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Erection Problems (Erectile Dysfunction)
What are erection problems?
A man has erection problems if he cannot get or keep an erection that is firm enough for him to have sex. Erection problems are also called erectile dysfunction or impotence.
Most men have erection problems every now and then. This is normal. These problems can occur at any age. But they are more common in older men, who often have other health problems. Treatment can help both older and younger men.
What causes erection problems?
Erection problems can have many causes. These include:
- Physical problems, such as injury to nerves or loss of blood supply to the penis.
- Other health problems, such as diabetes, high blood pressure, anxiety, and depression.
- Side effects of certain medicines.
- Drinking too much alcohol or smoking.
- Surgery, such as for prostate cancer.
What are the symptoms?
The only symptom of an erection problem is being unable to get and keep an erection that is firm enough to have sex. But even with an erection problem, a man may still have sexual desire and be able to have an orgasm and to ejaculate.
How are erection problems diagnosed?
Your doctor can find out if you have an erection problem by asking questions about your health and doing a physical exam. Your doctor will want to know how often the problem happens. The exam, lab tests, and sometimes mental health tests can help find out the cause of the problem.
How are they treated?
Doctors usually start with lifestyle changes and medicines. They usually don't advise surgery or other treatments unless those first steps don't help.
Treatment can include:
- Avoiding tobacco and drugs and limiting alcohol.
- Talking about the issue with your partner, doing sensual exercises, and getting counseling.
- Finding and then stopping medicines that may be causing the problem. In some cases you can take a different medicine that doesn't cause erection problems.
- Taking prescription medicine that can help you get erections. These include pills such as sildenafil (for example, Viagra), tadalafil (for example, Cialis), and vardenafil (for example, Levitra). Check with your doctor to see if it is safe for you to take one of these medicines with your other medicines. These pills can be dangerous if you have heart disease that requires you to take nitroglycerin or other medicines that contain nitrates.
- Taking medicines and getting counseling for depression or anxiety.
- Using vacuum devices or getting shots of medicine into the penis.
- Having surgery to place an implant in the penis.
Can you prevent erection problems?
Erection problems are most often caused by a physical problem. So it's important to eat healthy foods and get enough exercise to help you stay in good health.
To reduce your risk of having an erection problem, don't smoke, drink too much alcohol, or use illegal drugs.
You may be able to avoid erection problems related to anxiety and stress by talking with your partner about your concerns. This may help you relax.
Health Tools help you make wise health decisions or take action to improve your health.
Erection problems may be caused by physical problems related to the blood vessels, nerves, and hormones. Or they may be caused by psychological issues.
Normally, an erection occurs when your imagination or senses (vision, hearing, touch, smell, taste) are stimulated and you become aroused. Your central nervous system sends nerve impulses that increase blood flow to your penis.
Physical problems cause about 8 out of 10 cases of erectile dysfunction. Physical problems are often the cause of erection problems in men age 50 or older. They include:
- Side effects of medicines, including some medicines used to treat benign prostatic hyperplasia (BPH), depression, and prostate cancer. In some cases it may be possible to change the dose of the medicine or to use another medicine. Talk to your doctor.
- The use of tobacco, alcohol, or illegal drugs. Stopping or reducing the use of these substances may make the erection problem less severe.
- Problems with the blood vessels. These problems may prevent blood from filling the penis or from staying there long enough to maintain an erection. For example, long-term high blood pressure can cause damage to blood vessels and lead to erection problems.
- Problems with the nerves (neurologic problems). These may prevent arousal signals from traveling from the brain and spinal cord to the penis.
- Problems with the structure of the penis or its surrounding tissues.
- Hormonal factors, such as a low level of the hormone testosterone.
- Pelvic injuries and complications of prostate or other surgeries that interfere with nerve impulses or blood flow to the penis.
Psychological issues seem to be involved in many cases of erection problems. These mental issues include:
- Depression (which also has a physical component).
- Problems with current or past relationships.
These things interfere with the erection process by distracting the man from things that would normally arouse him.
Erection problems in men younger than 40 who have no physical risk factors are more likely to be caused by mental factors than physical causes.
Symptoms of erection problems include being unable to:
- Have an erection, most of the time.
- Keep an erection firm enough for sexual intercourse.
- Keep an erection long enough to complete sexual intercourse.
