What causes erectile dysfunction? Physical, medical and mental causes

In short: an erection depends on blood flow, nerve signals, hormones and a mind that is not under too much strain. Erectile dysfunction (ED) happens when one or more of those links stops working well. The National Institutes of Health (NIH) groups the causes into four families: diseases and conditions, medicines, mental health or emotional issues, and lifestyle behaviors. This page walks through each family, what the research says about which causes are most common, and why the answer for any one man usually takes a clinician’s look rather than a guess.

What are the common causes of ED?

The NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says ED “can have different causes.” Diseases or conditions that affect your blood vessels, nerves or hormones can lead to it, and so can certain medicines, mental or emotional issues, and lifestyle behaviors (NIDDK, Symptoms & Causes of ED). A 2016 review by an international group of specialists describes ED the same way, as a condition that can involve organic, relational and psychological parts of the erectile response (Yafi et al., Nat Rev Dis Primers 2016). The table below sets out the causes NIDDK lists within those families, with the pages on this site that go deeper into each one.

Source for every row: NIDDK, Symptoms & Causes of ED.

What is the most common cause of erectile dysfunction?

Problems with blood flow. The American Urological Association (AUA) guideline states that there is “compelling evidence” that “the most common underlying mechanism of ED is vascular,” and that ED and cardiovascular disease share causes as well as the way they develop in the body (AUA ED Guideline). That is why the conditions that strain blood vessels, such as high blood pressure, high cholesterol, diabetes and smoking, come up again and again on this page. Our guide to what ED can signal about your health looks at that link in more detail.

One older study is often quoted on this question. The Massachusetts Male Aging Study surveyed a random sample of men aged 40 to 70 living near Boston between 1987 and 1989. Age was “the variable most strongly associated with” ED. After adjusting for age, ED was more likely in men with heart disease, high blood pressure, diabetes, the medicines that go with those conditions, and higher scores on measures of anger and depression (Feldman et al., J Urol 1994). The authors concluded that ED has “multiple determinants,” including some risk factors for vascular disease. That is an association found in a survey, not proof of cause in any one man, but it points the same way as the guideline.

How do heart and blood vessel problems lead to ED?

An erection depends on blood flowing into the penis and staying there. When blood vessels are narrowed or stiffened, that flow can fall short. NIDDK lists heart and blood vessel diseases, including atherosclerosis, high blood pressure and stroke, among the most common conditions that can lead to ED (NIDDK).

The AUA guideline gives a sense of how often these overlap. It reports that high blood pressure is present in 38% to 42% of men with ED, that about 35% of men with high blood pressure have some degree of ED, and that high blood pressure “often contributes to” ED through narrowing of the arteries. It also reports that up to 42.4% of men with ED have high cholesterol, and that higher total and LDL cholesterol were significantly correlated with moderate to severe ED (AUA ED Guideline). These figures describe groups of men, and the guideline draws them from several studies. They do not tell you which factor is behind ED in a particular person.

The guideline adds a point worth knowing: symptoms of ED “may precede a cardiovascular event by up to five years,” and it asks clinicians to counsel men that ED is a risk marker for underlying heart disease and other conditions that may need evaluation (AUA ED Guideline). Our page on ED and heart disease covers that link in detail.

How does diabetes cause ED?

Diabetes is the first condition on NIDDK’s list of the most common diseases and conditions that can lead to ED (NIDDK). The AUA guideline calls ED “one of the most common complications” of diabetes, with rates that range from 20% to 85% depending on how severe the diabetes is and how long a man has had it. It also notes that ED occurs at an earlier age in men with diabetes, and that in some cases ED may be a sign of diabetes that had not yet been diagnosed (AUA ED Guideline). Our guide to diabetes and ED covers why the two overlap and what managing diabetes can change.

Which other health conditions can lead to ED?

Beyond the heart and diabetes, NIDDK names several other groups of conditions (NIDDK):

• Hormone issues, such as low testosterone and thyroid imbalance. The AUA guideline recommends measuring morning testosterone in men with ED (AUA ED Guideline). Our page on ED and low testosterone explains what that test can and cannot show.
• Nerve damage or disorders, such as multiple sclerosis, spinal cord injuries, and damage from pelvic surgery. See nerve conditions and ED.
• Long-term conditions, such as chronic kidney disease, obesity and overweight, and chronic obstructive pulmonary disease (COPD). Our page on chronic conditions and ED looks at what the research on each one found.
• Problems of the male reproductive system, such as an enlarged prostate and penile curvature, also called Peyronie’s disease.

