Erectile dysfunction: causes, treatment options and when to see a doctor

Most men have an occasional night when an erection does not cooperate, and on its own that means very little. Erectile dysfunction (ED) is different: it describes a pattern where getting or keeping an erection firm enough for satisfying sex becomes unreliable over weeks or months. It is a medical condition with identifiable causes, it is common, and in many men it can be treated. This guide gives an overview of what ED is, why it happens, the options doctors use, and when it is worth booking an appointment rather than waiting it out.

What counts as erectile dysfunction

Doctors define ED as a persistent difficulty getting or maintaining an erection that is good enough for satisfying sexual activity. The word "persistent" matters. A single difficult evening after a long day, a few drinks or a stressful week is not ED. A change that keeps coming back, or that has gradually crept in over months, is worth taking seriously.

ED also exists on a scale. Some men find erections are softer than they used to be, or fade before sex is finished. Others can get an erection on their own but not with a partner, or the other way round. Some men find erections are rarely possible at all. Where a man sits on that scale, and what pattern he notices, gives a doctor useful clues about the likely cause.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, ED is not a routine or inevitable part of getting older. It becomes more common with age, but that is largely because the conditions behind it (such as diabetes, high blood pressure and narrowed arteries) also become more common.

How common is it?

ED is one of the most common health problems men experience, even though it is rarely talked about. In the Massachusetts Male Aging Study, a long-running community study of men aged 40 to 70, about half reported some degree of ED, from minimal to complete. Complete ED rose from roughly 5% of men at age 40 to about 15% at 70.

A later US national survey estimated that around 18% of men aged 20 and over, close to 18 million men at the time, had ED, with rates climbing sharply in older age groups. Different studies use different definitions and severity cut-offs, so the exact figures vary, but the overall picture is consistent: ED is widespread, and it becomes more likely with each decade.

Why it happens

An erection depends on several systems working together. Nerves carry signals from the brain and from touch, blood vessels in the penis relax to let blood flow in, and hormones and mood set the background. A problem anywhere in that chain can interfere.

The main groups of causes are:

• Blood vessel problems, such as narrowed or stiffened arteries, which are linked to high blood pressure, high cholesterol and smoking.
• Metabolic and long-term conditions, including diabetes, obesity and chronic kidney disease.
• Hormonal factors, such as low testosterone or thyroid problems.
• Nerve-related causes, including spinal injury, multiple sclerosis and some pelvic surgery.
• Medications, including some antidepressants and blood pressure medicines.
• Psychological factors, such as stress, anxiety, depression and relationship strain.
• Lifestyle factors, including heavy drinking, smoking, recreational drugs and low physical activity.

In practice, most men have more than one factor at play. A physical cause often brings anxiety with it, which can make things worse. Our guide to what causes erectile dysfunction goes through each group in more detail.

The link with heart health

The arteries that supply the penis are small, so they can show the effects of narrowing earlier than the larger arteries around the heart. Large studies have found that men who develop ED have a higher risk of later heart attacks and strokes, and in many men ED appears a few years before any heart symptoms.

That is why doctors increasingly treat new ED as a reason to check blood pressure, cholesterol, blood sugar and overall heart risk, especially in younger men. ED can be an opportunity to pick up a problem early. Our guide to ED and heart health explains the connection and what a sensible check-up looks like.

Treatment options

There is no single treatment that suits everyone. A doctor will usually look at the likely causes, general health, other medications and personal preferences before suggesting a plan. Options generally fall into a few groups.

Lifestyle changes

For many men, improving the factors behind ED is the foundation of treatment. In a randomized trial of men with obesity, a program of diet and exercise aimed at weight loss led to a meaningful improvement in erectile function for about a third of participants. Stopping smoking, cutting back on alcohol and being more active may help both erections and long-term heart health. See our guide to lifestyle changes for ED.

PDE5 inhibitors such as tadalafil

The most widely used medicines for ED belong to a class called PDE5 inhibitors. They support the natural process that relaxes blood vessels in the penis, so they help an erection happen in response to sexual stimulation rather than causing one on their own. Tadalafil is one of these medicines. It is long-acting and is FDA-approved for ED both as a lower daily dose and as a higher dose taken when needed. Our guide to tadalafil for ED covers how it works and what the evidence shows.