Even with an erection problem, a man may still have sexual desire and be able to have an orgasm and to ejaculate.
Most men have erection problems now and then. But when erection problems are lasting, they can affect your self-image, sex life, and relationship. When you have erection problems often, "performance anxiety" can make the problem worse. If you cannot keep an erection that is firm enough for intercourse, or if you have an orgasm before or right after entering your partner (premature ejaculation), you may feel frustrated and believe you aren't pleasing your partner. All of these things could affect how you view your relationship.
Fortunately, many of the things that cause erection problems can be treated.
What Increases Your Risk
Your risk of having an erection problem increases with age. Other things that increase your risk include:
- Diseases that affect blood vessels, such as diabetes, high blood pressure, and high cholesterol. About half of men with diabetes develop erection problems.
- Diseases that affect nerves. These include multiple sclerosis and Parkinson's disease.
- Smoking or using tobacco.
- Other health problems, such as low testosterone levels.
- Injuries to the pelvic area, a spinal cord injury, or treatment such as pelvic surgery or radiation in the pelvic area.
- Using substances, such as long-term (chronic) heavy alcohol use.
- Psychological risk factors, such as depression or a recent life change.
Activities that constrict blood flow to the penis may increase the risk for erection problems. For example, frequent long-distance bicycle riding on a hard, narrow saddle may increase risk. But the possible link between bike riding and erection problems has not been proved. Experts continue to debate this issue.
A vasectomy usually doesn't cause erection problems. But pain after the operation may affect sexual performance for a time. And if a man wasn't comfortable with his decision to have a vasectomy, or if he's having second thoughts, it could affect him psychologically.
When should you call your doctor?
Call your doctor now or seek medical care right away if:
- You have an erection that lasts longer than 3 hours.
- You have taken sildenafil (for example, Viagra) or vardenafil (for example, Levitra) in the past 24 hours or tadalafil (for example, Cialis) in the past 48 hours, and you have chest pain. Do not take nitroglycerin. Make sure all the doctors you see know that you took one of these medicines.
- You have erection problems that occur along with pain or difficulty with urination, fever, or pain in the lower belly.
Call a doctor if erection problems occur:
- With any type of injury to the back, legs, buttocks, groin, penis, or testicles.
- With other symptoms such as loss of hair, enlargement of the breasts, or backache.
- With any change to the medicine you take.
If your erection problem happens just now and then, there is no reason to call your doctor. If it happens often and upsets you or your partner, it is okay to call your doctor. If an erection problem doesn't bother you or your partner, you may choose not to call your doctor.
Watchful waiting means a "wait-and-see" approach. A single episode of an erection problem is often a temporary problem that is easy to reverse. Don't assume it will happen again. Try to forget about it, and expect a more successful experience the next time. If you or your partner is concerned about it, talk about the problem. Openly discuss your fears and anxieties.
If self-care has not helped after 2 weeks and you are concerned about your erection problem, see a doctor who has experience in dealing with these problems.
Who to see
The following health professionals can evaluate symptoms of erection problems:
If it is possible that a psychological problem is contributing to your erection problem, your doctor may refer you to a health professional such as a:
Exams and Tests
Because both physical and mental factors are often involved, it may be difficult to diagnose the exact cause of your erection problem.
To start, your doctor may:
- Review your risk factors for an erection problem.
- Ask questions about your sexual function.
- Do a complete physical exam of the abdomen, penis, prostate, rectum, and testicles.
- Do lab tests for:
- Testosterone. A low level of testosterone may reduce sexual desire, leading to an erection problem.
- Prolactin, follicle-stimulating hormone, and luteinizing hormone. If you have low testosterone levels, your doctor may recommend these blood tests.
- Thyroid hormone. A thyroid hormone level that is too high or too low may cause problems with sexual desire or erections.
- Blood sugar (glucose) levels. A high blood sugar level may mean the presence of diabetes, which can contribute to erection problems.
At this point, pills such as sildenafil (for example, Viagra), tadalafil (for example, Cialis), and vardenafil (for example, Levitra) are often recommended unless an easily treated cause (such as a medicine side effect or testosterone deficiency) has been identified.
If pills don't work or if your doctor feels more testing is needed, he or she may recommend:
- Specific tests for erection problems. These tests help find out whether physical or mental factors are causing your erection problem.
- A psychological evaluation, if a mental issue is suspected.