The AUA guideline adds that urinary symptoms from an enlarged prostate are reported in up to 72% of men with ED, and that the two conditions are independent risk factors for each other that share risk factors such as age, obesity, high blood pressure and diabetes (AUA ED Guideline).

Can medicines cause ED?

Yes. NIDDK says ED “can be a side effect of many common prescription and over-the-counter medicines.” Its list includes antidepressants, appetite suppressants, antihistamines for allergies or heartburn, blood pressure medicines and diuretics (water pills), chemotherapy and hormone medicines, some pain relievers such as NSAIDs, codeine and oxycodone, sedatives, and ulcer medicines (NIDDK). The Massachusetts Male Aging Study also found ED more likely in men taking medicines for heart disease, high blood pressure and diabetes, after adjusting for age, though a survey like that cannot separate the medicine from the condition it treats (Feldman et al., 1994).

The most important point here is about what not to do. NIDDK says a clinician may review your medicines and suggest a different dose or a switch to another medicine, and it is direct: “Do not stop taking any medicines on your own. Talk with your health care professional first” (NIDDK, Treatment for ED). Our guide to medications that affect erections goes through the main classes one by one.

Can the cause of ED be mental?

Yes. NIDDK says some mental health or emotional issues “can either cause ED or make it worse,” including anxiety, depression or stress, feeling isolated or lonely, and low self-esteem, lack of confidence or negative body image (NIDDK). The AUA guideline lists depression among the recognized risk factors that ED shares with heart disease (AUA ED Guideline). Our pages on ED and depression and on telling ED apart from performance anxiety go further.

How often is the cause mainly mental? One study gives a real-world snapshot. Researchers in Milan looked at 2,009 men seeking help for ED for the first time and sorted them by whether they had any of the physical risk factors listed in European urology guidelines. Of those men, 1,632 had at least one physical risk factor and 377 had none, which the authors used as a marker for “primary psychogenic” ED, meaning ED that is mainly psychological in origin. Men in the two groups had erectile function scores that were similar, so ED with a mainly psychological cause was not milder (Pozzi et al., Andrology 2022). It was one clinic’s patients, and the authors name possible selection bias as their main limitation, but the takeaway they draw is that every man deserves a full workup, whatever the likely cause.

Mental health also works in the other direction. NIDDK lists depression, anxiety and low self-esteem among the complications of ED (NIDDK, Definition & Facts), and the 2016 specialist review notes that most men with ED have symptoms of depression and anxiety related to sexual performance (Yafi et al., 2016). When stress is part of the picture, NIDDK says a clinician may suggest counseling to help lower anxiety and stress about sex (NIDDK, Treatment for ED).

Can lifestyle habits cause ED?

They can contribute. NIDDK lists not getting enough physical activity, drinking too much alcohol, smoking cigarettes and using recreational or illicit drugs as behaviors that may contribute to ED (NIDDK). The AUA guideline counts smoking, obesity and a sedentary lifestyle among the independent risk factors that ED and heart disease share (AUA ED Guideline). In the Massachusetts Male Aging Study, smoking went with a greater chance of complete ED in men who had heart disease or high blood pressure (Feldman et al., 1994).

NIDDK also notes that illicit drugs and too much alcohol may “mask other mental health, emotional, or physical factors that cause ED,” and that a clinician may suggest quitting smoking, limiting alcohol, moving more, keeping a healthy weight and eating well (NIDDK, Treatment for ED). Our pages on lifestyle and ED and on smoking and ED cover what the evidence shows about changing these habits.

Can there be more than one cause of ED?

Often, yes. The Massachusetts Male Aging Study described ED as having “multiple determinants” (Feldman et al., 1994), and the AUA guideline lists a shared set of risk factors (age, smoking, diabetes, high blood pressure, high cholesterol, depression, obesity and a sedentary lifestyle) that ED and heart disease share (AUA ED Guideline). A man with diabetes may also have high blood pressure, take a blood pressure medicine, and feel anxious after some trouble with erections. Each of those can play a part.

