted into the penis. When a man wishes to have sex, he uses a pump in the scrotum to fill the penis with fluid. After, he can deflate the device to return to his normal state. Surgery is the most reliable therapy for providing patients with the ability to get an erection on demand and is generally recommended after other treatment options have failed, according to Dr. Kohler.

Many men's health clinics tout additional therapies or treatment options, but they are often expensive and there's limited research on their effectiveness. "Restorative therapies such as stem cell therapy (SCT), platelet-rich plasma (PRP), and low-intensity shockwave therapy (LiSWT) are aimed at regenerating the damaged tissues that may be causing ED," according to SMSNA. "Although early clinical trials of these therapies have shown some improvements in patients (particularly those with mild ED), there is currently not enough evidence to support their efficacy in treating ED."

"Many clinics also market supplements specifically for erectile dysfunction or low testosterone, but it's important to know there's not much research behind their effectiveness," Dr. Patel says. "For the most part, these supplements just contain lower doses of things like Viagra."

Can you prevent erectile dysfunction?

"I tell patients if you take good care of your health, your penis will take good care of you," says Dr. Kohler. "Things like eating a healthy diet, exercise, and quitting smoking are powerful for both preventing dysfunction and curing it. With care, you can have great sexual function into your 70s and 80s."

Here are more tips from Dr. Kohler and Dr. Patel on what you can do to prevent ED:

  • Get regular check-ups with your physician to monitor blood pressure and cholesterol
  • Eat plenty of protein and avoid foods high in saturated fat
  • Get adequate sleep
  • Reduce stress at work and home
  • Address mental health issues with a physician or therapist

Advice for couples

Erectile dysfunction can put strain on a relationship, especially when partners don't talk openly about what's going on. Dr. Patel says many resources can help start the conversation, like online forums, podcasts, and sex therapy.

If you're the partner of a loved one struggling with erectile issues, consider the following tips from Dr. Kohler and the Mayo Clinic:

  • Formulate a plan. Dr. Kohler advises couples to be bold, have courage, and set up an appointment with a doctor. Come with an open mind, ready to discuss what's happening and set up a treatment plan.
  • Help your partner talk to his doctor. You may be able to remember changes or symptoms your partner has forgotten that are important for the doctor to know.
  • Help your partner with therapy. You can help your partner to adhere to the plan you've developed with the doctor.
  • Understand the physiology and psychology of sexual function. Once you know more about the underlying causes, you can help your partner understand why ED happens and make it less embarrassing. You can also learn more about the role you can play in treatment options.

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