Erectile dysfunction

Erectile dysfunction (ED), sometimes called impotence, is a common male sexual disorder. It involves a persistent or repeated difficulty in getting or keeping an erection firm enough for satisfying sexual activity. This condition is the most frequent sexual issue among men and often leads to emotional distress, affecting self-esteem and intimate relationships. It is important to note that ED is distinct from other erection problems, such as priapism.

Most cases of ED stem from physical causes. These can involve blood vessels, nerves, the penis itself, hormones, or side effects from drugs. Key risk factors include getting older, heart disease, diabetes, high blood pressure, obesity, abnormal cholesterol levels, low testosterone, smoking, depression, and certain medications. About 10% of cases are linked to psychological or relationship issues, like stress, depression, or problems with a partner. The condition becomes more common with age: it is reported in 18% of men aged 50 to 59, and in 37% of those aged 70 to 75.

Treatment focuses on addressing underlying causes, making lifestyle changes, and dealing with psychological factors. Medications called PDE5 inhibitors, such as sildenafil, are often used. They work by widening blood vessels, which increases blood flow into the penis—similar to opening a valve wider to increase water flow through a hose. Other, less common treatments include inserting a prostaglandin pellet into the urethra, injecting muscle relaxants or vasodilators directly into the penis, using a penile implant or a vacuum pump, or, in some cases, vascular surgery.

**Signs and symptoms** The main sign of ED is the persistent or repeated inability to get or keep an erection firm enough for satisfactory sex. This difficulty must last for at least three months to meet the clinical definition.

**Psychological impact** ED often affects the emotional health of both the man and his partner. Many men avoid seeking help because they feel embarrassed. As a result, about 75% of diagnosed cases go untreated.

**Causes** Contributors to ED include: - Diets high in saturated fat, which are linked to heart disease—a condition that raises ED risk. Plant-based diets are associated with a lower risk. - Prescription drugs, such as SSRIs, beta blockers, antihistamines, alpha-2 adrenergic receptor agonists, thiazides, hormone modulators, and 5α-reductase inhibitors. - Nerve disorders, including diabetic neuropathy, temporal lobe epilepsy, multiple sclerosis, Parkinson's disease, and multiple system atrophy. - Conditions affecting the penis, like Peyronie's disease. - High levels of the hormone prolactin (hyperprolactinemia), sometimes from a prolactinoma. - Psychological issues: performance anxiety, stress, and mental disorders. - Surgery, such as radical prostatectomy. - Aging: after age 40, aging itself is a risk factor, though other age-related conditions like low testosterone, heart disease, or diabetes often interact. - Kidney disease: chronic kidney disease shares common mechanisms with ED, including vascular and hormonal problems, and often coexists with conditions like high blood pressure and diabetes. - Lifestyle habits, especially smoking, which narrows arteries and is a key risk factor. Some studies describe tobacco as an anaphrodisiacal substance because it can cause loss of erection. - COVID-19: early research suggests the viral infection may affect sexual and reproductive health. - Surgical treatments for conditions like prostate cancer (prostatectomy or radiation) can damage nerves or blood supply needed for erections, though the prostate itself is not required. For inguinal hernia surgery, most cases without complications lead to recovery of sexual function in those with pre-surgery problems, and usually does not affect those with normal function beforehand. - Bicycling, due to compression that can cause nerve and blood vessel problems, raises the risk about 1.7-fold. - Concerns that pornography causes ED have little support from a 2015 review. According to researcher Gunter de Win, men who watch 60 minutes a week and feel addicted are more likely to report dysfunction than those who watch 160 minutes without worry. A 2026 review found that simple pornography consumption does not cause ED; the relationship is more complex. - In rare cases, medications like SSRIs, isotretinoin (Accutane), and finasteride (Propecia) may cause long-lasting sexual dysfunction, including ED. These conditions—post-SSRI sexual dysfunction (PSSD), post-retinoid sexual dysfunction (PRSD), and post-finasteride syndrome (PFS)—are poorly understood and lack effective treatments, though they may share a common cause. - Rarely, impotence can result from aromatase being activated.