Erectile Dysfunction (ED): Causes and Treatment

Jun 14, 2024

Fact Checked

Erectile dysfunction (ED) affects millions of men in the United States. We explore ED causes and treatments in our guide.

Edited by: Donya Currie, MA, Senior Editor at NCOA

Reviewed by: Susan Stiles, PhD, Healthy Aging Expert at NCOA

Erectile dysfunction (ED) is defined by persistent trouble getting or keeping an erection that’s firm enough for satisfactory sex. If you’re experiencing ED, know that 30 million men* in the United States can relate. ^[1]

Formerly known as “impotence,” ED has many possible causes (such as vascular, neurological, hormonal, psychological, and lifestyle factors), which vary depending on the person. Often, multiple causes contribute. ED is a common, highly researched sexual health issue with plenty of effective treatment options.

If you’re concerned about ED, talk to a urologist or your primary care physician. They’re trained to help pinpoint ED causes and offer solutions, such as medications or other therapies. We’ve created this guide to erectile dysfunction causes and treatments to help you feel prepared when you talk with a health care provider.

*For brevity, we refer to all people assigned male at birth as men throughout this guide.

What is erectile dysfunction?

Erectile dysfunction (ED) refers to difficulty getting or keeping an erection that’s firm enough for satisfactory sex. Erections rely on nerve signals, hormones, blood flow, and muscle control to stay firm. Erectile dysfunction happens when factors such as nerve damage, hormonal imbalances, or inadequate blood flow interfere. ^[2]

ED can be long-term or temporary—occasional erectile dysfunction isn’t usually a cause for concern. If your erection issues are frequent or worsening, or if they’re affecting your personal or relationship well-being, consider consulting a health care provider.

Not sure if you have erectile dysfunction? The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) notes ED may present in different ways:

You can get an erection sometimes, but not every time you want to have sex.
You can get an erection, but it doesn’t last long enough for satisfactory sex.
You’re unable to get an erection at any time.

ED prevalence

The 2021 National Survey of Sexual Wellbeing offered the first update to national ED prevalence stats in almost 20 years. ^[3] The survey included 1,822 cisgender men ranging from 18–87 years old.

Survey results showed an overall ED prevalence rate of 24.2%. Results also suggested ED prevalence generally increases with age, although age doesn’t directly cause ED. Prevalence of ED tends to decrease from the early teens and 20s to mid 30s or early 40s before spiking, indicating that rates are not a straight linear trend with age, but there is an overall increase. Additionally, most survey participants (over 90%) who met ED criteria had not received a formal diagnosis from a doctor for their ED.

Age group	75+	65–74	55–64	45–54	35–44	18–24	25–34
Prevalence of Erectile Dysfunction	52.2%	48.0%	33.9%	25.3%	12.7%	13.3%	17.9%

Causes of ED

A lot of different factors can contribute to ED, and often multiple factors are at play. ^[4] Across ED research, vascular (blood flow) issues are the biggest culprit of erectile dysfunction. Other factors include genetics, neurological disorders, hormonal imbalances, cardiovascular disease, diabetes, drug-induced ED, psychological causes, and lifestyle factors.

Nerve-related ED factors

With nerve-related (neurological) ED, the brain or spinal cord’s nerve signals have trouble reaching the penis. During sexual arousal, the brain sends nerve signals through the spinal cord, prompting the muscles in the penis to relax and blood to rush to the penis, causing an erection. Certain health conditions can damage nerves and block these nerve signals before they reach the penis, hindering erections, as explained by the Urology Care Foundation. ^[5]

Some common neurological causes of ED include: ^[6]

Diabetes
Multiple sclerosis or neurodegenerative disorders
Alcohol use disorder
Nerve and spinal cord injuries
Nerve damage from abdominal or pelvic surgeries

Hormonal ED factors

In addition to the brain sending sexual-arousal nerve signals to the penis, hormones also play a big role. Hormones are released that help the constricted muscle tissue in the penis relax and widen. That way, more blood can flow in for an erection. Hormone-induced ED complicates this chain of events, making erections less predictable. ^[5]

Common hormonal causes of ED include:

Steroid misuse
Thyroid disorders
Hypogonadism (low testosterone)
Hormones administered for prostate cancer

ED and testosterone

Testosterone deficiency can contribute to ED, but diabetes and vascular disease are much more common ED causes ^[4] .

