What Is Erectile Dysfunction?

“I can’t get it up” is the common complaint of millions of men who deal with varying degrees of erectile dysfunction, formerly known as impotence, often used interchangeably with the abbreviation ED.

Men of all ages can develop ED. Young men and inexperienced men may have psychological issues that keep them from becoming aroused to enable them to have an erection. Men of all ages can suffer nerve damage that prevents arousal signals from traveling from the brain to the blood vessels that engorge the penis to make it hard. Men of all ages can suffer hypogonadism, a condition of low testosterone levels. And ED can result as a complication of high blood pressure, diabetes, high cholesterol, tobacco abuse, and coronary artery disease, or as a side effect of medications used to treat those conditions. 

Producing an erect penis requires a man’s body to integrate psychological and physiological processes that depend on life experiences, emotions, and attitudes, but also adequate function of the central nervous, peripheral nervous, vascular, and hormonal systems of a man’s body. Any abnormality in any of those systems has a significant impact on the ability to sustain an erection, ejaculate, and feel an orgasm. On the other hand, any improvements in just one of those systems can be what a man needs to once again achieve good sex.

What Are the Symptoms of Erectile Dysfunction?

Erectile Dysfunction is a sensitive subject. Many men who have ED don’t know how to bring up the topic. Modern doctors are trained to ask “How is your sex life?” If there is any hesitation in answering the question, the doctor will usually follow up with questions to determine:

  • Whether the patient has difficulty achieving an erection.
  • Whether the erection is strong enough for penetration.
  • Whether the erection can be maintained long enough for the patient’s partner to achieve orgasm.
  • Whether there is ejaculation. (Some men, most often diabetics, develop retrograde ejaculation, emission of semen into the bladder instead of into the penis. These men may notice a white mass when they urinate.)
  • Whether both partners are satisfied with the sexual experience.

If these questions indicate a strong possibility of ED, the doctor will then ask about the man’s sexual history. The doctor will need to know if the patient has ever been capable of having strong erections. There will be questions about how long the patient has had ED, and whether it is getting worse, getting better, or stable. The doctor will ask about nocturnal emissions, pain during ejaculation, premature ejaculation, how often the patient has sexual activity, whether it is spontaneous or planned, whether there is foreplay, and how far the patient would like to go to resolve the problem.

Most men find the medical testing needed for a definitive diagnosis of ED and its causes to be invasive and unpleasant. But a urologist typically is able to find what is causing ED and to prescribe a treatment for it. How much treatment a man receives depends on how strongly he wants to change his ability to have erections.

ED Is All About a Man’s Ability to Achieve Satisfaction in Sex

Healthy sexual intercourse is all about a couple’s ability to achieve mutual satisfaction in sex. Erectile dysfunction, on the other hand, focuses on a man’s inability to achieve personal satisfaction in sex. Correcting erectile dysfunction won’t necessarily cure any and all problems in a man’s sex life. Treating erectile dysfunction aims to restore a man’s ability to maintain a firm penis for sexual activity.

Modern medicine defines erectile dysfunction in terms of a man’s satisfaction with sexual intercourse. The American Urological Association defines ED as “the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance” or “the recurrent or consistent inability to reach and/or maintain erection of the penis sufficient for sexual satisfaction.”

Not being able to achieve sufficient erectile strength to enjoy sex generally means that men have difficulty starting an erection, or can’t maintain an erection long enough to have sex, or have either premature or delayed ejaculation. In some men, orgasm and ejaculation are out of sync. This symptom is diagnosed and treated in some of the same ways as ED.

Men who are interested in sex, who are aroused romantically, but cannot have sexual intercourse, may also have ED. We’ll be discussing this situation in more detail below.

Some men have a form of erectile dysfunction that doctors call “complete ED,” the inability to achieve any kind of erection at all. Many more men report that they have “moderate ED,” the inability to achieve an erection often enough that they feel it interferes with their sex life. A smaller number of men have “mild ED,” an occasional inability to achieve an erection.

Just How Common Is Erectile Dysfunction?

The Massachusetts Male Aging Study (MMAS) revealed that as many as 52 percent of all men at any age have some degree of ED that interferes with their enjoyment of sex.

