Erectile dysfunction: what it is, what causes it, and what helps
The short answer
Erectile dysfunction (ED) is trouble getting or keeping an erection firm enough for sex. It is common, and more common with age, but it is not a routine part of aging. ED can come from blood vessel, nerve or hormone problems, medicines, stress or habits, and it can often be treated.
In short: erectile dysfunction, usually shortened to ED, means trouble getting or keeping an erection that is firm enough for sex (NIDDK, Definition & Facts). It is common, it becomes more common with age, and it is often treatable. It can also be a sign worth listening to, because the American Urological Association (AUA) says men should be told that ED is a risk marker for heart and blood vessel disease and other health conditions (AUA Erectile Dysfunction Guideline, J Urol 2018). This page is the starting point for the whole site. It covers what ED is, how common it is, what causes it, how it is diagnosed, what treatments exist, what you can do to lower your risk and how ED relates to fertility, and it links to the deeper guides on each. It is educational information, not medical advice.
What is erectile dysfunction?
Erectile dysfunction is a condition that prevents you from getting or keeping an erection that is firm enough for sex. That is the definition used by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the US National Institutes of Health (NIDDK, Definition & Facts). The AUA guideline uses a closely matching definition, the inability to attain and/or maintain an erection sufficient for satisfactory sexual performance, and also endorses a version that adds the words “consistent or recurrent” (AUA ED Guideline, Background).
That last phrase matters. A single difficult night is not the same thing as a pattern. That definition describes a problem that keeps happening, not one evening when you were tired, anxious or had been drinking.
The guideline also places ED in a wider picture. It describes sexual response as a series of phases (desire, arousal, orgasm and resolution) and treats ED as a problem in the arousal phase (AUA ED Guideline, Executive Summary). So ED is a different question from low interest in sex, or from changes in climax or ejaculation, even though the three can overlap. If a medical word on this page is new to you, our plain-language ED glossary explains it.
What does erectile dysfunction mean in everyday terms?
In everyday terms, erectile dysfunction means erections that are not reliable enough for the sex life you want. NIDDK notes that ED used to be called impotence, but that this term is not used as much now (NIDDK, Definition & Facts).
The guideline is direct about why this is worth taking seriously. It says ED can negatively affect a man’s mental health, his relationship and his general well-being, and that its presence is an opportunity to look at several issues that affect a man’s overall health (AUA ED Guideline, Background). NIDDK makes a similar point more gently: you may be uncomfortable talking about ED, but a healthy sex life is part of healthy living, and ED can often be treated (NIDDK, Definition & Facts).
How common is erectile dysfunction?
Erectile dysfunction is common. NIDDK says research suggests that between 30 million and 50 million men in the United States have ED, and that it becomes more common with age: about 40% of men are affected at age 40, and 70% report having ED by age 70 (NIDDK, Definition & Facts). The AUA guideline gives a more conservative figure of up to 30 million men in the United States and 150 million worldwide (AUA ED Guideline, Epidemiology). The estimates differ, but both sources put the number of affected US men in the tens of millions.
Age is only part of the story. NIDDK is clear that you are more likely to have ED as you get older, but that ED is not a routine part of aging. Other factors that raise the odds include diseases such as diabetes, heart disease and obesity, certain medicines, mental health issues such as anxiety and stress, and habits such as smoking or drinking too much alcohol (NIDDK, Definition & Facts). In other words, being older makes ED more likely, but it does not explain it on its own, and it is not a reason to skip a checkup.
What are the symptoms of erectile dysfunction?
The symptoms of erectile dysfunction are changes in how reliably erections happen and how long they last. NIDDK lists three patterns (NIDDK, Symptoms & Causes):
- getting an erection sometimes, but not every time you want to have sex
- getting an erection, but it does not last long enough for sex
- being unable to get an erection at any time
NIDDK adds one more line that is easy to miss: ED may be a symptom of another health problem (NIDDK, Symptoms & Causes). That is why the rest of this page spends as much time on causes and checkups as it does on treatments.
