What Is Erectile Dysfunction?
Medically reviewed by Matthew Wosnitzer, MD
Erectile dysfunction (ED), formerly known as impotence, is the inability to achieve or maintain a penile erection firm enough for sex. ED is more common in older people but is not "caused" by age and can ultimately affect people of any age. Most cases are due to physical causes, but there are also psychological factors that can contribute to or independently cause ED.
ED can have a profound effect on a person's self-image and undermine both their confidence and relationships. While ED tends to be chronic and progressive due to natural changes in an aging body, many cases are temporary. Whatever the situation, there are treatments that can help, including medications, lifestyle changes, devices, therapy, and even surgery.
The article describes the causes and symptoms of erectile dysfunction. It also helps you navigate the treatment options and how to discuss ED with both your partner and healthcare provider.
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A Note on Gender and Sex Terminology
Verywell Health acknowledges that sex and gender are related concepts, but they are not the same.
Sex refers to biology: chromosomal makeup, hormones, and anatomy. People are most often assigned male or female at birth based on their external anatomy; some people do not fit into that sex binary and are intersex.
Gender describes a person's internal sense of self as a woman, man, nonbinary person, or another gender, and the associated social and cultural ideas about the roles, behaviors, expressions, and characteristics.
Research studies sometimes don't use the terminology in this way. For example, terms that describe gender (“woman,” “man”) may be used when terms for sex (“female,” “male”) are more appropriate.
To reflect our sources accurately, this article uses terms like "female," "male," "woman," and "man" as the sources use them.
Related: How Common Is Erectile Dysfunction?
Erectile Dysfunction Causes
The causes of erectile dysfunction can be broadly classified as being either organic (physical) or psychogenic (psychological). These causes can contribute independently or collectively to a condition that affects roughly 30 million people in the United States, according to the National Institutes of Health.
Organic Causes
One of the main risk factors for ED is older age. Before age 40, only around 2.1% of males experience ED. Thereafter, the rate steadily increases with each decade—from 5.7% between the age of 40 to 50 to 11.5% between the ages of 60 and 69.
Other studies suggest that the rate is far higher, ranging anywhere from 26% to 76% by age 80.
There are several reasons for this. Levels of testosterone (a hormone that influences sexual function in males) naturally decline with age, along with the muscles, blood vessels, and nerves that facilitate erections. Also, many diseases common in older people can undermine how these muscles, blood vessels, and nerves work.
Many of these diseases can also affect males under 40 and lead to the earlier onset of ED symptoms.
Organic causes of EC include:
Atherosclerosis (hardening of the arteries)
Hypertension (high blood pressure)
Hypogonadism (testosterone deficiency)
Lifestyle factors like smoking and alcohol or substance abuse
Having obesity and metabolic syndrome (a group of conditions that combined can lead to a higher risk of stroke, heart disease, and type 2 diabetes)
Pelvic or spinal cord surgery or trauma
Peyronie's disease (fibrous scar tissue develops on the penis causing it to curve and leading to painful erections)
Prescription drugs like alpha-blockers (blood pressure medicine), antidepressants, antihistamines, and H2 blockers (ulcer medications)
Sleep disorders like obstructive sleep apnea (breathing stops and restarts throughout the night)
Related: Risk Factors of Erectile Dysfunction
Is ED Psychological?
Psychogenic causes of ED can affect people of any age but are far more common in those under age 40. Psychogenic causes are more likely when someone has normal erections with masturbation or experiences erections while asleep or waking.
Psychogenic causes of ED include:
Anxiety, including performance anxiety and financial or work-related stress
Depression, which decreases sex drive and increases the risk of alcohol/substance abuse
Low self-esteem, including poor body image or concerns about penis size
Relationship issues, including a fear of commitment, a loss of attraction, and the desire to avoid pregnancy
Feelings of guilt related to past performance or infidelity
Cultural or religious beliefs that promote feelings of inadequacy, shame, or guilt
Sexual trauma, including a history of sexual abuse or violence
A Vicious Cycle
How a person thinks or feels can have a cause-and-effect relationship to ED. On the one hand, anxiety or depression can lead to erectile dysfunction. On the other, a person with ED may develop anxiety or depression as a result of their dysfunction which only makes ED symptoms worse.
Related: Erectile Dysfunction in Younger Males
Erectile Dysfunction Symptoms
Erectile dysfunction is the regular or repeated inability to achieve or maintain an erection of sufficient firmness to engage in sex. How ED manifests can differ from one person to the next.
You can get an erection sometimes, but not every time you want to have sex.
You can get an erection but can't keep it long enough for fulfilling or satisfactory sex.
You are unable to get an erection at any time.
While the degree of dysfunction can vary, what most people with ED share are feelings of frustration and an unfulfilled sex life. This may not only affect their relationship but also their general well-being and how they see or feel about themselves.
ED can also affect a couple's chances of getting pregnant, further adding to the stress. A 2013 study in the Journal of Sexual Medicine reported that the rate of ED among males with infertility was more than double that of males with fertility (18.05% vs. 8.28%).
How Long Is the Average Erection?
The duration of an erection can vary by a person's age, but most studies suggest that a healthy young person can sustain an erection for around 30 minutes with a rigidity of roughly 70%.
Talking With a Healthcare Provider About ED
You may find it embarrassing to speak with a healthcare provider about ED, but doing so can improve both your sex life and quality of life. If you feel awkward talking to your primary care provider, meet with a urologist (a specialist in disorders of the reproductive tract), if possible.
