A person with erectile dysfunction will regularly find it difficult to attain or keep a firm enough erection to have sex. This can interfere not only with sexual activity but also with a person’s quality of life.

Some people will occasionally experience some difficulty with their penis becoming hard or staying firm. However, erectile dysfunction (ED) is often only a concern if satisfactory sexual performance is consistently impossible.

The awareness that ED can be a treatable condition has increased since the discovery that the drug sildenafil, or Viagra, affected penile erections. However, people who have a problem with their sexual performance may be reluctant to talk with their doctor, seeing it as an embarrassing issue.

ED is now well understood and there are various treatments available.

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ED may affect up to 20 million people in the U.S. The condition’s prevalence is over 50% in those over 50 years old and increases with a person’s age.

Normal erectile function can be affected by problems with a person’s blood flow, nervous system, and hormone levels. A person may also experience ED due to psychological factors, such as anxiety over sexual performance.

Gay men report ED at a higher rate than heterosexual men, according to a 2019 review. However, the exact reasons for this remain unknown, and researchers recommend more study in the field.

Physical causes

Most cases of ED are secondary. This means that erectile function has been normal but becomes problematic. Causes of a new and persistent problem are usually physical.

In rare cases, a person may have primary ED. This is where a person has never achieved an erection. The cause of primary ED may be psychological or the result of a physical condition.

A person should consult a medical professional if they experience persistent erection problems, as an underlying medical condition could be causing the issue. A proper diagnosis can help address any underlying medical issues and help resolve sexual difficulties.

Some of the most common physical causes of ED include:

Atherosclerosis is a common cause of blood flow problems. Atherosclerosis causes a narrowing or clogging of arteries in the penis, preventing the necessary blood flow to produce an erection.

Numerous prescription medications can also cause ED. A person taking prescription medications should consult their doctor before stopping or changing their medications. Some drugs that may cause ED include:

  • drugs to control high blood pressure
  • heart medications such as digoxin
  • anxiety treatments
  • antidepressants, including monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants
  • opioid painkillers
  • some cancer drugs, including chemotherapeutic agents
  • anticholinergics
  • hormone drugs

Physical causes account for 90 percent of ED cases, with psychological causes much less common.

Psychological causes

Psychological factors can cause or contribute to ED, with factors ranging from treatable mental health illnesses to everyday emotional states that most people experience at some time. These are less common than physical causes, however.

Psychological factors can include:

A person may also be unable to attain a full erection due to specific sexual performance anxiety, a common psychological factor in people with ED. Sexual performance anxiety affects 9-25% of males, according to a review.

It is also important to note that there can be an overlap between medical and psychosocial causes. For instance, if a person is obese, blood flow changes can affect that person’s ability to maintain an erection, which is a physical cause. However, the person may also have low self-esteem, impacting erectile function, which is a psychosocial cause.

Does riding a bicycle cause ED?

Questions remain about the effects on men’s health of riding a bicycle.

Some research has raised concerns that men who regularly cycle for long hours could have a higher risk of ED, in addition to other men’s health issues such as infertility and prostate cancer.

A 2014 study found no link between riding a bike and ED, but it found an association between longer hours of cycling and the risk of prostate cancer. However, a further study published in 2020 found no correlation between cycling and ED or prostate cancer.

The association between cycling and prostate cancer remains controversial and requires more research.

Prostate disease and ED

Early-stage prostate cancer does not cause ED, but advanced forms of prostate cancer can.

Prostate surgery to remove tumors and radiation therapy to treat prostate cancer can cause ED.

Some medications for prostate cancer may also result in ED. For example, hormone therapies can lower a person’s libido, and by association lead to ED. Research has shown that the medication finasteride may cause sexual dysfunction in men.

The good news is that there are many treatments for ED, and most people will find a solution that works for them.

Drug treatments

A person with ED can take a group of drugs called PDE-5 (phosphodiesterase-5) inhibitors.

Most of these pills are taken 30 to 60 minutes before sex, the best known being the blue-colored pill sildenafil (Viagra). Other options are:

  • vardenafil (Levitra)
  • tadalafil (taken on demand, or as a once-daily pill called Cialis)
  • avanafil (Stendra)

PDE-5 inhibitors are only available by prescription. A doctor will check for heart conditions and ask about other medications a person is taking before prescribing them.