ED also sits next to other sexual concerns that are easy to confuse with it. The AUA guideline notes that in surveys of men with ED, roughly 30% to 60% also reported premature ejaculation, and it lists depression and urinary symptoms from an enlarged prostate among other conditions commonly seen alongside ED (AUA ED Guideline, Epidemiology). Describing exactly what changed, and when, helps a clinician tell these apart.
What causes erectile dysfunction?
Erectile dysfunction has several kinds of causes, and more than one is often involved. NIDDK says diseases or health conditions that affect your blood vessels, nerves or hormones can lead to ED, and that certain medicines, mental or emotional issues and lifestyle behaviors may lead to it as well (NIDDK, Symptoms & Causes). The AUA guideline adds that there is compelling evidence that the most common underlying mechanism of ED is vascular, meaning it involves blood flow (AUA ED Guideline, Epidemiology).
The table below groups the causes NIDDK lists. Each row is a category a clinician may look at, not a checklist for self-diagnosis.
| Category | Examples NIDDK lists |
|---|---|
| Long-term health conditions | Diabetes; chronic kidney disease; obesity and overweight; chronic obstructive pulmonary disease (COPD) |
| Heart and blood vessels | Atherosclerosis (hardened arteries); high blood pressure; stroke |
| Hormones | Low testosterone; thyroid imbalance |
| Nerves | Multiple sclerosis; spinal cord injuries; damage from pelvic surgery |
| Male reproductive system | Enlarged prostate; penile curvature (Peyronie’s disease) |
| Medicines | Antidepressants; appetite suppressants; antihistamines; blood pressure medicines and diuretics; chemotherapy and hormone medicines; some pain relievers; sedatives; ulcer medicines |
| Mental and emotional health | Anxiety, depression or stress; feeling isolated or lonely; low self-esteem, lack of confidence or negative body image |
| Habits | Not getting enough physical activity; drinking too much alcohol; smoking cigarettes; using recreational and illicit drugs |
Source: NIDDK, Symptoms & Causes.
Two points from the sources help make sense of the table. First, mental and physical causes are not either-or. NIDDK says some mental health or emotional issues can either cause ED or make it worse (NIDDK, Symptoms & Causes), and the AUA guideline’s evaluation covers medical, sexual and psychosocial history together (AUA Guideline, Statement 1). Second, if you suspect a prescribed medicine, do not stop it on your own. NIDDK says a clinician may review your medicines and may suggest a different dose or a different medicine, and that you should talk with your health care professional first (NIDDK, Treatment).
Can ED be a sign of another health problem?
Yes, ED can be an early sign of another health problem, which is one of the best reasons to have it checked. The AUA guideline says men should be counseled that ED is a risk marker for underlying cardiovascular disease and other health conditions that may warrant evaluation and treatment (AUA Guideline, Statement 3). It explains that ED and cardiovascular disease share risk factors (age, smoking, diabetes, high blood pressure, abnormal blood fats, depression, obesity and an inactive lifestyle), that symptoms of ED may come up to five years before a cardiovascular event, and that ED in younger men in particular predicts a marked increase in the risk of future cardiac events (AUA ED Guideline, Epidemiology).
Diabetes is the other big link. The guideline describes ED as one of the most common complications of diabetes, with reported prevalence ranging from 20% to 85% depending on how severe and long-standing the diabetes is, and says that in some cases ED may be a sign of diabetes that has not yet been diagnosed (AUA ED Guideline, Epidemiology).
A risk marker is a reason to look, not a diagnosis. Having ED does not mean you have heart disease or diabetes. It means a clinician has a good reason to check your blood pressure, blood sugar and cholesterol, and to ask about your heart. Our guide to what ED can signal about your overall health walks through these connections in more detail.
How is erectile dysfunction diagnosed?
