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
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.
Erection problems can have many causes. These include:
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.
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
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:
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
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.
Learning about erection problems:
Living with erectile dysfunction:
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:
issues seem to be involved in many cases of erection problems. These mental issues include:
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.
erection problems include being
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.
of the things that cause erection problems can be treated.
Your risk of having an
erection problem increases with
age. Other things that increase your risk include:
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
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.
Call your doctor now or seek medical care right away if:
Call a doctor if erection problems occur:
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
The following health professionals can evaluate symptoms of erection
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:
To prepare for your appointment, see the topic Making the Most of Your Appointment.
Because both physical and
mental factors are often involved, it may be difficult to diagnose the
exact cause of your
To start, your doctor may:
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
ultrasound may be done if your doctor thinks you may
have a circulation problem (peripheral arterial disease).
Treatment for an
erection problem depends on the
cause of the problem. The cause may be mental, physical, or a combination of
Many doctors take a step-by-step approach to treating
erection problems. They use the least invasive treatments first. The treatment steps
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.
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.
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
Here are some other things you can do that may reduce your risk for erection problems:
In some cases, occasional
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
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
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:
Other medicines that may be used include:
Hormones and other medicines may be prescribed for men
who have low
testosterone or high
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 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:
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
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.
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
erection problems. Surgery will
rarely be recommended before nonsurgical treatment and counseling have been
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.
Counseling also may be used with medicine treatment or vacuum devices for erection problems that have psychological and
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.2 Treatments include:
The National Kidney and Urologic Diseases Information
Clearinghouse (NKUDIC) provides information about diseases of the
kidneys and urologic system to people with these problems and to
their families, to health professionals, and to the public. NKUDIC answers
inquiries; develops, reviews, and distributes publications; and works closely
with professional and patient groups and government agencies to
coordinate resources about kidney and urologic diseases.
NKUDIC, a federal agency, is a service of the National
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIDDK is part
of the National Institutes of Health under the U.S. Department of Health and
UrologyHealth.org is a website written by urologists
for patients. Visitors can find specific topics by using the "search"
The website provides information about adult and
pediatric urologic topics, including kidney, bladder, and prostate conditions.
You can find a urologist, sign up for a free quarterly newsletter, or click on
the Urology A–Z page to find information about urologic problems.
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.
May 14, 2012
E. Gregory Thompson, MD - Internal Medicine
& Christopher G. Wood, MD, FACS - Urology, Oncology
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