Erectile Dysfunction: Causes, Assessment and Treatment Options

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Erectile dysfunction (ED) is a persistent or recurrent difficulty getting or keeping an erection firm enough for sexual activity. An occasional problem after stress, tiredness or excess alcohol does not by itself establish a diagnosis. When erection difficulties keep happening, the assessment should look beyond the penis alone: cardiovascular and metabolic health, diabetes, blood pressure, hormones, nerves, medicines, previous pelvic treatment, psychological factors and relationship context can all matter. Treatment is then selected according to the likely cause, medical safety, patient preference and response to previous options.

What is erectile dysfunction?

ED can involve difficulty achieving an erection, difficulty maintaining it, or both. The pattern matters. Some men can become fully erect but lose rigidity during sexual activity; others have reduced rigidity from the beginning. Morning or nocturnal erections may change, but their presence or absence does not by itself prove whether the cause is physical or psychological.

A clinical assessment becomes more useful when the problem is recurrent, is affecting sexual activity or quality of life, or is accompanied by symptoms such as reduced sexual desire, penile pain or curvature, ejaculatory problems, or a recent change in general health.

Is erectile dysfunction simply part of ageing?

No. ED becomes more common with age because cardiovascular disease, diabetes, medication use and other associated conditions also become more common. It should not be dismissed as an inevitable consequence of getting older.

A younger man can have ED because of anxiety, depression, medication effects, endocrine disease, vascular risk factors, neurological problems, pelvic trauma or several factors at the same time. An older man may also have a predominantly situational or psychological component. Age helps frame the assessment; it does not replace it.

What can cause erectile dysfunction?

An erection depends on coordinated signals from the brain and nerves, adequate blood flow, responsive penile tissue and an appropriate hormonal environment. ED can therefore have several overlapping causes:

• vascular disease, hypertension, high cholesterol and smoking;
• diabetes, obesity and metabolic syndrome;
• neurological disease or nerve injury;
• testosterone deficiency and selected other endocrine disorders;
• medicines that can affect sexual function;
• pelvic surgery, radiotherapy or trauma;
• Peyronie’s disease or painful penile deformity;
• depression, anxiety, performance anxiety and relationship stress;
• heavy alcohol use, recreational drugs, poor sleep and physical inactivity.

A separate page examines these mechanisms in more detail: causes of erectile dysfunction.

Why can ED matter for cardiovascular health?

ED and cardiovascular disease share many risk factors, including diabetes, smoking, hypertension, abnormal lipids and obesity. Current EAU guidance treats ED as clinically relevant to cardiovascular risk assessment rather than only as a sexual symptom.

This does not mean that every man with ED has coronary artery disease or needs advanced cardiac imaging. It means that persistent or newly developed ED can be an opportunity to check blood pressure, glucose control, lipids, smoking status, exercise tolerance and other cardiovascular risk indicators, particularly when a vascular cause is plausible.

Chest pain, marked breathlessness, fainting or concerning palpitations during exertion or sexual activity require medical assessment. Ongoing severe chest pain or severe breathlessness is an emergency.

Is ED always psychological?

No. Psychological factors can cause ED, worsen an organic problem or develop after repeated unsuccessful sexual experiences. A common cycle is a difficult erection followed by fear that it will happen again; increased monitoring and anxiety then interfere with arousal and make the next episode more likely.

Sudden onset, strong situational variation and preserved spontaneous erections may suggest a psychogenic component, but none of these findings is diagnostic on its own. Physical and psychological factors frequently coexist.

When appropriate, psychological or psychosexual support may be combined with medical treatment. That does not mean the symptom is imaginary; it addresses one of the mechanisms that can sustain it.

When should ED be medically assessed?

A urology or appropriate medical assessment is reasonable when erection difficulty:

• keeps recurring or persists;
• begins suddenly without an obvious temporary explanation;
• is accompanied by reduced libido or symptoms suggesting hormonal disease;
• occurs in a person with diabetes, hypertension, high cholesterol or cardiovascular disease;
• follows pelvic surgery, radiotherapy or trauma;
• is associated with penile curvature, pain or a palpable plaque;
• begins after starting or changing a medicine;
• is causing significant distress, avoidance or relationship difficulty;
• is prompting use of unregulated online medicines or supplements.

The purpose of assessment is not to steer every patient toward medication or a procedure. It is to understand the pattern, identify relevant health conditions and decide what, if anything, needs treatment.

How is erectile dysfunction assessed?

Most initial assessments are based on a detailed medical and sexual history, focused examination and selected laboratory tests. Not everyone needs specialised imaging.

Medical and sexual history

Useful questions include when the problem started, whether it is consistent or situational, whether erections occur during masturbation or sleep, how long rigidity lasts, whether sexual desire has changed, whether ejaculation or orgasm is affected, and whether there is pain or curvature. Medical conditions, operations, medicines, supplements, smoking, alcohol, sleep, mood and previous ED treatments are also relevant.

Validated tools such as the International Index of Erectile Function (IIEF), its shorter SHIM form or the Erectile Hardness Score can help structure assessment and follow-up. They support clinical judgement rather than replace it.

Physical examination

The examination is guided by history and may include blood pressure, pulse, weight or waist circumference, signs of vascular or neurological disease, evidence of endocrine problems and examination of the penis and testes. Any intimate examination should be explained in advance and performed with consent.

Laboratory tests

If recent results are not available, current EAU guidance includes glucose or HbA1c, a lipid profile and early-morning total testosterone in the basic work-up. Other tests are selected according to symptoms and findings rather than ordered routinely for everyone.