When meeting with a provider, come prepared with all the information needed to help narrow the causes of your condition. This includes what you are experiencing physically and what you feel emotionally.
This should include:
How often you can get an erection
How long you can sustain an erection
When the problem started
If there are specific situations where you are unable to get an erection
Any medical conditions you have, including past surgeries
Any medications you take
What your daily lifestyle is like
Whether you smoke, drink, or take drugs
If you have relationship problems
If you are experiencing stress, anxiety, or depression
If you have other symptoms like genital pain or urination problems
The more your healthcare provider knows, the better able they will be to offer a diagnosis and deliver effective treatment.
Related: What Causes Sudden ED?
Erectile Dysfunction Treatment: Different Approaches
Some cases of ED may go away on their own. But more often than not, treatment is needed. Sometimes, several treatments may be prescribed based on the underlying cause or causes.
Lifestyle Changes
Positive lifestyle changes help manage health conditions that contribute to ED and improve your mood and feelings about yourself.
These lifestyle changes may include:
Eating a healthy, low-fat diet
Achieving and maintaining a healthy weight
Exercising routinely
Quitting cigarettes
Improving your sleep habits
Reducing alcohol intake
Avoiding recreational drugs
Prescriptions
Prescription medications are typically the frontline response for treating ED. Oral ED medications may be prescribed for mild to moderate cases. People who do not respond to these drugs may be given medications injected into the penis.
Two categories of drugs are used to treat ED directly:
Phosphodiesterase type 5 (PDE5) inhibitors: This is the first-line option for ED that works by relaxing blood vessels in the penis. Options include Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil), and Stendra (avanafil).
Alprostadil: This vasodilator drug works by widening blood vessels in the penis. Caverject is the form injected into the penis, while Muse is a suppository inserted into the opening of the penis (urethra).
ED and Testosterone Therapy
Testosterone replacement therapy, prescribed as an injection, patch, or gel, may also be used if diagnosed with hypogonadism. Testosterone does not help with ED if you have normal testosterone levels.
Devices
Two devices are commonly used to achieve and sustain an erection, either on their own or in combination with ED medications:
Vacuum erectile device (VED): Also known as a penile pump, the cylindrical device is placed over the penis and draws blood into the penis with gentle suction.
Constriction ring: Also known as a cock ring, this is an elastic band placed around the base of the penis and testicles ("balls") to retain blood during an erection.
Surgery
When conservative treatments fail to improve ED (or you have a neurological or vascular condition that makes erections impossible), surgery may be considered.
Two possible options include:
Penile revascularization: This is a type of bypass surgery used to redirect and improve blood flow into the penis. It is typically performed by a urologic surgeon trained in microsurgery.
Penile implant surgery: These are devices implanted into the shaft of a penis to make it rigid. There are inflatable implants that you manually pump up and semi-rigid implants that you bend into shape.
Psychotherapy
People with psychogenic ED (or those experiencing anxiety or depression as a result of ED) may be advised to seek therapy to root out the psychological causes of their condition.
Treatment modalities include:
Cognitive-behavioral therapy (CBT): Used to identify and change negative thought patterns and behaviors
Sex-positive education: Used to remove judgment, shame, or guilt from sex by stressing consensual consent and pleasure
Masturbation skills training: Used to identify and focus on thoughts, fantasies, and sensations that spur sexual arousal
Sensate focus: Used in couples to increase the awareness and sensitivity of touch without preconceived notions of what "should" happen
Medications may be needed for people with severe depression or anxiety, including those with post-traumatic stress disorder (PTSD).
How to Talk to Your Partner About Erectile Dysfunction
Erectile dysfunction creates stress for the person who has it and their partner in a relationship. By creating an open and healthy dialogue, you affirm not only your commitment to finding a solution but your commitment to each other as well.
Here are ways to achieve effective communication:
Find the right time to talk: Instead of bringing up ED in the bedroom, find a time and place where you can sit without distraction and neither person feels vulnerable or "on the spot."
Don't make assumptions: While it's important to educate yourself about ED, don't try to "diagnose" ED. It can kill two-way conversation and lead to arguments if you don't agree.
Focus on feelings: Discuss how you feel rather than how your partner makes you feel. Acknowledge and discuss your partner's feelings rather than trying to defend yourself.
Keep on topic: Now is not the time to bring in all of the other issues in your relationship. Remember that you are not here to air grievances but to find solutions.
Use your healthcare provider: Consider going to the next appointment together. Couples who work together—and learn the facts about ED together—are more likely to find a solution.
Related: Living Well With Erectile Dysfunction
Outlook for ED
The treatment of erectile dysfunction has historically been challenging, but the introduction of Viagra in 1998 dramatically improved the outlook for people who previously had to live with their condition. Today, the success rate for Viagra and Cialis hovers between 50% and 85%, depending on a person's age and the severity of their condition.
Even people with prostate cancer who have had their prostate removed may experience a twofold improvement in ED symptoms compared to counterparts not treated with PDE5 inhibitors.
Psychotherapy has also greatly improved outcomes for people with psychogenic ED and those being treated for organic causes. Studies have shown that PDE5 inhibitors remain more effective over the long term if paired with couples therapy, further highlighting how physiology and emotion contribute to the risk and treatment of erectile dysfunction.
Related: Can You Prevent Erectile Dysfunction?
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