A man is considered to have erectile dysfunction if he regularly finds it difficult getting or keeping a firm enough erection to be able to have sex, or if it interferes with other sexual activity.

Most men have occasionally experienced some difficulty with their penis becoming hard or staying firm. However, erectile dysfunction (ED) is only considered a concern if satisfactory sexual performance has been impossible on a number of occasions for some time.

Since the discovery that the drug sildenafil, or Viagra, affected penile erections, most people have become aware that ED is a treatable medical condition.

Men who have a problem with their sexual performance may be reluctant to talk with their doctor, seeing it can be an embarrassing issue.

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

This MNT Knowledge Center article offers helpful information for people experiencing this problem, or those close to them.

Fast facts on erectile dysfunction:

  • Erectile dysfunction (ED) is defined as persistent difficulty achieving and maintaining an erection sufficient to have sex.
  • Causes are usually medical but can also be psychological.
  • Organic causes are usually the result of an underlying medical condition affecting the blood vessels or nerves supplying the penis.
  • Numerous prescription drugs, recreational drugs, alcohol, and smoking, can all cause ED.

Normal erectile function can be affected by problems with any of the following systems:

  • blood flow
  • nerve supply
  • hormones

Physical causes

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Erectile dysfunction can cause embarrassment.

It is always worth consulting a physician about persistent erection problems, as it could be caused by a serious medical condition.

Whether the cause is simple or serious, a proper diagnosis can help to address any underlying medical issues and help resolve sexual difficulties.

The following list summarizes many of the most common physical or organic causes of ED:

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 the penis to produce an erection.

Numerous prescription medications can also cause ED, including those below. Anyone taking prescription medications should consult their doctor before stopping or changing their medications:

  • drugs to control high blood pressure
  • heart medications such as digoxin
  • some diuretics
  • drugs that act on the central nervous system, including some sleeping pills and amphetamines
  • anxiety treatments
  • antidepressants, including monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants
  • opioid painkillers
  • some cancer drugs, including chemotherapeutic agents
  • prostate treatment drugs
  • anticholinergics
  • hormone drugs
  • the peptic ulcer medication cimetidine

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

Psychological causes

In rare cases, a man may always have had ED and may never have achieved an erection. This is called primary ED, and the cause is almost always psychological if there is no obvious anatomical deformity or physiological issue. Such psychological factors can include:

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.

Less commonly, psychological factors cause or contribute to ED, with factors ranging from treatable mental health illnesses to everyday emotional states that most people experience at some time.

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

The most recent study to investigate this found that there was no link between riding a bike and ED, but it did find an association between longer hours of cycling and the risk of prostate cancer.

Prostate disease and ED

Prostate cancer does not cause ED.

However, prostate surgery to remove the cancer and radiation therapy to treat prostate cancer can cause ED.

Treatment of non-cancerous, benign prostate disease can also cause the condition.

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

Drug treatments

Men 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 as a once-daily pill called Cialis)
  • avanafil (Stendra)

PDE-5 inhibitors are only available on prescription. A doctor will check for heart conditions and ask about other medications being taken before prescribing.

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.

Most men prefer a pill, however, so these locally acting drugs tend to be reserved for men who cannot take oral treatment.

Online pharmacies

It is possible to buy treatment over the internet for ED. However, caution is advised.

The United States (U.S.) Food and Drug Administration (FDA) has a consumer safety guide about this, including a recommendation to check that the online pharmacy:

    • is located in the U.S. and licensed
    • has a licensed pharmacist to answer questions.
    • requires a prescription.
    • offers direct contact with a person who can discuss any problems.

    You can check whether the pharmacy is licensed using this list of Verified Internet Pharmacy Practice Sites (VIPPS).

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

    • There is no way to contact the website by phone.
    • Prices are dramatically lower than those offered by legal online pharmacies.
    • Prescription drugs are offered without requiring a prescription - which is illegal.
    • Personal information is not protected.

    The FDA adds that these illegal sites may send drugs of unknown quality and origin, even sending the wrong drug or a dangerous product.

    Vacuum devices

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

    The penis is made rigid by the use of a vacuum pump sealed around it that draws up blood. This is prevented from then leaving the penis by the use of an accompanying band.

    The lack of spontaneity with the use of vacuum devices means that many men find other treatments for ED preferable.

    Surgical treatments

    There are several surgical treatment options:

    • Penile implants: These are a final option reserved for men who have not had any success with drug treatments and other non-invasive options.
    • Vascular surgery: Another surgical option for some men is vascular surgery, which attempts to correct some blood vessel causes of ED.

    Surgery is a last resort and will only be used in the most extreme cases. Recovery time varies, but success rates are high.

    Do dietary supplements and alternative treatments work?

    The short answer is "no."

    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, the FDA has warned of hidden risks of "treatments" sold online.

    Men may not always successfully achieve an erection, and if this rarely happens, it is not considered a medical problem.

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

    A man is considered to have ED when these symptoms occur regularly.

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

    The best way to treat erectile dysfunction without medication is by strengthening the pelvic floor muscles with Kegel exercises. These are often associated with women looking to strengthen their pelvic area during pregnancy, but they can be effective for men looking to regain full function of the penis.

    Firstly, find the pelvic floor muscles. You can achieve this by stopping mid-stream two or three times the next time you urinate. The muscles you can feel working during this process are the pelvic floor muscles, and they will be the focus of Kegel exercises.

    One Kegel exercise consists of tightening and holding these muscles for 5 seconds and then releasing them. Try to do between 10 and 20 repetitions each day. This may not be possible when you first start doing the exercises. However, they should become easier over time.

    You should be able to notice an improvement after 6 weeks.

    Make sure you are breathing naturally throughout this process and avoid pushing down as if you are forcing urination. Instead, bring the muscles together in a squeezing motion.

    Aerobic exercise, such a jog or even a brisk walk, can also help the blood to 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 a lot of questions and arrange for blood tests to be performed. 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.

    Before considering a diagnosis that requires treatment, a doctor will look for symptoms that have persisted for at least 3 months.

    Once a medical history has been established, a doctor will then undertake further investigation. One simple test, known as the 'postage stamp test,' can be helpful in determining 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.