Treatment for an erection problem depends on the cause of the problem. The cause may be mental, physical, or a combination of both.
Many doctors take a step-by-step approach to treating erection problems. They use the least invasive treatments first. The treatment steps are:
- Looking for and then stopping medicines that may be causing your condition. In some cases, a different medicine can be tried.
- Trying testosterone or another treatment to fix a hormone problem, such as low testosterone, if tests show that you have one.
- Trying pills called PDE-5 inhibitors, such as sildenafil (for example, Viagra), tadalafil (for example, Cialis), and vardenafil (for example, Levitra).
- Trying counseling if a psychological cause is suspected.
- Trying medicines that are injected or inserted into the penis.
- Trying a vacuum device.
- Trying penile implant surgery.
Taking medicines safely
PDE-5 inhibitors have relatively few side effects. But they can be dangerous in certain men. If you are taking nitrate-containing medicines, such as nitroglycerin, you cannot use sildenafil (for example, Viagra), tadalafil (for example, Cialis), or vardenafil (for example, Levitra).
You also should not take certain alpha-blockers—used to lower blood pressure and to treat an enlarged prostate gland—with these medicines. There is a risk of a dangerous drop in blood pressure. Check with your doctor to see whether you can take PDE-5 inhibitors with your alpha-blocker.
What to think about
Oral medicines are commonly tried first before other medicine or surgery.
It is important to involve your partner in your decision, regardless of the treatment you choose.
Many men overestimate how important being able to have erections is to their relationships. Some men find that when they are able to have erections again, the hassle of using the treatment isn't worth the effort. Other men may find that being able to have erections doesn't change their relationship as much as they or their partners had expected.
You may be able to avoid erection problems related to anxiety and stress by taking a more relaxed approach to sex. Talk to your partner about your problems and concerns. Sexual intimacy is a form of communication. If you and your partner talk about sex, it will help reduce your stress and anxiety. And you may become more relaxed.
Erections may gradually become more difficult to get and keep as you get older. But foreplay—erotic stimulation before intercourse—and the right environment can help increase your ability to have an erection, regardless of your age.
Here are some other things you can do that may reduce your risk for erection problems:
- Quit smoking.
- Avoid using illegal drugs.
- Limit alcohol. Even small amounts of alcohol can cause erection problems.
- Manage high blood pressure and high cholesterol. This can help lower your risk of hardening of the arteries (atherosclerosis).
- Keep your blood sugar in your target range if you have diabetes.
- Exercise regularly.
- Lose weight, especially if you are obese.
- Lower stress in your life.
In some cases, occasional episodes of erection problems can be treated at home, without a doctor's help. But do involve your partner in the process. And don't be embarrassed about seeking professional help if erection problems are consistent and troublesome. You may be able to help yourself by:
- Examining your relationships and life events.
- Talking with your partner.
- Trying sensual exercises with your partner.
Some men may try methods available in health food stores or through magazine ads. Most of these methods have never been medically proved to work. They may be unsafe, and they are often expensive. They are not recommended.
Making lifestyle changes such as quitting smoking and drinking less alcohol can also help make erection problems less likely. To learn more, see Prevention.
Medicines that can help produce an erection may be used to treat erection problems that are caused by blood vessel (vascular), hormonal, nervous system, or psychological problems. They also may be used along with counseling to treat erection problems that have psychological causes.
Commonly used oral medicines include:
- PDE-5 inhibitors such as sildenafil (for example, Viagra), tadalafil (for example, Cialis), and vardenafil (for example, Levitra).
Other medicines that may be used include:
- Injected medicines.
- Intraurethral alprostadil (MUSE).
What to think about
Although oral medicines for erection problems can be purchased over the Internet, you need to talk with your doctor before using this medicine. This is especially important if you have a heart problem.
PDE-5 inhibitors and heart problems
PDE-5 inhibitors should never be used if you may need to take a nitrate-containing medicine, such as nitroglycerin. Taking nitroglycerin and a PDE-5 inhibitor within 24 hours of each other may greatly lower your blood pressure. This could lead to a heart attack, stroke, or death.
Talk with your doctor about whether medicines for erection problems are safe for you if you:
- Have heart disease.
- Have heart failure or low blood pressure.
- Are taking drugs for high blood pressure.