Side-effects associated with PDE-5 inhibitors include:

Less commonly used drug options include prostaglandin E1, which is applied locally by either injecting it into the penis or inserting it down the opening of the urethra.

Online pharmacies

It is possible to buy treatments over the internet for ED. However, a person should be cautious when doing so.

The United States Food and Drug Administration (FDA) has a consumer safety guide regarding online pharmacies.

Before ordering, a person should check that their online pharmacy is licensed in the U.S., has a licensed pharmacist, requires a prescription, and offers direct contact with customer relation staff.

People can check whether the pharmacy is licensed using the list of Verified Internet Pharmacy Practice Sites.

The FDA also offers tips for spotting the dangers of an unsafe website, including watching out for the following:

  • There is no way to contact the website by phone.
  • Prices are dramatically lower than those offered by legal online pharmacies.
  • Prescription drugs do not require a prescription for purchase, which is illegal.
  • Personal information is not protected.

These illegal sites may send drugs of unknown quality and origin. They may even send the wrong drug or a dangerous product.

Vacuum devices

Vacuum erection devices are a mechanical way of producing an erection for people who do not want to use drug treatments or find they are not working.

A person makes their penis rigid by using a vacuum pump sealed around it that draws up blood. The use of an accompanying band then prevents this blood from then leaving the penis.

The lack of spontaneity with vacuum devices means that many people with ED find other treatments preferable. However, other treatments, such as oral medications, can also reduce spontaneity.

Vacuum devices may also be susceptible to mechanical faults that affect their efficacy, such as poor seals.

Surgical treatments

There are several surgical treatment options available to patients, including penile implants. In this procedure, a doctor inserts a malleable or inflatable device into the penis. This surgery may help a patient reach and maintain erections if drug-based treatments have not worked.

In very rare cases, a patient may undergo vascular surgery to treat ED.

Typically a doctor will only recommend surgery only after exhausting all other treatment avenues.

Do dietary supplements and alternative treatments work?

No guidelines followed by doctors, nor any established sources of evidence, support the use of dietary supplements such as herbal pills.

In addition to there being no evidence in favor of non-prescription alternatives for ED, alternative supplements and treatments may be harmful, and in some instances, fatal.

People may not always successfully achieve an erection. If this happens occasionally, it is not considered a medical problem. However, if a person is consistently unable to achieve an erection, then they may have ED.

There is no defined length of time frame over which a person must experience ED to receive a diagnosis. Some professionals suggest 6 months is suitable.

However, ED does not only refer to a complete inability to achieve an erect penis. Symptoms can also include struggling to maintain an erection for long enough to complete intercourse or an inability to ejaculate.

There are often emotional symptoms, such as embarrassment, shame, anxiety, and a reduced interest in sexual intercourse.

There are exercises a person can carry out to reduce the effects of ED.

Research suggests that strengthening pelvic floor muscles through exercise can be a beneficial treatment for people with ED.

Learn more about pelvic floor exercises here.

Aerobic exercise, such as a jog or even a brisk walk, can also help the blood circulate better and can help improve ED in men who have circulation issues.

The numerous potential causes of ED mean that a doctor will typically ask many questions and arrange blood tests.

Such tests can check for heart problems, diabetes, and low testosterone, among other things. The doctor will also carry out a physical examination, including of the genitals.

Once a doctor establishes a medical history, they will then do further investigation. One test, known as the “postage stamp test,” can help determine if the cause is physical rather than psychological.

Men usually have 3 to 5 erections a night. This test checks for the presence of erections at night by seeing if postage stamps applied around the penis before sleep have snapped off overnight. Other tests of nocturnal erection include the Poten test and Snap-Gauge test.

These methods provide limited information but can help guide a doctor’s choice of further tests.

Erectile dysfunction (ED) is when a person is regularly unable to attain a full erection. The condition is common and affects around 20 million Americans.

A person may experience ED as a result of physical factors such as high cholesterol levels, or due to psychological reasons, such as sexual performance anxiety.

A doctor may recommend a number of treatments for ED including prescription medication or, in rare cases, surgical intervention.