It’s one of the most under-discussed issues in male health—yet, it’s remarkably common.

The issue is, not only does suffering from erectile dysfunction have a negative impact on our bedroom activities, but it can also place stress on relationships and impinge our mental health.

However, there’s a light at the end of the tunnel.

Numerous effective treatments ensure that we can enjoy the sex life we deserve.

This article is the complete guide to erectile dysfunction—detailing its causes, prevention, and treatment.

What Is Erectile Dysfunction?

Also known as impotence, erectile dysfunction is the inability to either attain or maintain an erection. To fully comprehend the condition, it’s important to understand exactly how the erection process works.

Through either psychological or physiological stimulation, the nerve branches within the penis release acetylcholine—one of the body’s primary neurotransmitters.1

In turn, acetylcholine stimulates the production of nitric oxide—a vasodilator. As such, it opens up the arteries in the penis allowing blood to flow easily into its length.2

Inside the male member are two, longitudinal and sponge-like lengths of erectile tissue known as the corpora cavernosa—extending from the base through to the glans (head). Effectively, they “soak-up” the blood, expand, and enable the penis to become both enlarged and firm.3

Additionally, the bulbospongiosus and ischiocavernosus muscles act to compress the veins of the corpora cavernosa—restricting the drainage of blood from the penis—ensuring that it remains erect.4

After ejaculation or when stimulation subsides, the arteries in the male manhood constrict, pushing the blood out of the erectile tissue—enabling the penis to return to its original flaccid state.

While a remarkably simple process—failure in either the psychological or physiological mechanism can prevent the development or maintenance of an erection.

And that is erectile dysfunction.

This is not uncommon. Research indicates that around one in two males suffers from this condition. Furthermore, the older we become, the more likely we are to encounter erection issues. Incidence rates are about 40 percent at the age of 40 years which increase by 10 percent as every decade passes.5

Hence, by the time you reach 70 years of age, there’s a 70 percent chance you will have erectile dysfunction.

Symptoms

As men, we’ve all experienced erectile dysfunction at some point in our lives.

That embarrassing situation where the mind is willing, but the manhood just will not perform as you require. This is usually a short-lived episode, and often the next time you attempt to engage in sexual activity—it functions correctly.

However, erectile dysfunction becomes an issue when symptoms become more frequent—and occur for an extended period. Medically, it’s described as—a persistent or recurrent inability to either achieve and/or maintain an erection of sufficient firmness to allow satisfactory sexual activity experienced for a period of at least three months.6

Typically, the signs of erectile dysfunction are:

Difficulty in obtaining an erection through either mental or physical stimuli.

Issues with maintaining a firm penis throughout sexual activity—whether alone or with a partner.

Reduced interest in participating in sexual intercourse.

Lack of pleasure when the penis is stimulated.

Additionally, further sexual disorders can be a secondary symptom of erectile dysfunction, including:

Delayed ejaculation.

Premature ejaculation.

The inability to achieve an orgasm (anorgasmia).7

Causes

Generally speaking, erectile dysfunction is caused by either physiological or emotional factors.

Physiological Causes of Erectile Dysfunction

Cardiovascular disease—the leading cause of impotence, with the venous and arterial system being unable to adequately supply the penis with blood. 8

Diabetes—blood flow to the male member is impeded by damage to the vascular system that hyperglycemia can induce. 9

Hypertension—causes the smooth muscles of the penis to become ineffective at holding blood. 10

Neurogenic disorders—diseases such as multiple sclerosis, muscle atrophy, and Parkinson’s disease can impact on the penis’ ability to both recognize and respond to stimulation. 11

Aging—the corporal smooth muscle cells are lost as the years pass—just a 15 percent reduction means the blood cannot be prevented from “leaking” out of the penis. 12

Penis disorders—fibrosis of the penis can lead to deformity and inhibited satisfactory blood flow into the male member. 13

Hyperprolactinemia—tumors of the pituitary gland preventing the production of testosterone. 14