Centrally acting options such as apomorphine

Apomorphine works differently. Instead of acting on blood vessels, it acts on dopamine pathways in the brain that help start the erection process. It was studied as an under-the-tongue tablet for ED and was authorized for a time in Europe, but it has never been FDA-approved for ED in the United States. Our guide to apomorphine explains what is known.

Other medical options

Some men use vacuum devices, medicines injected into or placed in the penis, or, less often, surgical implants, usually under the care of a urologist.

Psychological support

When stress, anxiety or relationship difficulties are part of the picture, talking therapy or sex therapy may help, either alone or alongside medication. Our guide to performance anxiety and ED looks at this side of things.

What Curekey is preparing

Curekey is preparing a physician-prescribed dissolvable tablet that combines tadalafil 3 mg and apomorphine 1 mg. It is a compounded medication, meaning it is prepared by a licensed pharmacy for individual patients. It is not FDA-approved, and the two medicines have not been studied together as a combination in published clinical trials. A licensed physician would review each man's health history before deciding whether it is appropriate. Our guide to tadalafil and apomorphine together sets out plainly what is and is not known about the combination.

Safety basics

ED medicines are not suitable for everyone. Men who take nitrate medicines for chest pain, or who use "poppers" (amyl or butyl nitrite), must not take PDE5 inhibitors such as tadalafil, because the combination can cause a dangerous fall in blood pressure. Men with recent heart attacks or strokes, unstable chest pain or very low or uncontrolled blood pressure need specialist advice first. Apomorphine has its own interactions, including with some anti-nausea medicines. Our guides to ED medication safety and side effects go into detail.

Get emergency help if you have chest pain during or after sex, an erection that lasts longer than 4 hours, or a sudden loss of vision or hearing.

When to see a doctor

It is worth speaking to a doctor if:

• erection problems have lasted for more than a few weeks or keep returning
• ED started suddenly, or appeared alongside other new symptoms
• you have diabetes, high blood pressure, heart disease or high cholesterol
• you take medicines that might be contributing
• the problem is affecting your mood, confidence or relationship

A doctor can look for underlying causes, check your heart health, review your medicines and talk through options. There is nothing embarrassing about raising it: ED is a routine part of men's health care, and the conversation can lead to useful findings beyond the bedroom.

Explore this topic

• What causes erectile dysfunction?: the physical, psychological and lifestyle factors behind ED.
• ED and heart health: why ED can be an early warning sign of cardiovascular disease.
• Tadalafil for ED: how this PDE5 inhibitor works, doses and evidence.
• Apomorphine for ED: a centrally acting option and its regulatory history.
• Tadalafil and apomorphine together: what is and is not known about the combination.
• ED medication safety: who should not take ED medicines, and dangerous interactions.
• Side effects of ED medicines: what to expect and when to get help.
• Lifestyle changes for ED: exercise, weight, smoking and alcohol.
• Performance anxiety and ED: the psychological side and talking with a partner.

Sources

1. National Institute of Diabetes and Digestive and Kidney Diseases: Symptoms and causes of erectile dysfunction
2. Feldman HA et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol, 1994
3. Selvin E et al. Prevalence and risk factors for erectile dysfunction in the US. Am J Med, 2007
4. Thompson IM et al. Erectile dysfunction and subsequent cardiovascular disease. JAMA, 2005
5. Esposito K et al. Effect of lifestyle changes on erectile dysfunction in obese men. JAMA, 2004
6. Tadalafil US prescribing information (DailyMed)
7. US Food and Drug Administration: Compounding and the FDA, questions and answers
8. Nehra A et al. The Princeton III Consensus recommendations. Mayo Clin Proc, 2012

This article is for education only and is not a substitute for professional medical advice. Do not start, stop or change a medication without speaking to a licensed clinician. If you have chest pain, an erection lasting more than four hours, or sudden loss of vision or hearing, seek emergency care.