Lifestyle ED factors

Certain behavioral factors can impact erectile function. For example, smoking can amplify ED risk factors like hypertension and vascular disease. For smokers who quit, erectile function improved by 25% after one year. ^[4]

The International Society for Sexual Medicine (ISSM) outlines lifestyle factors that can contribute to erection problems: ^[2]

Smoking
Certain diets, including foods high in saturated fats, cholesterol, and salt
Lack of exercise
Heavy drug and alcohol use

Blood flow ED factors

Many health conditions reduce blood flow into the penis, compromising its ability to get and stay hard. Blood flow issues (also called “vascular” or “vasculogenic”) are the most common cause of ED. ^[4]

Some common vasculogenic causes of ED:

Corporal veno-occlusive dysfunction (CVOD): The most common vasculogenic cause of ED is corporal veno-occlusive dysfunction. Also called venous leakage, CVOD is found in 67%–75% of men with ED. ^[7]
Hypertension (high blood pressure): Hypertension hardens arteries, which restricts blood flow to the penis. Around 40% of men with ED also have hypertension. ^[4] With age, risk increases for hypertension to contribute to erectile dysfunction.

Diabetes (high blood sugar): Erectile dysfunction is 3.5 times more common for men with diabetes than men without it. ^[8] Due to high blood sugar, diabetes can damage nerves and restrict blood flow to the penis, hindering erections. Around one-third of men with diabetes also have hypogonadism (low testosterone), another cause of erectile dysfunction.
Cardiovascular disease: Erectile function and heart health are related. The Urology Care Foundation warns that ED is linked to cardiovascular disease and can sometimes serve as an early warning sign for it. ^[5]
Priapism: Priapism is a prolonged, unwanted erection. Left unaddressed, it can lead to untreatable ED. The Urology Care Foundation advises that people with erections longer than two to four hours seek emergency medical care. Erections that last more than 36 hours lead to permanent erectile dysfunction. ^[9]
Arterial disease: Arterial ED usually stems from arteriosclerosis, the hardening of the arteries. Johns Hopkins Medicine warns that “the controllable risk factors for arteriosclerosis—being overweight, lack of exercise, high cholesterol, high blood pressure, and cigarette smoking—can cause erectile failure often before progressing to affect the heart.” ^[6]

ED, cardiovascular disease, and depression

Studies show that ED, cardiovascular disease, and depression are linked and tend to reinforce each other. If you have depression and suspect erectile dysfunction, experts recommend heading to the doctor. A comprehensive look at your physical and mental health can help uncover the root cause(s), and you can take cautionary measures if cardiovascular issues are at play ^[6] .

Medical conditions as ED factors

Various medical conditions can cause erectile dysfunction—and ED often has multiple causes and/or coexisting conditions. These medical conditions and treatments can contribute to ED: ^[4]

High cholesterol: Also known as hyperlipidemia, high cholesterol levels are found in 42% of men with ED.
Enlarged prostate: Up to 80% of men with benign prostatic hyperplasia (enlarged prostate) with lower urinary symptoms (BPH with LUTS) also have ED. ^[10]
Peyronie’s disease: With this condition, also called penile fibrosis, scar tissue causes the penis to curve. Experts aren’t yet sure exactly why men with Peyronie’s disease often develop ED, but they believe it may be due to scar tissue interference with the erectile tissue’s normal function. ^[11]
Other conditions: Strokes, glaucoma, sleep apnea, obesity, and chronic obstructive pulmonary disease (COPD) are also associated with erectile dysfunction.
Cancer treatments: ED can result from cancer surgeries or radiation treatments. For those with prostate cancer, 85% of radical prostatectomy surgery patients can expect ED afterward. Definitive radiation therapy has less ED risk at 25%.
Medication side effects: Many prescription medications can cause erectile dysfunction, including certain medications for heart disease, hypertension, insomnia, peptic ulcers, and depression. Some recreational drugs also contribute to ED. ^[6]
Premature ejaculation (PE): PE increases the risk of ED by four times, according to a recent review. ^[12] This risk increased for older patients and men with anxiety and depression. ED treatment often alleviates PE.