A single low testosterone value should not automatically lead to testosterone treatment. The result needs to be interpreted in the correct clinical context and, where appropriate, confirmed.

Does everyone need a penile Doppler ultrasound?

No. Penile dynamic duplex ultrasound is a second-level test. It may be useful when a vasculogenic cause needs more detailed evaluation, for example in selected men with diabetes or multiple vascular risk factors, poor response to oral therapy, trauma, or when specialised treatment planning requires haemodynamic information.

The test also has limitations: anxiety, technique and drug response can affect measurements. It should answer a clinical question rather than be ordered simply because ED is present.

Are nocturnal erection tests routinely required?

No. Nocturnal penile tumescence and rigidity testing can sometimes help distinguish an intact erectile mechanism from certain organic causes, but sleep quality, age, depression and other factors can influence the result. It is not part of routine assessment for most patients.

What treatment options can be considered?

ED care is not a rigid ladder that every patient must climb in exactly the same order. Current EAU guidance emphasises personalised decision-making according to effectiveness, invasiveness, tolerability, safety and patient preference.

Options can include:

• lifestyle changes and treatment of relevant cardiovascular or metabolic risk factors;
• phosphodiesterase type 5 inhibitors (PDE5 inhibitors), such as sildenafil or tadalafil, when suitable;
• vacuum erection devices;
• intracavernosal injection therapy;
• selected intraurethral or topical treatments where available;
• psychological or psychosexual interventions when indicated;
• testosterone therapy only when a true androgen deficiency is established and treatment is appropriate;
• low-intensity shockwave therapy in selected vasculogenic ED, with important evidence limitations;
• penile prosthesis surgery when other treatments are unsuitable, unacceptable or unsuccessful, or according to informed patient preference.

The role and sequencing of these choices is covered separately in erectile dysfunction treatment options.

Can lifestyle changes make a difference?

They can, particularly when ED is linked to modifiable cardiovascular and metabolic risk. Smoking cessation, regular physical activity, weight management, moderation of alcohol intake and control of diabetes, blood pressure and lipid abnormalities can support sexual and general health.

Lifestyle measures do not reliably resolve ED on their own. Their importance is that ED can be one manifestation of broader vascular or metabolic health, and improving those factors can benefit more than sexual function alone.

Are ED tablets suitable for everyone?

No. PDE5 inhibitors are first-line medical therapy for many men, but they require a safety review. They do not create an erection without sexual stimulation and they do not treat every underlying cause of ED.

A key contraindication is concurrent use of organic nitrates or nitric-oxide donors, because the combination can cause a dangerous fall in blood pressure. Other cardiovascular conditions and medicines may also affect whether a PDE5 inhibitor is appropriate.

Apparent “treatment failure” should not automatically be accepted after one attempt. Timing, food effects for some agents, sexual stimulation, dose selection, adherence and use of a legitimate medicine can all affect response. Medicine doses should be decided with a clinician rather than copied from online instructions.

Where does shockwave therapy fit?

Low-intensity shockwave therapy (Li-SWT/LI-ESWT) has been studied mainly in vasculogenic ED. The EAU currently gives it a weak recommendation in selected patients, including some men with mild vasculogenic ED and some poor responders to PDE5 inhibitors.

The evidence shows, at most, a modest average improvement in erectile-function scores, with major variation in devices, protocols and patient selection. Radial pressure-wave devices should not be assumed to be equivalent to the focused shockwave systems used in much of the clinical research.

Read about shockwave therapy for ED.

What about PRP, P-Shot, stem cells or exosomes?

These interventions are often marketed under “regenerative” labels, but the evidence is not equivalent to established ED treatments. Current EAU guidance states that evidence for intracavernosal platelet-rich plasma remains insufficient to make a treatment recommendation. Stem-cell and exosome approaches also lack the level of evidence required for routine, standard ED care.

They should not be presented as established cures or as replacements for proper diagnosis of vascular, endocrine, neurological or psychogenic causes.

When is a penile prosthesis considered?

A penile prosthesis is a surgically implanted device that provides mechanical rigidity. It may be considered when other treatments have failed, are unsuitable or are not acceptable to the patient, or when an informed patient prefers this definitive mechanical option after counselling.

It does not increase sexual desire, restore ejaculation lost after prostate surgery or act as a cosmetic lengthening operation. The surgery is also not meaningfully “reversible” in the sense of returning the erectile tissue to its pre-implant state.

See penile prosthesis and when to consider a penile implant.

Can ED occur with other sexual or penile problems?

Yes. ED can coexist with premature ejaculation, reduced desire, delayed ejaculation, orgasmic problems or Peyronie’s disease. These symptoms should be separated during assessment rather than assuming that treating erection quality will automatically correct everything else.

For example, penile curvature can make intercourse mechanically difficult even when rigidity is adequate. Conversely, severe ED can make a moderate curve seem more functionally limiting. The treatment question changes when both conditions are present.

When is urgent assessment needed?

ED itself is usually not an emergency, but associated symptoms can be. Urgent or emergency assessment may be needed for:

• ongoing chest pain, severe breathlessness or collapse;
• an erection lasting more than four hours, particularly if painful;
• significant penile or pelvic trauma;
• sudden severe genital pain or swelling;
• acute neurological symptoms such as new limb weakness or loss of bladder/bowel control.

Medical information note

This page provides general medical information. It does not diagnose the cause of an individual’s erection difficulty or determine which medicine, device or procedure is appropriate. Persistent ED deserves assessment because sexual symptoms can be connected with broader cardiovascular, metabolic, endocrine, neurological or psychological health.