What is erectile dysfunction?

Erectile dysfunction¹, or ED, is the inability to get or maintain an erection that is firm enough for sex.

Erectile dysfunction is a common affliction. While occasional difficulty getting or maintaining an erection isn’t usually a cause for alarm, recurrent ED can lead to stress, anxiety, and problems with self-confidence and sexual relationships.

Rates of ED generally rise with age; however, aging alone does not cause ED. In fact, because the factors that contribute to ED are so complex and varied, it is often difficult to pinpoint one exact cause for the condition in an individual.

Ongoing erectile dysfunction can sometimes indicate the presence of health problems like cardiovascular disease. Treating an underlying condition can often improve or eliminate an individual’s ED.

How common is erectile dysfunction?

According to the Urology Care Foundation, ED affects as many as 30 million men² and is the sex problem most commonly reported by men to their healthcare providers.

The Massachusetts Male Aging Study assessed the prevalence of erectile dysfunction. The study found that more than half (52%)³ of men aged 40–70 experienced mild to moderate erectile dysfunction.

While the research found links between ED and overall health and emotional well-being, age had the strongest correlation with the prevalence of ED: rates increased from 5% at age 40 to 15% at age 70⁴.

What is an erection?

In order to understand erectile dysfunction, it’s important first to understand how an erection works⁵.

The penis contains two chambers called the corpora cavernosa. These chambers, which run from the head of the penis into the pelvis, contain spongy erectile tissue and a maze of blood vessels.

Usually, the penis remains soft (flaccid). In this state, the arteries that supply blood to the penis are only partially open. This ensures that enough blood is flowing to keep penile tissues healthy.

An erection begins with sexual arousal⁶. In this state, physical and mental stimulation trigger the release of hormones. These hormones open the arteries in the penis and relax the muscles of the corpora cavernosa, increasing blood flow into the chambers. When these chambers fill, the blood becomes trapped under high pressure, creating an erection.

When the brain no longer sends the signals that indicate sexual arousal, the hormone response stops. The muscles in the penis contracts and blood is once again able to flow out, causing the penis to become flaccid again.

There are two types of responses⁷ that cause erections. This does not mean that there are different “types” of erections in the physical sense; these responses are simply classified according to the type of stimulus that causes an erection.

The first response is to direct physical touch or stimulation of the shaft of the penis. This response is controlled by the peripheral nerves and lower spinal cord and is called a reflex erection.

The second response is to erotic or emotional stimuli (arousal that is not caused by physical contact). This form of stimulus triggers a psychogenic erection, which instead relies on the brain’s limbic system.

Erectile dysfunction causes

A variety of physical factors, such as the presence of pre-existing conditions, can play a role in erectile dysfunction. Heart health is a large contributor to overall sexual health. Psychological issues and stressors can also contribute to difficulty performing sexually.

Erectile dysfunction is generally classified⁸ as either psychogenic or organic. Psychogenic ED refers to erectile dysfunction that is related to psychological factors, such as depression, stress, anxiety, or performance anxiety. This is the most common diagnosis of ED for men under 40. Organic ED, on the other hand, is caused by physical factors like neurological or hormonal issues or the side effects of different medications. This form of erectile dysfunction is estimated to comprise only 15–20% of cases of ED.

Because the factors that contribute to ED are so complex and broad-reaching, it can be difficult to determine one specific cause for erectile dysfunction.

Generally, ED can occur⁹:

• When the flow of blood to the penis is limited or nerves are damaged
• As a result of stress or emotional state
• Due to (and, in many cases, as an early warning sign of) serious illnesses like atherosclerosis, cardiac and cardiovascular disease, high blood pressure, and high blood sugar

Determining the cause(s) of your erectile dysfunction can help identify and treat underlying conditions and improve your overall health.

Conditions that contribute to ED

Some chronic medical conditions can contribute to difficulty getting and maintaining erections. Those that affect the vascular system can prevent enough blood from flowing into the penis, while disorders of the nervous system can affect the sensitivity of the penis, causing erectile difficulties.