Psychological ED factors

Psychological (psychogenic) factors can also cause erectile dysfunction. Even when physical ED causes are at play, psychological factors can play a big part.

A 2023 review outlines common psychological causes for ED: ^[13]

Anxiety
Depression
Acute or chronic stress
Sexual attitudes and schemas
Relationship/interpersonal conflicts
Antidepressant medication side effects
Cognitive interference (performance anxiety, shifts in attention)
Personality (high neuroticism and low extraversion increases ED risks) ^[14]

ED, perspective, and attitude

The extent to which ED impacts depression and well-being might depend on your perception of ED, according to recent research. The researchers elaborate on sexual attitude as an ED factor: “An individual with the mindset that ‘I can sexually please my partner in other ways, which is still exciting for me’ might be less likely to be adversely affected by erectile dysfunction.” ^[13]

Erectile dysfunction treatment

Your primary care physician or urologist can help you find personalized ED treatment options. They might suggest lifestyle changes, psychological treatment, or medication before exploring more invasive ED treatment options like surgery. Common ED treatment options include: ^[5]

Penile injections

Vacuum erection devices
Hormone replacement therapy
Psychotherapy, couples therapy
Treatment for depression or anxiety
Intraurethral medication (IU Alprostadil, IU PDE5i gels)
Oral medications [Phosphodiesterase type 5 (PDE5) inhibitors such as avanafil (Stendra), vardenafil (Levitra), tadalafil (Cialis), and sildenafil (Viagra)
Lifestyle adjustments (e.g. diet, exercise, or reducing smoking/alcohol/drugs)
Penile implants (inflatable penile prosthesis or semi-rigid penile prosthesis)

Regenerative therapies such as stem cell injections, platelet rich plasma, or penile shockwave treatments are still considered investigational or experimental by the AUA.

What to expect during an ED appointment

Your doctor will likely ask about your ED severity, medical history, and treatment preferences. Curious about what else might come up? The Urology Care Foundation website has typical ED questions from doctors and what to expect from physical ED exams. Our article,

“How to Talk About Your Sexual Health,” might also come in handy.

ED treatment efficacy

The most effective ED treatment will vary by person. That said, testosterone therapy and PDE5 inhibitors were deemed the most effective ED treatments in a 2019 review that had more than 3 million study participants. ^[15] Psychological treatments and behavioral changes were deemed about as effective as medication but are a bit harder to measure precisely.

Among ED medications, erection onset and duration vary. ^[16] Vardenafil has a fast onset (as fast as 15 minutes), while tadalafil has a longer duration (as long as 36 hours).

ED prescription savings

Want to save money by going generic? The prescription service Hims offers lower-priced generic ED medications, like tadalafil (generic Cialis) and sildenafil (generic Viagra).

Bottom line

Erectile dysfunction affects millions of men in the United States, and it’s more common as we age. While vascular issues are the primary cause, various factors like neurological, hormonal, and lifestyle aspects can contribute. There’s no shame in getting treatment for ED, and there are many options to consider—from medications to lifestyle changes and surgeries. Your health care provider can help you find underlying ED causes and offer treatment options tailored to your needs.

Frequently asked questions

Vascular (blood flow) issues are the leading cause of erectile dysfunction. That said, a lot of factors can contribute to ED, such as neurological disorders, hormonal imbalances, cardiovascular disease, psychological causes, genetics, diabetes, lifestyle factors, and medication side effects.

You have plenty of options. Because erectile dysfunction has so many possible causes and coexisting conditions, it’s best to visit your urologist or primary care physician. They can tailor a treatment plan to your needs.