Hypogonadism—while studies indicate there’s a link between low testosterone levels and erectile dysfunction, the pathological process is not understood.15

Emotional Causes of Erectile Dysfunction

Stress—impairs the brain’s ability to signal the genitalia to promote erections. 16

Anxiety—nervousness before intercourse or previous experience of erectile dysfunction can create a barrier to attaining an erection. 17

Depression—it’s unclear whether depression causes erectile dysfunction or vice versa.18

While the causes of erection issues are mainly related to the above mental and physical conditions—our lifestyle can also heavily impact on our sexual lives.

Certain risk factors can significantly increase the chance of developing erectile dysfunction, outlined below.

Smoking

Lighting up a cigarette, in addition to elevating cancer probability, has two main effects on the penis.

Firstly, research has shown that it impacts the production of male hormones, most importantly, testosterone. This restricts the androgen’s ability to induce erections and can also lower sperm quality.19

Secondly, smoking promotes narrowing of the arteries—preventing sufficient blood from entering the penis for a useable erection.20

Obesity

Being overweight can lead to atherosclerosis—the narrowing of the arteries. This prevents adequate blood supply to obtain and maintain an erection.

Furthermore, scientists have discovered that obesity leads to a reduction in testosterone production, lowering libido, and causing erectile dysfunction.21

Alcohol

The good news is, light to moderate drinking is known to improve erection issues. Experts believe this is because it can relax the arteries and lower blood pressure—ensuring that the male member receives sufficient blood flow to attain an erection.22 23

However, don’t open that bottle of wine just yet.

Excessive consumption can have the opposite effect. Most of us have experienced the situation where, after a few hours of enjoyable drinking, our manhood simply will not function—despite the fact that our desire has rapidly elevated.

This is usually a short-term symptom and purely related to that evening’s social pleasure. The next day, our penis’ are back functioning normally again.

Yet, drinking too much over an extended period of time can have longer-lasting implications.

Scientists explain that alcohol acts as a neurotoxin—affecting the brain’s ability to stimulate erection attainment. Additionally, it lowers the effectiveness of gonadal hormones.24

How Erectile Dysfunction Is Diagnosed?

Usually, clinicians will diagnose erectile dysfunction based upon examination of the symptoms presented earlier.

Most often, your doctor will conduct a physical exam—listen to your lungs and heart, check your blood pressure, and examine your penis, testicles, and prostate.

In some cases, the medical practitioner may conduct further tests (such as blood and urine) to ensure that underlying factors such as prolactinoma, hypogonadism, or groin hernia are not causing the erectile dysfunction.

The doctor will be looking for clues to whether the erection issues are related to physiological or psychological factors.

One of the simplest methods for ruling out psychogenic causes is for the clinician to explore whether you obtain involuntary erections. For example, achieving an erection during the night when sleeping or first thing upon waking (known as nocturnal penile tumescence).25

A battery-powered unit is worn on the thigh while you enjoy your slumber. It evaluates the quality and frequency of nocturnal erections and saves the electronic data—which your doctor can then assess.

If it transpires that you are experiencing “healthy” erections by “accident”—it tends to indicate that the physiological aspects are fine and the problems are related to psychological reasons.

Furthermore, the doctor may question whether you can obtain a rigid penis through manual stimulation alone—to check whether the impotence is caused by performance anxiety when with a partner.

In severe cases, clinicians often recommended an ultrasound scan of the male member to explore its blood flow capability.

How Erectile Dysfunction Is Treated?

The causes of erectile dysfunction are numerous. Hence, the best course of treatment is tailored specifically for the underlying reasons for the problem. In some cases, a combination of methods is the ideal route—which can include medication, lifestyle adjustments, or psychological therapy.

Here are the most popular ways to alleviate erectile dysfunction:

Oral Medicines

Generally speaking, we can separate these treatments into two distinct groups—natural and pharmaceutical-grade medication.