Erectile dysfunction is diagnosed with a conversation, a physical exam and selected tests. NIDDK says health care professionals, including urologists, use your medical, sexual and mental health history, a physical exam, and lab and other tests (NIDDK, Diagnosis). The AUA guideline’s first statement says the same: men with symptoms of ED should have a thorough medical, sexual and psychosocial history, a physical examination and selective laboratory testing (AUA Guideline, Statement 1).
| Step | What it involves | Source |
|---|---|---|
| History | Your medicines, vitamins and supplements; questions about desire, erection, climax and ejaculation; your mental health; sometimes questions for your partner | NIDDK, Diagnosis |
| Questionnaires | Validated questionnaires to gauge how severe ED is and to track treatment | AUA, Statement 2 |
| Physical exam | Checks for blood vessel, nerve and hormone problems, and for injury or physical problems with the penis | NIDDK, Diagnosis |
| Blood tests | Selected tests, which may include thyroid and prostate tests; the AUA says a morning total testosterone level should be measured | NIDDK, Diagnosis; AUA, Statement 4 |
| Specialist tests, for some men | Ultrasound of penile blood flow, a nighttime erection test, or an in-office injection test | NIDDK, Diagnosis; AUA, Statement 5 |
Not every man needs every test. The AUA guideline says specialized testing may be necessary for some men, to guide treatment (AUA Guideline, Statement 5). Our step-by-step guide to how ED is diagnosed explains what each test can and cannot show.
What treatments exist for erectile dysfunction?
Treatments for erectile dysfunction range from lifestyle changes and counseling to pills, injections, devices and surgery. NIDDK says health care professionals treat the underlying cause of ED when possible, and focus on improving sexual function when the exact cause is not known (NIDDK, Treatment). The table summarizes the main options from NIDDK and the AUA guideline.
| Option | What it is, in brief | Source |
|---|---|---|
| Lifestyle changes | Quitting smoking, limiting alcohol, more physical activity, a healthy weight, a healthy eating plan, stopping recreational drugs | NIDDK, Treatment; AUA, Statement 7 |
| Counseling | Help with anxiety and stress about sex, sometimes with a partner present | NIDDK, Treatment; AUA, Statement 6 |
| Reviewing current medicines | A clinician checks whether a medicine you take for another condition is contributing | NIDDK, Treatment |
| Oral PDE5 inhibitors | Prescription tablets that improve blood flow to the penis and may help you get and keep an erection | NIDDK, Treatment; AUA, Statement 8 |
| Testosterone, for men with low levels | May be prescribed together with a PDE5 inhibitor | NIDDK, Treatment; AUA, Statement 12 |
| Injections and urethral suppositories | Medicines that act directly on the penis; a clinician teaches you how to use them | NIDDK, Treatment; AUA, Statements 14 and 16 |
| Vacuum erection device | A tube, a pump and an elastic ring that draw blood into the penis | NIDDK, Treatment; AUA, Statement 13 |
| Penile implant surgery | A surgically placed device; NIDDK says most men with ED do not need surgery | NIDDK, Treatment; AUA, Statement 18 |
Oral PDE5 inhibitors are the class that includes sildenafil and tadalafil. The AUA guideline says men with ED should be informed about the option of an FDA-approved oral PDE5 inhibitor, including its benefits and risks, unless it is not safe for them (AUA Guideline, Statement 8), and its review of the trials found these medicines had similar efficacy in the general ED population (AUA ED Guideline, Appendix B1). Our guide to how ED medications work explains the mechanism in plain language.
Two things about the guideline’s approach are worth knowing. It treats shared decision-making as the cornerstone of care: all men should be told about every option that is not medically ruled out for them, and while many start with the least invasive option, it is valid to begin with any of them, or to choose no treatment (AUA ED Guideline, Executive Summary). It also says all men, whether or not they treat their ED, should be strongly advised to address any underlying medical issues that may contribute to it (AUA ED Guideline, Background). Our full guide to ED treatment options compares them side by side.