Medications like Viagra and Cialis can help boost blood flow to the penis. Lifestyle changes like diet, exercise, or reducing smoking/alcohol/drug usage can also help ED. Psychotherapy can treat psychological causes. Other common ED treatments include penile injections, penile implants, vacuum erection devices, hormone replacement therapy, and intraurethral medication.

Have questions about this review? Email us at reviewsteam@ncoa.org.

Sources

National Institute of Diabetes and Digestive and Kidney Diseases. Erectile dysfunction (ED). July 2017. Found on the internet at https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction
International Society for Sexual Medicine. How do erections work? Found on the internet at https://www.issm.info/sexual-health-qa/how-do-erections-work
Mark K, et al. Erectile Dysfunction Prevalence in the United States: Report From the 2021 National Survey Of Sexual Wellbeing. Journal of Sexual Medicine. Feb 26, 2024. Found on the internet at https://pubmed.ncbi.nlm.nih.gov/38410029/
Leslie S, Sooriyamoorthy T. Erectile Dysfunction. StatPearls Publishing. Jan. 9, 2024. Found on the internet at https://www.ncbi.nlm.nih.gov/books/NBK562253/
Urology Care Foundation. Erectile dysfunction (ED). June 2018. Found on the internet at https://www.urologyhealth.org/urology-a-z/e/erectile-dysfunction-(ed)
Johns Hopkins Medicine. Erectile dysfunction. Found on the internet at https://www.hopkinsmedicine.org/health/conditions-and-diseases/erectile-dysfunction
Ferrini M, et al. Aging Related Erectile Dysfunction—Potential Mechanism to Halt or Delay Its Onset. Translational Andrology and Urology Journal. February 2017. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5313305/
Kouidrat Y, et al. High Prevalence Of Erectile Dysfunction In Diabetes: A Systematic Review And Meta-Analysis Of 145 Studies. Diabetic Medicine Journal. September 2017. Found on the internet at https://pubmed.ncbi.nlm.nih.gov/28722225/
Bennett N, Mulhall J. Sickle Cell Disease Status and Outcomes of African-American Men Presenting with Priapism. The Journal of Sexual Medicine. May 5, 2008. Found on the internet at https://pubmed.ncbi.nlm.nih.gov/18312286/
Seftel AD, et al. Coexisting Lower Urinary Tract Symptoms and Erectile Dysfunction: A Systematic Review of Epidemiological Data. International Journal of Clinical Practice. Oct. 22, 2012. Found on the internet at https://pubmed.ncbi.nlm.nih.gov/23082930/\
Campbell J, Alzubaidi R. Understanding the Cellular Basis and Pathophysiology of Peyronie’s Disease to Optimize Treatment for Erectile Dysfunction. Translational Andrology and Urology. February 2017. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5313310/
Corona G. Erectile Dysfunction and Premature Ejaculation: A Continuum Movens Supporting Couple Sexual Dysfunction. Journal of Endocrinological Investigation. May 3, 2022. Found on the internet at https://link.springer.com/article/10.1007/s40618-022-01793-8
Allen M, et al. The Psychology of Erectile Dysfunction. Current Directions in Psychological Science. Sept. 8, 2023. Found on the internet at https://journals.sagepub.com/doi/10.1177/09637214231192269
Allen M, Walter E. Linking Big Five Personality Traits to Sexuality and Sexual Health: A Meta-Analytic Review. Psychology Bulletin Journal. Found on the internet at https://pubmed.ncbi.nlm.nih.gov/29878796/
Allen M, Walter E. Erectile Dysfunction: An Umbrella Review of Meta-Analyses of Risk-Factors, Treatment, and Prevalence Outcomes. The Journal of Sexual Medicine. April 2019. Found on the internet at https://pubmed.ncbi.nlm.nih.gov/30833150/
Gareri P, et al. Erectile Dysfunction in the Elderly: An Old Widespread Issue with Novel Treatment Perspectives. International Journal of Endocrinology. March 17, 2014. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3976909/

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