Natural Erectile Dysfunction Treatments

There are numerous supplements and pills on the market that promise to enhance erection quality—the problem is, the efficacy of these varies widely.

Beware, of so-called “miracle-pills” which promise to provide all-night-long erections, elevate orgasm quality, and improve penis length. Most frequently, these are no more than placebos and will do nothing apart from lower your bank balance.

That said, some natural remedies are grounded in science, and prove useful for treating some cases of erectile dysfunction. The most effective are:

Vitamin pills—minerals and nutrients such as magnesium, zinc, and vitamin D are required to attain an erection. 26

Testosterone boosters—as discussed, low T-levels can contribute to your manhood’s ability to remain firm—these supplements elevate testosterone, enhancing penile strength.

Nitric oxide heighteners—they open up the vascular system improving the delivery of blood to the penis.

Pharmaceutical Treatments

The most commonly prescribed pills for erectile dysfunction are Sildenafil (Viagra) and Tadalafil (Cialis).

These tablets are PDE5 (phosphodiesterase type 5) inhibitors. They block enzymes which can prevent the attainment of an erection while dilating the blood vessels to increase blood flow.27

While highly effective, they can induce side effects such as flushing, headaches, and heartburn and should be used with caution—especially if you suffer from cardiovascular disease.28

Testosterone Therapy

This process involves introducing exogenous testosterone directly into the bloodstream—elevating the body’s ability to gain an erection. There are numerous methods of administration, including:

Testosterone Injections

Testosterone enters the bloodstream via the muscle tissues through a hypodermic injection—often administered every two to four weeks. Most commonly, a health practitioner will do this on your behalf.

Mouth Strips

A testosterone-dosed strip that adheres to the gums of the mouth behind your teeth. Usually administered once daily, it releases testosterone into the bloodstream through the thin lining of the mouth.

Testosterone Patches and Gels

You absorb testosterone through your skin tissues, providing a specific dose as prescribed by your health practitioner.

Testosterone Tablets

This is the least common method of testosterone therapy. You swallow a tablet in which the stomach digests—enabling the testosterone to enter the bloodstream. However, your body processes it through the liver—which can cause damage to this vital organ.

Exogenous testosterone, when taken for extended periods, can induce the unwanted side effects of:

Sleep apnea. 29

Prostate cancer.

Urinary tract issues.

Excessive red blood cell production.

Penile Injections

You self-administer an injection into the side of your penis, which delivers drugs such as phentolamine and alprostadil.30

They work as vasodilators, increasing blood supply to promote an erection. Typically, the effects are noticed around 10 minutes after administration and last for about 45 minutes.

Side effects can include localized bruising and scarring.

Intraurethral Medications

Possibly one of the most uncomfortable treatments for erectile dysfunction.

You push a plastic tube-like applicator into the opening in the head of the penis to a depth of 1.25 inches. This then delivers the prescribed dose of alprostadil (in the form of a pellet) into the urethra—acting as a vasodilator.31

This was one of the most common forms of erectile dysfunction treatment until the emergence of Viagra in 1998.

Vacuum Erection Devices

These are tubes that fit over your penis, which then electronically or manually create a vacuum. The negative pressure encourages blood to enter the penis forming an erection.

Frequently, they are used alongside penis rings—which limits the amount of blood “draining” from the penis—increasing the longevity of your erection.

Studies show they are effective in mild cases of erectile dysfunction—although they can cause bruising, numbness, and pain.32

Penile Implants

These are the final treatment for erectile dysfunction—used when all other methods have failed.

Prosthetics are inserted into the penis’ erection chambers, to provide both form and strength. Most commonly, they come in two distinct types.

Semi-rigid rods—meaning that the penis is always in a state of being half erect.

Inflatables—a doctor positions saline-filled cylinders in the penis chambers, with a pump in the scrotum—when squeezed, it inflates the cylinders providing an erection.33

Surgery

This form of treatment addresses the blood supply issues of erections.