In the MMAS:

  • 50 percent of men over 40 reported some degree of ED.
  • 52 percent of men of all ages reported ED.
  • 25 percent of men of all ages reported “moderate” ED, problems getting erections more than 50 percent of the time.
  • 17 percent of men of all ages reported “mild” ED, problems getting erections less than 50 percent of the time.
  • 10 percent of men of all ages reported “complete” ED, never being able to get erections at all.


These figures held up in a nationwide study of men called the National Health and Social Life Survey (NHSLS), which also found that about 10 percent of men had not been able to sustain an erection in a year or more. However, the MMAS found that ED isn’t a problem that stays the same for years on end.

Over the 7 years of the MMAS study, participants were contacted every year. In any given year, 33 percent of men reported their ED was worse than the year before, and 37 percent of men reported their ED symptoms were better.

The class of drugs known as phosphodiesterase-5 inhibitors (Viagra, Levitra, and Cialis, which act similarly to the more recently introduced Stendra) was approved by the US FDA in the middle of the study. Despite the introduction of the “purple pill” and its competition, just about the same numbers of men reported their ED getting worse as reported it getting better.

The statistics about ED tell us that most men have problems achieving satisfactory erections at least some of the time. What these statistics don’t reveal is why so many men deal with some degree of ED. There are so many contributing factors to ED that men may suffer from more than one. But as we mentioned earlier, dealing with any of the causes of ED may relieve the problem.

Psychological Causes of Erectile Dysfunction

About 40 percent of all cases of Erectile Dysfunction, current research tells us, demonstrate the psychological origins of ED. Any man of any age can develop psychological issues that interfere with his ability to have erections. This form of ED known in medicine as psychogenic ED, however, is more common in men under 40 than in men over 40.

There used to be a saying, cleaned up a bit, that “sometimes your penis knows better than you do.” In some men, ED is tied to situations in which the consequences of having sexual intercourse would be intolerable.

Anxiety about HIV and STDs can interfere with a man’s ability to have an erection. Concern about breaking the law, violating trust, committing a sin, or offending social norms can generate reasonable fears that manifest themselves as ED.  These issues are seldom considered in therapy, but they affect many men. Your doctor’s role is not to judge your actions or your lifestyle, but recognizing the reality of anxiety, fear, and guilt is fundamental to choosing appropriate treatments.

Depression makes it hard for men to connect with others. Depression can cause ED. (As we will discuss a little later, some medications for depression can also cause ED.)

Men who have experienced physical or emotional trauma, or both, in the context of ED may be unable to perform. This situation always calls for skilled counseling. But psychogenic ED becomes a serious sexual health issue when it triggers a vicious cycle.

The cycle of psychogenic ED runs a course like this:

  • A man is anxious, depressed, or dealing with PTSD. When he attempts sexual intercourse, he isn’t able to have an erection.
  • Not being able to have an erection leaves the man understandably upset. The experience may also damage the man’s relationship with his sex partner.
  • The next time the man attempts to have sex, he is even more anxious, depressed, or traumatized, and even less able to have an erection. The cycle repeats itself until there is appropriate treatment or the man gives up on sex.

When ED arises from psychological reasons, a prescription for Viagra or a similar medication won’t be enough. Psychogenic ED is treated with couples counseling, relaxation techniques, medications for anxiety and depression, and/or psychotherapy, as appropriate. When one of the underlying components of psychogenic ED is arousal, treatment may include hormone therapy.

Hormones and Male Arousal

A laboratory study of male sexual arousal and hormone levels, both before and after sexual thoughts, found that one hormone has to be present in a man’s bloodstream before having a strong response to sexual stimulation.

It isn’t the male sex hormone testosterone. It’s the stress hormone cortisol.

Men who suffer adrenal burnout, a history of so much stress that their adrenal glands stop producing large amounts of cortisol, don’t have a strong physical response to sexual stimulation. To their partners, the lack of a reaction may seem like disinterest. The issue is that their bodies haven’t produced enough cortisol to activate their autonomic nervous system, the nerves that make their hearts beat faster, their hands and mouths and penis become more sensitive to touch, and release energy for intense physical activity.

Testosterone is also essential to a man’s sexual response, but at a different point in the process.