Some options are not established yet. The guideline calls low-intensity shock wave therapy and stem cell therapy investigational, and platelet-rich plasma (PRP) experimental (AUA Guideline, Statements 23 to 25). For dietary supplements, NIDDK advises talking with your health care professional before using them, for safety reasons (NIDDK, Treatment).
What are the safety warnings with ED medicines?
ED medicines have side effects that need prompt care, and NIDDK names two. It says ED medicines taken by mouth, by injection or as a suppository can cause erections that last longer than 4 hours (priapism), and that oral ED medicines can be followed by vision or hearing loss, and it advises calling your health care professional right away if either happens (NIDDK, Treatment).
These are not the only safety points. The guideline says men should be told about oral PDE5 inhibitors, including their benefits and risks, unless the medicine is contraindicated for them (AUA Guideline, Statement 8), and it frames every option as a discussion of benefits and risks with a clinician (AUA ED Guideline, Executive Summary). The amount and timing of any prescription medicine are set by the prescriber and the label, not by this page.
Can erectile dysfunction be prevented?
Erectile dysfunction cannot always be prevented, but changing some daily habits may help prevent it or improve it. NIDDK says lifestyle factors can often lead to ED or make its symptoms worse, and it lists these steps (NIDDK, Treatment):
- Quit smoking. NIDDK calls this one of the best things you can do for your ED and your overall health, because smoking is linked to heart and blood vessel disease, which can lead to ED.
- Follow a healthy eating plan. NIDDK says eating well helps maintain erectile function, and suggests a registered dietitian if possible.
- Maintain a healthy weight. A healthy weight can improve testosterone levels and self-esteem and can help prevent diabetes and high blood pressure, which can cause ED.
- Be physically active. Activity increases blood flow through the body, including the penis. NIDDK cites the federal guideline of at least 150 minutes of moderate-intensity activity, such as brisk walking, each week.
- Reduce stress. Looking after your mental and emotional health can help, and NIDDK suggests relaxation techniques such as deep breathing.
- Avoid drugs and limit alcohol. Some drugs can block arousal, and NIDDK notes that illicit drugs and too much alcohol may mask other causes of ED.
The research on exercise is reasonably encouraging. A 2023 meta-analysis of 11 randomized controlled trials found that aerobic exercise improved erectile function scores compared with no exercise, with larger improvements in men whose ED was more severe at the start (Khera et al., J Sex Med 2023). The AUA guideline is more measured about how strong the evidence is: it says men with ED who have conditions known to affect erections should be told that lifestyle changes, including diet and more physical activity, improve overall health and may improve erectile function, and it rates that evidence as low certainty (AUA Guideline, Statement 7). Habits are worth changing for your health as a whole, but they are not a substitute for finding out what is behind your ED.
Does erectile dysfunction affect fertility?
Erectile dysfunction can affect fertility by making sex, and therefore conception, harder. NIDDK lists being unable to get a partner pregnant among the possible complications of ED (NIDDK, Definition & Facts). The National Institute of Child Health and Human Development (NICHD) lists ED under conditions that affect sperm transport, noting that some men have problems getting an erection, which makes having sex difficult (NICHD, Causes of male infertility).
ED is only one piece of fertility, though. NICHD says the most common issues behind male infertility are problems that affect how the testicles work, that other problems include hormone imbalances and blockages, and it lists other factors such as varicocele and retrograde ejaculation (NICHD, Causes of male infertility). If you and a partner are trying for a pregnancy, say so at your appointment, so a clinician can consider whether a fertility evaluation is needed as well.
What else does ED affect?
ED can affect your mood, your relationship and how you feel about yourself. NIDDK lists an unfulfilled sex life, a loss of intimacy with a partner, and mental health or emotional issues such as depression, anxiety and low self-esteem among its possible complications (NIDDK, Definition & Facts). That can turn into a loop, because NIDDK also lists anxiety, stress, depression and low self-esteem among the things that can cause ED or make it worse (NIDDK, Symptoms & Causes).