Usually, the arteries are widened to increase blood flow. Or alternatively, blocking veins inside the penis to prevent blood loss from the chambers, increasing the duration of the erection.

What Can I Do to Prevent Erectile Dysfunction?

Following the steps below can drastically reduce the risks of developing erection problems.

Don’t Smoke

Smelling of cigarettes isn’t the greatest turn-on for your partner. Plus, as already mentioned, it restricts blood flow to the penis and lowers testosterone levels.

Cut Down on Alcohol

Enjoy an occasional drink—but not to excess.

Taking control of your alcohol intake can prevent both short and long-term erection issues.

Enjoy a Healthy Diet

Ensure you are receiving adequate amounts of the erection-enhancing zinc, magnesium, and vitamin D through your food intake. If personal preferences or intolerances make this problematic—consider supplementation.

Furthermore, a sensible diet promotes a healthy weight. Obesity is the enemy of erections.

Exercise Regularly

Working out improves cardiovascular function—and elevates energy levels.34

Your heart is the “pump” behind your erections—pushing blood into the corpora cavernosa creating a firm and hard male member. Additionally, regular exercise can ensure that you don’t pile on the erection-killing pounds.

You may also consider Kegel exercises which strenghten pelvic floor muscles and therefore support erections.

Lower Your Stress Levels

Financial, work, and family matters can leave us feeling worried and anxious—and cause erectile dysfunction.

Take time in your day to do something that you both enjoy and find relaxing—such as spending time with friends, yoga, or mindfulness meditation.

Sexual Therapy and Erectile Dysfunction

Sexual problems can place a serious strain on relationships.

Often, a man with erectile issues encounters performance anxiety—making him reluctant to initiate sexual intercourse. His partner could perceive this as a rejection or a feeling of unattractiveness—which can lead to emotions of resentment and frustration.

Sex therapy can help both partners overcome this negative state of mind and re-ignite intimacy.35

Therapists can teach couples techniques for overcoming the concern about losing an erection during intercourse.

For example, a man and his partner become intimate to the level of stimulation where sex would typically begin.

They then consciously stop—so the penis becomes less erect. The couple then re-starts stimulation until the erection returns. When couples do this exercise continually—both partners learn to relax—understanding that he is able to regain his erection should it be lost.

Often, couples use sex therapy alongside medications and other treatments. Health practitioners sometimes prescribe drugs, such as beta-blockers, to help men overcome short-term performance anxiety and suggest sex therapy to help the couple push through the emotional part of the problem.

Once a man’s confidence is restored, they are frequently able to attain an erection without the use of medication.

Living with Erectile Dysfunction

While erectile dysfunction can be depressing, worrying, and lead to embarrassment—it doesn’t have to be that way.

Firstly, talk about it.

Be open with your partner. You do not have to deal with the issue alone. The more honest you can be, the lower the performance anxiety when it comes to bedroom action time.

Alternatively, speak to your buddies. Statistically, if you think of two of your friends, one of them also has erectile dysfunction. They may even welcome the fact that you’ve raised this issue and enable them to talk freely.

Next, decide to be proactive—don’t just accept it.

Consider whether you believe it to be psychological or physiological. If you’re waking in the morning with a firm manhood—it’s most likely to be a mental problem—one which you can solve through talking.

Over-the-counter treatments such as testosterone boosters, nitric oxide heighteners, and vitamin pills can often be a simple solution. Combine these with the lifestyle tips which I mentioned earlier—surgery and invasive injections are in most cases not required.

However, if you have been suffering from erectile dysfunction for an extended period of time—and it shows no signs of improvement—visit your doctor.

They are trained in determining the exact cause of the erection issue—and can recommend a course of treatment specific to your requirements.

Once you’ve decided to address the issue—it’s surprising what a positive effect this can have on your life.

This article has been medically reviewed by Dr. Biswadeep Das in August 2019