If you are taking a PDE-5 inhibitor and are going to have a test for heart disease, make sure that your doctor knows you are taking it. You should not take sildenafil (for example, Viagra) or vardenafil (for example, Levitra) for 24 hours before the test. Do not take tadalafil (for example, Cialis) for at least 48 hours before the test. Then if you have a problem during the test, it will be safe to use nitrate-containing medicines such as nitroglycerin.
If you are using a combination of drugs for high blood pressure, PDE-5 inhibitors could cause low blood pressure (hypotension). Also for this reason, you should not take alpha blockers—used to lower blood pressure and to treat an enlarged prostate—with these medicines without talking to your doctor. The combination could cause a dangerous drop in blood pressure.
Sex when you have heart problems
Sexual activity is exercise. If you have a heart condition and have not been sexually active for a while, talk with your doctor to make sure you can engage in sexual activity safely.
In a few cases, surgery may be an option to treat erection problems. Surgery will rarely be recommended before nonsurgical treatment and counseling have been tried.
- Penile implants
- Surgery on penile blood vessels
What to think about
Think carefully about nonsurgical options and about the possible risks of surgery. Include your partner in your decision.
Doctors who specialize in conditions of the urinary tract (urologists) do most penile implants. Specially trained urologic surgeons usually do blood vessel repair surgery.
Other treatment choices
- Vacuum devices are useful for all types of erection problems—physical, psychological, or both. The device has a tube you place around the penis. You pump the device to create a vacuum that leads to an erection.
- Counseling (psychotherapy) is recommended for men whose erection problems are caused, at least in part, by psychological factors. Treatment may include:
- Sex therapy. It focuses on ways to improve attitudes toward sex. It also focuses on specific sexual techniques.
- Group therapy. Evidence shows that group therapy helps with erection problems in some men. Adding group therapy to treatment with sildenafil (for example, Viagra) helped more than sildenafil alone. Men who were taking part in group therapy also were more likely to keep taking their medicine.footnote 1
Counseling also may be used with medicine treatment or vacuum devices for erection problems that have psychological and physical causes.
Medicines are usually the main treatment for erection problems. But some men try complementary therapies. If you don't want to use medicine, or if medicine doesn't work for you, you may want to talk with your doctor about some of the following options. Most of these treatments need more research before doctors can know if they work for sure.footnote 2 Treatments include:
- Ginseng. It has been shown to work for some men who have erection problems. But because it is sold as a dietary supplement, it is hard to know if you are getting the right amount.
- The amino acid L-arginine. Some men take this dietary supplement to try to treat erection problems. The amino acid increases the amount of nitric oxide in the blood, which relaxes blood vessels. In theory, L-arginine could improve erections. But L-arginine may be harmful.
- Zinc. Some men who have low zinc levels in their body have had success using zinc supplements to treat erection problems. But high doses of zinc can be dangerous.
- Melnik T, et al. (2007). Psychosocial interventions for erectile dysfunction. Cochrane Database of Systematic Reviews (3).
- Burnett AL (2012). Evaluation and management of erectile dysfunction. In AJ Wein et al., eds., Campbell-Walsh Urology, 10th ed., vol. 1, pp. 721–748. Philadelphia: Saunders.
Other Works Consulted
- American Urological Association (2005, reviewed and confirmed 2011). Management of Erectile Dysfunction: An Update. Baltimore: American Urological Association. Also available online: http://www.auanet.org/content/clinical-practice-guidelines/clinical-guidelines.cfm?sub=ed.
- Cheitlin MD, et al. (1999). Use of sildenafil (Viagra) in patients with cardiovascular disease. ACC/AHA expert consensus document. Circulation, 99(1): 168–177.
- Esposito K, et al. (2004). Effect of lifestyle changes on erectile dysfunction in obese men. JAMA, 291(24): 2978–2984.
- Montague DK (2012). Prosthetic surgery for erectile dysfunction. In AJ Wein et al., eds., Campbell-Walsh Urology, 10th ed., vol. 1, pp. 780–791. Philadelphia: Saunders.
- Schulman SP, et al. (2006). L-arginine therapy in acute myocardial infarction. JAMA, 295(1): 58–64.
Current as of: February 11, 2020
Author: Healthwise Staff
E. Gregory Thompson MD - Internal Medicine
Adam Husney MD - Family Medicine
Christopher G. Wood MD, FACS - Urology, Oncology
Current as of: February 11, 2020
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