That overlap is the reason a single label rarely tells the whole story. The Milan study found comparable severity in men with mainly physical and mainly psychological ED (Pozzi et al., 2022), and the specialist review describes ED as “multidimensional” (Yafi et al., 2016). Treating one cause can help, and it may still leave another one in place.

Is ED just a normal part of getting older?

No, though it does become more common with age. NIDDK says about 40% of men are affected at age 40 and 70% report ED by age 70, but that “ED is not a routine part of aging” (NIDDK, Definition & Facts). In the Massachusetts Male Aging Study, age was the factor most strongly linked to ED (Feldman et al., 1994). In younger men, the AUA guideline notes that ED predicts a marked rise in the risk of future heart events, and suggests that young men with ED in particular would benefit from heart risk screening (AUA ED Guideline). So ED at any age is worth raising, not waiting out.

How does a clinician find the cause?

The AUA guideline says men with ED symptoms should have a thorough medical, sexual and psychosocial history, a physical exam and selective lab testing (AUA ED Guideline). NIDDK fills in the detail. A clinician will ask about prescription and over-the-counter medicines, vitamins and supplements; about desire, erection, ejaculation and climax; and about your mental health and emotions. The exam often checks for blood vessel, nerve and hormone problems and for physical problems with the penis, and blood tests may include thyroid and prostate tests. A nighttime erection test can help show whether ED has a physical cause (NIDDK, Diagnosis of ED). Our guide to how ED is diagnosed explains each step.

Once the likely causes are clear, NIDDK says clinicians treat the underlying cause when possible (NIDDK, Treatment for ED). NIDDK describes options that include reviewing medicines, counseling, lifestyle changes and ED medicines. Which ones fit is a decision to make with the clinician who knows your history.

The bottom line

ED usually has a physical cause, and the most common one is a problem with blood flow, tied to conditions such as high blood pressure, high cholesterol and diabetes. Nerve damage, hormone issues, many common medicines, anxiety, depression, stress, smoking, heavy drinking and inactivity can also play a part, and more than one cause is often involved. ED becomes more common with age but is not a routine part of it, and it can be an early signal of heart disease or diabetes. The steady next step is a checkup that looks at the whole picture, not a guess about a single cause.

Sources

Every clinical statement on this page traces to a primary or guideline source:

• NIH NIDDK, Symptoms & Causes of Erectile Dysfunction (last reviewed October 2024): the four families of causes; the most common diseases and conditions; the list of medicines; mental health and emotional issues; lifestyle behaviors.
• NIH NIDDK, Definition & Facts for Erectile Dysfunction (last reviewed October 2024): about 40% of men affected at 40 and 70% by 70; ED is not a routine part of aging; complications including depression, anxiety and low self-esteem.
• NIH NIDDK, Diagnosis of Erectile Dysfunction (last reviewed October 2024): medical, sexual and mental health history; physical exam; blood tests; nighttime erection test.
• NIH NIDDK, Treatment for Erectile Dysfunction (last reviewed October 2024): treating the underlying cause; medicine review and not stopping medicines on your own; counseling; lifestyle changes; alcohol and drugs masking other causes.
• American Urological Association, Erectile Dysfunction Guideline (Burnett et al., J Urol 2018): vascular cause as the most common mechanism; shared risk factors with heart disease; figures for high blood pressure, cholesterol, diabetes and enlarged-prostate symptoms; ED as a risk marker; evaluation and testosterone statements.
• Feldman HA, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study (J Urol, 1994): age as the strongest associated factor; age-adjusted links with heart disease, high blood pressure, diabetes, related medicines, anger and depression; smoking; “multiple determinants.”
• Yafi FA, et al. Erectile dysfunction (Nat Rev Dis Primers, 2016): ED as multidimensional, involving organic, relational and psychological components; depression and anxiety related to sexual performance.
• Pozzi E, et al. Primary organic versus primary psychogenic erectile dysfunction: findings from a real-life cross-sectional study (Andrology, 2022): 2,009 men seeking first help for ED; 1,632 with at least one physical risk factor and 377 with none; comparable severity; single-center limitation.