Partners can be part of the answer. NIDDK says choosing an ED treatment is a personal decision and that a couple may want to talk together about treatments that work for them (NIDDK, Treatment), and the AUA panel recommends inviting a man’s partner into the decision when possible and clinically appropriate (AUA ED Guideline, Background). The guideline also says referral to a mental health professional should be considered for men being treated for ED, to help with performance anxiety and with fitting treatment into a sexual relationship (AUA Guideline, Statement 6).
When should you talk to a clinician about ED?
You should talk to a clinician when erection problems keep happening or bother you, and right away if you have warning signs. The guideline’s point about ED as a risk marker means an ongoing change is worth a checkup even if you are not sure you want treatment (AUA Guideline, Statement 3). NIDDK acknowledges that you may be uncomfortable talking about ED (NIDDK, Definition & Facts), and you do not need clinical words to start. Saying what changed and when is enough to begin.
When to talk to a clinician:
- Right away: an erection lasting more than 4 hours, or vision or hearing loss after taking an oral ED medicine (NIDDK, Treatment).
- Soon: ED that keeps happening, especially if you also have diabetes, high blood pressure, high cholesterol or heart disease, smoke, or are on medicines that NIDDK lists as possible causes.
- At your next visit: any change that bothers you or your partner, or a question about whether a medicine you take could be involved.
Our guide on when to see a doctor about ED covers these signs in more depth and what to bring to the appointment.
Sources
Every clinical statement on this page traces to one of these sources:
- NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases), Definition & Facts for Erectile Dysfunction, last reviewed October 2024. Definition; the older term impotence; 30 million to 50 million US men; about 40% at age 40 and 70% by age 70; not a routine part of aging; risk factors; complications including inability to get a partner pregnant: niddk.nih.gov, ED definition and facts
- NIDDK, Symptoms & Causes of Erectile Dysfunction, last reviewed October 2024. The three symptom patterns; ED as a possible symptom of another health problem; the conditions, medicines, mental health issues and lifestyle behaviors in the causes table: niddk.nih.gov, ED symptoms and causes
- NIDDK, Diagnosis of Erectile Dysfunction, last reviewed October 2024. History, physical exam, blood tests, ultrasound, nocturnal erection test and injection test: niddk.nih.gov, ED diagnosis
- NIDDK, Treatment for Erectile Dysfunction, last reviewed October 2024. Treating the underlying cause; lifestyle changes; counseling; medicine review and not stopping medicines on your own; PDE5 inhibitors; testosterone; injections and suppositories; vacuum devices; surgery; supplements; the seek-care-right-away warnings; the prevention steps: niddk.nih.gov, ED treatment
- Burnett AL, et al. Erectile Dysfunction: AUA Guideline. J Urol 2018;200:633. Statements 1 to 8, 12 to 14, 16, 18 and 23 to 25: auajournals.org, AUA ED guideline
- American Urological Association, Erectile Dysfunction (ED) Guideline (2018), web version. Executive summary (definition, phases of sexual response, shared decision-making), background (definitions, risk marker, partner involvement, addressing underlying conditions), epidemiology (prevalence, shared risk factors with cardiovascular disease, diabetes, related conditions) and Appendix B1 (similar efficacy of PDE5 inhibitors): auanet.org, ED guideline
- Khera M, Bhattacharyya S, Miller LE. Effect of aerobic exercise on erectile function: systematic review and meta-analysis of randomized controlled trials. J Sex Med 2023;20(12). 11 randomized trials; improvement in erectile function scores versus controls, larger in more severe ED: pubmed.ncbi.nlm.nih.gov/37814532
- NICHD (Eunice Kennedy Shriver National Institute of Child Health and Human Development), What are some possible causes of male infertility? ED among conditions affecting sperm transport; the most common causes of male infertility: nichd.nih.gov, causes of male infertility
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