Some conditions¹⁰ that can lead to erectile dysfunction include:

• Cardiac (heart) and cardiovascular (blood vessel) diseases
• Atherosclerosis: the buildup of plaque on arterial walls
• Hypertension (high blood pressure)
• Hyperglycemia (high blood sugar) and type 2 diabetes: men with type 2 diabetes are over 3 times more likely¹¹ to develop erectile dysfunction than men without diabetes
• Chronic kidney disease
• Multiple sclerosis¹²: a disease in which the immune system attacks the protective coating surrounding nerve fibers
• Peyronie’s disease¹³: occurs when scar tissue (plaque) forms under the skin of the penis Some injuries and procedures used to treat problems in the prostate and urinary tract can also contribute to ED:
• Injury caused by treatments for prostate cancer (such as radiation therapy, prostatectomy)
• Surgery for bladder cancer (such as transurethral resection, radical or partial cystectomy)

Medications that can cause ED

Despite the correlation between age and erectile dysfunction, there are many other factors that can contribute to ED. One of the reasons for this correlation is the fact that older men are more likely to be on certain medications than younger men.

According to a Harvard Special Health Report, roughly 25% of all erectile dysfunction¹⁴ is a side effect of medication.

The type of drug most commonly linked to erectile dysfunction is high blood pressure (hypertension) medication. Furthermore, erectile dysfunction is linked to hypertension itself: according to a study of 1.9 million medical records, men with ED are roughly 38% more likely¹⁵ to have high blood pressure than those without erectile dysfunction.

Other medications¹⁶ that can contribute to erectile dysfunction include:

• Antiandrogens (medications used in prostate cancer therapy)
• Antidepressants and anxiety medications¹⁷: lithium, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants
• Antihypertensive drugs, such as diuretics (spironolactone, thiazides) and beta blockers
• Tranquilizers and prescription sedatives
• Antihistamine medications
• Opiate analgesics

Emotional and psychological causes of ED

Emotional distress and high stress levels can cause difficulty with sexual performance. Oftentimes, this is a very complicated matter: stress can lead to sexual dysfunction, which can, in turn, lead to more stress, creating a feedback loop of sorts.

Basically, the more stressed you are, the more likely you are to experience difficulty performing sexually, which creates even more stress, and so on.

You may develop erectile dysfunction if you experience one or more of the following emotional issues:

• Anxiety
• Depression
• Stress (general life stress, external or self-imposed pressure on sexual performance) in particular
• Fear of sexual failure or dysfunction
• Guilt about sex or self-imposed stress
• Low self-esteem

The most important thing you can do to help remedy emotional blocks to sexual well-being is to talk about these problems. Talking to a mental health professional is an excellent place to start dealing with overall stress and mental health.

Seeing a psychotherapist or sex therapist¹⁸—a licensed Ph.D. trained in providing sex counseling, coaching, and education for couples and individuals—may be helpful for addressing erectile dysfunction in particular.

Erectile dysfunction risk factors

There are a variety of factors that can increase your risk of developing erectile dysfunction. Along with the previously mentioned pre-existing conditions, mental health, and the side effects of medication, the following lifestyle factors and conditions¹⁹ may contribute to erectile dysfunction:

• Neurological conditions, such as cerebrovascular accidents, Parkinson’s disease, and injuries to the spinal cord
• Smoking
• Excess alcohol consumption
• The use of illicit drugs
• Being overweight or obese
• Physical inactivity

Erectile dysfunction symptoms

The symptoms of erectile dysfunction include:

• Being able to get an erection sometimes, but not every time you want to
• Being unable to maintain an erection through the entirety of sex or masturbation
• Being completely unable to get an erection

Do not be embarrassed or worried about discussing sexual problems with your healthcare provider. They can help you determine whether you have erectile dysfunction and identify what lifestyle factors and health conditions may be contributing to your condition.

Complications from erectile dysfunction

Erectile dysfunction can lead to a number of complications²⁰, including:

• Stress and lack of fulfillment in sex life
• Relationship strain and problems with intimacy between you and a partner
• Depression, anxiety, and feelings of low self-esteem
• Difficulty getting a partner pregnant