Erectile dysfunction (ED)

What is erectile dysfunction?

Erectile dysfunction is the persistent difficulty getting or keeping an erection firm enough for satisfying sexual activity. It is one of the most common conditions urologists treat, and it becomes more frequent with age — though it is not an inevitable part of aging. An erection depends on healthy blood flow, nerves, hormones and psychological well-being, so ED can reflect changes in any of these systems.

Common causes

ED is frequently multifactorial. Contributing factors include:

• Vascular: high blood pressure, atherosclerosis, high cholesterol, diabetes — the most common physical causes.
• Neurologic: nerve injury, pelvic or prostate surgery, spinal cord conditions, diabetes-related nerve damage.
• Hormonal: low testosterone and other endocrine imbalances.
• Lifestyle: smoking, excessive alcohol, obesity, and physical inactivity.
• Psychological: stress, anxiety, depression and relationship factors.
• Medication-related: certain blood pressure drugs, antidepressants and others.

How ED is diagnosed

Evaluation begins with a confidential conversation about your symptoms, medical history and medications, followed by a focused physical exam. Depending on your situation, testing may include blood work (such as glucose, lipids and testosterone) and, in select cases, specialized vascular studies. The goal is to identify treatable underlying causes — not just the symptom.

Treatment options

ED is highly treatable. Care is tailored to the cause, your health and your preferences, and typically follows a stepwise approach:

• Lifestyle changes: exercise, weight management, quitting smoking, and better control of diabetes, blood pressure and cholesterol.
• Oral medications (PDE5 inhibitors): sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra) are the most studied first-line therapy. See our ED medications guide.
• Other medical therapies: options such as injection therapy, vacuum devices, urethral suppositories, and testosterone treatment when a deficiency is present.
• Procedural options: penile implants for men who do not respond to or prefer not to use other treatments.

A closer look at ED medications

Oral PDE5 inhibitors work by improving blood flow into the penis in response to sexual stimulation. They are prescription medications and are not appropriate for everyone — in particular, they should never be combined with nitrate heart medications. We've put together detailed, evidence-based guides to each one: