Erectile dysfunction, or ED, is the most common sex problem that men report to their doctor. It affects as many as 30 million men. ED is defined as trouble getting or keeping an erection that's firm enough for sex.
Though it's not rare for a man to have some problems with erections from time to time, ED that is progressive or happens routinely with sex is not normal, and it should be treated.
ED can happen:
  • Most often when blood flow in the penis is limited or nerves are harmed 
  • With stress or emotional reasons
  • As an early warning of a more serious illness, like: atherosclerosis (hardening or blocked arteries), heart disease, high blood pressure or high blood sugar from Diabetes
Finding the cause(s) of your ED will help treat the problem and help with your overall well-being. As a rule, what's good for your heart health is good for your sex health.
How Erections Work
During sexual arousal, nerves release chemicals that increase blood flow into the penis. Blood flows into two erection chambers in the penis, made of spongy muscle tissue (the corpus cavernosum). The corpus cavernosum chambers are not hollow.

During erection, the spongy tissues relax and trap blood. The blood pressure in the chambers makes the penis firm, causing an erection. When a man has an orgasm, a second set of nerve signals reach the penis and cause the muscular tissues in the penis to contract and blood is released back into a man's circulation and the erection comes down. When you are not sexually aroused, the penis is soft and limp. Men may notice that the size of the penis varies with warmth, cold or worry; this is normal and reflects the balance of blood coming into and leaving the penis.
Symptoms

With Erectile Dysfunction (ED), it is hard to get or keep an erection that is firm enough for sex. When ED becomes a routine and bothersome problem, your primary care provider or a Urologist can help.

ED may be a major warning sign of cardiovascular disease indicating blockages are building in a man's vascular system. Some studies have shown men with ED are at significant risk of getting a heart attack, stroke or circulatory problems in the legs. ED also causes:

    • Low self-esteem
    • Depression
    • Distress for the man and his partner 

    If ED is affecting a man's well-being or his relationships, it should be treated. Treatment aims to fix or enhance erectile function, help circulatory health and help the quality of a man's life.

    Causes

    ED can result from health problems, emotional issues, or from both. Some known risk factors are:

    • Being over age 50 
    • Having high blood sugar (Diabetes)
    • Having high blood pressure 
    • Having cardiovascular disease
    • Having high cholesterol
    • Smoking
    • Using drugs or drinking too much alcohol
    • Being obese
    • Lacking exercise

    Even though ED becomes more common as men age, growing old is not always going to cause ED. Some men stay sexually functional into their 80s. ED can be an early sign of a more serious health problem. Finding and treating the reason for ED is a vital first step.

    Physical Causes of ED

    ED happens when:

    There is not enough blood flows into the penis

    Many health issues can reduce blood flow into the penis, such as hardened arteries, heart disease, high blood sugar (Diabetes) and smoking.

    The penis cannot trap blood during an erection

    If blood does not stay in the penis, a man cannot keep an erection. This issue can happen at any age.

    Nerve signals from the brain or spinal cord do not reach the penis

    Certain diseases, injury or surgery in the pelvic area can harm nerves to the penis.

    Diabetes can cause small vessel disease or nerve damage to the penis
    Cancer treatments near the pelvis can affect the penis' functionality

    Surgery and or radiation for cancers in the lower abdomen or pelvis can cause ED. Treating prostate, colon-rectal or bladder cancer often leaves men with ED. Cancer survivors should see a Urologist for sexual health concerns.

    Drugs used to treat other health problems can negatively impact erections

    Patients should talk about drug side effects with their primary care doctors.

    Emotional Causes of ED

    Normal sex needs the mind and body working together. Emotional or relationship problems can cause or worsen ED.

    Some emotional issues that can cause ED are:

    • Depression
    • Anxiety
    • Relationship conflicts
    • Stress at home or work
    • Stress from social, cultural or religious conflicts
    • Worry about sex performance

    Diagnosis

    Finding the cause of your ED will help direct your treatment options.

    Diagnosing ED starts with your health care provider asking questions about your heart and vascular health and your erection problem. Your provider may also give you a physical exam, order lab tests or refer you to a Urologist.

    Health and ED History

    Your doctor will ask you questions about your health history and lifestyle. It is of great value to share facts about drugs you take, or if you smoke or how much alcohol you drink. He/she will ask about recent stressors in your life. Speak openly with your doctor, so he/she can help you find the best choices for treatment

    What Questions Will the Health Care Provider Ask?

    • Questions about your health:
    • What prescription drugs, over-the-counter drugs or supplements do you take?
    • Do you use recreational drugs?
    • Do you smoke?
    • How much alcohol do you drink?
    • Have you had surgery or radiation therapy in the pelvic area?
    • Do you have any urinary problems?
    • Do you have other health problems (treated or untreated)?

    Questions About ED

    Knowing about your history of ED will help your health provider learn if your problems are because of your desire for sex, erection function, ejaculation, or orgasm (climax). Some of these questions may seem private or even embarrassing. However, be assured that your doctor is a professional and your honest answers will help find the cause and best treatment for you.

    Questions about your ED symptoms:

    • How long have you had these symptoms? Did they start slowly or all at once?
    • Do you wake up in the morning or during the night with an erection?
    • If you do have erections, how firm are they? Is penetration difficult?
    • Do your erections change at different times, like when going in a partner, during stimulation by mouth, or with masturbation?
    • Do you have problems with sex drive or arousal?
    • Do you have problems with ejaculation or orgasm (climax)?
    • How is this problem changing the way you enjoy sex?
    • Do you have painful with erections, feel a lump or bump in the penis or have penile curvature? These are signs of Peyronie's Disease which can be treated but calls for an expert in urology to assess and manage.

    Questions About Stress and Emotional Health

    Your health care provider may ask you questions about depression or anxiety. He or she may ask about problems in your relationship with a partner. Some health care providers may also ask if they may talk to your sex partner.

    • Are you often under a lot of stress, or has something recently upset you?
    • Do you have any anxiety, depression or other mental health issues? 
    • Are you taking any drugs for your mental health?
    • How satisfied are you with your sex life? Has there been any changes lately?
    • How is your relationship with your partner? Has there been any changes lately?

    Physical Exam

    A physical exam checks your total health. Examination focusing on your genitals (penis and testicles) is often done to check for ED. Based on your age and risk factors, the exam may also focus on your heart and blood system: heart, peripheral pulses and blood pressure. Based on your age and family history your doctor may do a rectal exam to check the prostate. These tests are not painful. Most patients do not need a lot of testing before starting treatment.

    Lab Tests

    Your health care provider may order blood tests and collect a urine sample to look for health problems that cause ED.

    Other Tests

    Questionnaires are often used by health experts to rate your ability to initiate and keep erections, gauge your satisfaction with sex and help identify any problems with orgasm.

    Advanced Erectile Function Tests

    For some men with ED, specialized testing may be needed to guide treatment or re-assess you after a treatment fails.

    • Blood work to check Testosterone and other male hormones
    • Blood work to measure blood sugar (Diabetes)
    • Ultrasonography (penile Doppler) to check blood flow
    • A shot into the penis with a vascular stimulant to cause an erection
    • Pelvic x-rays like arteriography, MRI or CT scanning are rarely needed to check ED unless there is history of trauma or cancer
    • Nocturnal penile tumescence (NPT), an overnight test to check for sleep erection

    Treatment

    The treatment for ED starts with taking care of your heart and vascular health. Your doctor may point out ‘risk factors' that can be changed or improved.

    You may be asked to change certain food habits, stop smoking, increase workouts or stop using drugs or alcohol. You may be offered alternatives to the drugs you take. (Never stop or change prescription drugs without first talking to your health care provider.)

    Your health care provider may also suggest treating emotional problems. These could stem from relationship conflicts, life's stressors, depression or anxiety from past problems with ED (performance anxiety).

    The treatments below are available to treat ED directly.

    ED Treatments

    Non-invasive treatments are often tried first. Most of the best-known treatments for ED work well and are safe. Still, it helps to ask your health care provider about side effects that could result from each option:

    • Oral drugs or pills known as phosphodiesterase type-5 inhibitors are most often prescribed in the U.S. for ED (Viagra, Cialis, Levitra, Stendra)
    • Testosterone Therapy (when low testosterone is detected in blood testing)
    • Penile Injections (ICI, intracavernosal Alprostadil)
    • Intraurethral medication (IU, Alprostadil)
    • Vacuum Erection Devices
    • Penile Implants
    • Surgery to bypass penile artery damage for some younger men with a history of severe pelvic trauma. Penile vascular surgery is not recommended for older men with hardened arteries.