Once cortisol has activated the brain and nerves elsewhere in a man’s body, testosterone binds to receptors in a part of the brain called the amygdala. The amygdala is the part of a man’s brain that processes signals from his partner in sex. Testosterone helps a man do the act of sex with greater responsiveness to his partner’s needs. It helps both to energize and to organize lovemaking toward the goal of orgasm and ejaculation.

Testosterone activates the right side of a man’s amygdala to make it possible for him to recognize sexual opportunity. (In women, activation of the amygdala gives greater weight to memories of sexual experiences to be avoided.) It also activates the formation of memories that make a man’s sexual experiences more vividly memorable, whether they are good or bad. It helps a man instantly associate the sight of his partner’s face with the pleasure, or lack of it, he felt in their having sex together.

Giving a man testosterone is never enough to resolve sexual issues. Testosterone gives a man a stronger response to sexual opportunity. It gives a man stronger memories of sexual experiences. But psychological issues and misunderstandings arising from inexperience must also be resolved for a man to gain the best possible results in his sex life from testosterone therapy.

Men also, of course, need to be healthy to get maximum enjoyment of sex.

Diseases That Can Cause Erectile Dysfunction

Many men have healthy attitudes about sex, positive memories about sex, and healthy hormone levels, but still have ED. There is an astonishing range of diseases that can interfere with the nerve signals that activate the penis for engorgement, the ability of a man to feel what is going on with his penis during sex, or that prevent the flow of blood into the penis for erection.

Let’s take a look at some of the conditions that can result in Erectile Dysfunction.

    • ED is a frequent complication of vascular conditions, including high blood pressure, heart attack, injury to blood vessels from radiation treatment, injury to blood vessels from trauma (for instance, long-distance bicycle riding), and vascular injury from prostate cancer treatment. The medications used to treat these conditions sometimes also cause ED.
    • Over 50 percent of men who have diabetes (type 1 or type 2) develop ED.
    • Snoring is linked to ED. Men who have sleep apnea may develop ED even after they go on CPAP.
    • Both hyperthyroidism and hypothyroidism can cause ED.
    • ED is a frequent complication of iron overload diseases, both hemochromatosis and beta-thalassemia.
    • Other conditions that can result in ED are a very long list: Penile conditions such as Peyronie disease, epispadias, and priapism; psychiatric conditions including widower syndrome and performance anxiety; stroke, epilepsy, Guillain-Barré syndrome, Alzheimer disease, and multiple sclerosis; scleroderma, lupus, and rheumatoid arthritis; kidney failure; liver cirrhosis; sickle cell anemia; malnutrition, and zinc deficiency.

There is a similarly long list of prescription medications that can cause ED. including medications for high blood pressure, depression, and ulcers, medications for lowering cholesterol, and medications for treating prostate cancer.

Men who use recreational drugs can suffer ED as a complication. Chronic use of methamphetamines (most common in men who use them to participate in a passive role in sex more often and for longer times) develop a kind of ED that drugs like Viagra, Cialis, Levitra, and Stentra won’t help. Cannabis may put some men in the mood for sex, but excessive use can interfere with sex drive. Alcohol abuse interferes with testosterone production, and excessive use of tobacco can cause vascular damage that keeps the veins in the penis from opening up to make the penis erect.

What About Low Testosterone and ED?

Testosterone replacement isn’t the answer for every man who has ED. But for many men who suffer “low-T,” testosterone levels below 300 ng per milliliter, testosterone is what is needed to remedy the problem.

Testosterone isn’t just important in sexual health. It is also important in maintaining mood, muscle tone, and bone health, and in regulating fat mass. Men who have higher testosterone levels have more spontaneous erections and more sex, and they also have better control over the orgasms and ejaculation.

Low-T and ED aren’t the same thing. ED can have many different causes. In men over 40, however, testosterone replacement therapy combined with care for other health issues is exactly what it needed to bring a man’s sex life to a satisfactory state once again.


Alternative Treatments: Shockwave Therapy

A Frequently Asked Question: Are the Only Medical Interventions for ED Talk Therapy, Drugs, and Surgery?

