Clinical Summary
See a doctor if ED persists for 3+ months, happens with most attempts at sex, or is accompanied by other symptoms. ED can be an early warning sign of heart disease, diabetes, or other serious conditions. Treatment is available and effective for most men.
Emergency Indications
Seek immediate medical attention if you experience:
- Chest pain or shortness of breath during sexual activity
- Painful erection lasting >4 hours (priapism - medical emergency)
- Sudden onset ED after head or genital trauma
- Curved or bent erection that prevents intercourse (Peyronie's disease)
Indications for Evaluation
Schedule an appointment with your physician if:
- Persistent erectile dysfunction occurring for 3 or more months
- Progressive worsening of erectile function over time
- Relationship impact causing significant distress
- Associated symptoms including decreased libido, premature ejaculation, or delayed ejaculation
- Comorbid conditions such as diabetes, hypertension, or cardiovascular disease
- Medication-related onset following initiation of new pharmacotherapy
- Psychological impact including depression, anxiety, or diminished self-esteem
Pathophysiology
Erectile dysfunction is defined as the consistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance. This condition affects approximately 30 million men in the United States.
Note: Occasional erectile difficulty is within normal physiological parameters and does not constitute erectile dysfunction. Clinical diagnosis requires persistent symptoms over several months affecting the majority of sexual encounters.
Etiology
Vascular Causes
Vascular insufficiency represents the most common etiological factor:
- Atherosclerosis: Arterial plaque formation (predominant cause)
- Hypertension: Endothelial dysfunction and vessel wall damage
- Hyperlipidemia: Contributes to progressive arterial stenosis
- Diabetes mellitus: Microvascular and macrovascular complications
- Obesity: Associated metabolic syndrome and vascular disease
Clinical Pearl: ED often precedes myocardial infarction by 3-5 years, serving as a sentinel marker for cardiovascular disease.
Neurological Causes
- • Multiple sclerosis: Nerve damage
- • Parkinson's disease: Affects nerve signals
- • Spinal cord injury: Disrupts nerve pathways
- • Stroke: Can affect erectile function
- • Pelvic surgery: Prostate, bladder, colon surgery
Hormonal Causes
- • Low testosterone: Affects libido and erectile function
- • Thyroid disorders: Hypo or hyperthyroidism
- • Pituitary problems: Elevated prolactin
- • Metabolic syndrome: Cluster of conditions
Psychological Causes
- • Performance anxiety: Fear of not performing well
- • Stress: Work, financial, relationship stress
- • Depression: Affects libido and function
- • Anxiety disorders: Generalized anxiety
- • Relationship problems: Communication, intimacy issues
- • Note: Psychological and physical causes often overlap
Medication Side Effects
- • Blood pressure medications: Beta-blockers, diuretics
- • Antidepressants: SSRIs especially
- • Antipsychotics: Various psychiatric medications
- • Antihistamines: H2 blockers like cimetidine
- • Prostate medications: Finasteride
Lifestyle Factors
- • Smoking: Damages blood vessels
- • Excessive alcohol: Impairs nerve function
- • Drug use: Marijuana, cocaine, amphetamines
- • Lack of exercise: Poor cardiovascular health
- • Sleep disorders: Sleep apnea
ED as a Warning Sign
ED often signals cardiovascular disease:
- • Shared risk factors: Same causes as heart disease
- • Early warning: Penile arteries smaller, show damage first
- • Timeline: ED typically appears 3-5 years before heart attack
- • Don't ignore: Evaluation may reveal treatable cardiovascular disease
- • Benefit: Treating ED risk factors improves heart health
What Your Doctor Will Check
Medical & Sexual History
- • Detailed sexual history (onset, frequency, morning erections)
- • Cardiovascular risk factors
- • Medication review
- • Psychological assessment
- • Relationship status and issues
Physical Exam
- • Vital signs: Blood pressure, heart rate
- • Genital exam: Check for anatomical abnormalities
- • Vascular exam: Peripheral pulses
- • Neurological: Sensation, reflexes
Laboratory Tests
- • Testosterone levels: Morning blood test
- • Glucose/HbA1c: Check for diabetes
- • Lipid panel: Cholesterol levels
- • Thyroid function: TSH
- • PSA: Prostate health (if indicated)
Treatment Options
First-Line: Oral Medications (PDE5 Inhibitors)
- • Sildenafil (Viagra): Lasts 4-5 hours, take 30-60 min before sex
- • Tadalafil (Cialis): Lasts up to 36 hours, daily or as-needed
- • Vardenafil (Levitra): Similar to sildenafil
- • Avanafil (Stendra): Fastest onset, 15-30 minutes
- • Success rate: 70-85% of men
- • Side effects: Headache, flushing, nasal congestion (usually mild)
- • Warning: Do NOT take with nitrates (heart medication) - dangerous interaction
Second-Line Treatments
- • Penile injections: Alprostadil directly into penis (very effective)
- • Urethral suppository: Alprostadil pellet inserted into urethra
- • Vacuum erection device: Mechanical pump creates erection
- • Testosterone replacement: If low testosterone confirmed
Surgical Options
- • Penile implants: Inflatable or malleable rods (last resort)
- • Success rate: 90-95% satisfaction
- • Vascular surgery: Rarely appropriate (only young men with trauma)
Psychological Therapy
- • Sex therapy: For psychological causes
- • Cognitive behavioral therapy: Address anxiety, depression
- • Couples counseling: Improve communication, intimacy
- • Combined approach: Often combine with medications
Lifestyle Changes That Help
- • Exercise regularly: 30-40 minutes, 4x/week improves function
- • Lose weight: If overweight - BMI reduction helps significantly
- • Quit smoking: Improves blood flow within weeks
- • Limit alcohol: No more than 2 drinks/day
- • Mediterranean diet: Heart-healthy eating improves ED
- • Manage stress: Meditation, yoga, adequate sleep
- • Communicate: Open dialogue with partner reduces anxiety
Medical Review
Reviewed by: Ricardo Hamilton, MD
Last Updated: November 26, 2025
Sources: American Urological Association, Mayo Clinic, National Institutes of Health