There are two drug-free, surgery-free shockwave treatments for ED licensed as Alma Duo and Gainswave. There have been no fewer than 56 peer-reviewed, published scientific studies of the effectiveness of shockwave therapy for ED, and there is general agreement that it can work. Men who don’t respond to medication and papaverine injections into the penis before sex often respond to shockwave therapy after one to three months of treatments—sometimes with dramatic improvement in the strength and duration of their erections.

Patients report that Alma Duo is pain free, whereas Gainswave is much more painful even though the device markets itself as painless.

Doctors at the University of North Carolina and the University of Utah have been using low-intensity vibrations to treat blood vessel damage from diabetes for about 20 years. In 2010, a group of doctors in tried low-power shockwave therapy focused on the penis for treating ED, and got good results they were able to replicate in other patients.

As more and more and doctors around the world started experimenting with shockwave therapy for difficult cases of ED, research confirmed that blood vessels in the penis are stimulated to grow to overcome the resistance created by the shockwave. Although an erect penis isn’t a “muscle,” it can grow stronger by repeated exposure to the right amount of resistance.

Shockwave treatment consists of placing a vibrating wand at specific locations on the penis for a 15-minute session once or twice a week. It’s not something men and their partners (unless their partners are doctors) can do at home. There is no set number of treatments for shockwave therapy, but most doctors recommend doing it for three weeks, followed by a three-week break, and another three weeks of treatments once a year.

For Treatment

Call us or book an appointment online for diagnosis and treatment of ED.

More FAQ’s

. The most common presentation of ED is “moderate” or “complete” interference with sexual satisfaction. Men who have ED don’t just have occasional problems with their erections. They are more likely to have erectile dysfunction more than 50 percent of the tie they attempt to have sex or not to be able to have erections at all than they are to have ED as only an occasional problem.

The sooner a man brings his concerns about erectile dysfunction to his doctor’s attention, the sooner he can get effective treatment. Erectile dysfunction can be a symptom of an undiagnosed condition requiring medical treatment, such as heart disease or diabetes. Seeing the doctor about ED may lead to lifesaving treatment for some other condition.

It may be OK to defer talking with the doctor about ED when a man believes it is caused by fatigue, passing depression, or a psychological issue he can resolve on his own. But it is usually better to seek treatment sooner rather than later.

It’s important for men who have a “little” problem with ED to realize that if they don’t do something about it, it has a way of becoming a big problem. And it may help men to know that their situation is hardly unique.

ED can be treated with injections of drugs like alprostadil and phentolamine. These drugs open the blood vessels in the cavernus cavernosum, the spongy vascular tissue in the penis that fills up with blood to make the penis erect. These injections can be highly effective, but men have to be shown injection technique and advised on injection timing by their doctors.

ED can be treated with vacuum pumps that enlarge the penis by lowering air pressure around it. And, as a last resort, it is possible to replace the blood vessels in a man’s penis with an inflatable device that makes the penis erect at the touch of a button. But this device can never be removed or replaced.

Not every man will respond to medications in the same class as Viagra, but 80 percent will. However, testosterone therapy is also effective for men who have hypogonadism (low-T), and it has benefits in addition to helping men get stronger erections.

Men who don’t get relief from any other treatment for ED who want to continue their sex lives can investigate implant surgery. However, if the procedure doesn’t work, the man can never have sexual intercourse again.

Urologists used to think that men who have or who have had successful treatment for prostate cancer, or who have PSA levels that suggest a high risk of prostate cancer, should not be given testosterone replacement therapy. Recent research has found that some men who have prostate cancer actually do better with testosterone therapy.

It’s important to be open and honest with your doctor about prostate health. Doctors can work with you even when you have prostate issues, but you should not make them repeat diagnostic procedures to help you.

Can men who have lots of problems with erections improve so that ED is only an occasional problem? Yes, usually. Can men who can’t have erections at all have erections again? Sometimes, although surgical intervention may be necessary. Testosterone therapy often brings men back to a state where they are happy about their sex lives.

Among men of all ages, psychological issues are the most common cause of ED. That doesn’t mean, however, that every man who has psychological issues that interfere with sexual performance has to resolve them in therapy. In many men, the emotional and cognitive boost from appropriate testosterone therapy is enough to restore normal erectile function with the right partner.