Erectile Dysfunction: Common Causes, Links to Heart Health and Diabetes, and When to See a Doctor

Erectile dysfunction (ED) is when you are unable to get an erection, or unable to keep one for long enough to have sex [1]. NIDDK, part of the U.S. National Institutes of Health, describes it as a condition that prevents you from getting or keeping an erection that is firm enough for sex [4].

Most men occasionally fail to get or keep an erection. The NHS says this is usually caused by stress, tiredness or drinking too much alcohol, and is nothing to worry about, but that you should see a GP if it keeps happening [1]. ED may be a symptom of another health problem [5], and the European Association of Urology (EAU) describes it as "a symptom, not a disease" [9]. You may feel uncomfortable talking about it, but a healthy sex life is part of healthy living, and ED can often be treated [4].

What Erectile Dysfunction Looks Like

NIDDK lists three patterns of ED [5]:

• getting an erection sometimes, but not every time you want to have sex
• getting an erection that does not last long enough for sex
• being unable to get an erection at any time

Depending on the cause, you may still be able to get an erection at other times, such as when you wake up [1]. Some men also notice a low sex drive [1].

How ED Can Affect Your Life

NIDDK says complications of ED may include an unfulfilled sex life, a loss of intimacy between you and your partner, depression, anxiety and low self-esteem [4]. It also lists being unable to get a partner pregnant [4]. For more on fertility, see Male Fertility: What Affects Sperm Health.

How Common Is It, and Is It Part of Getting Older?

The NHS describes erectile dysfunction as very common, particularly in men over 40 [1]. In the United States, NIDDK says about 40 percent of men are affected at age 40, while 70 percent report having ED by age 70 [4].

You are more likely to have ED as you get older, and the American Diabetes Association (ADA) says a man's ability to get and hold an erection typically wanes with age [14]. However, NIDDK says ED is not a routine part of aging [4]. Younger men can be affected too. The EAU cites a study of men seeking first medical help for new-onset ED in which one in four was younger than 40 [10].

What Causes Erectile Dysfunction?

ED can have different causes. NIDDK says diseases or health conditions that affect your blood vessels, nerves or hormones can lead to ED, and that mental or emotional issues and lifestyle behaviors may also play a part [5]. The EAU says ED is commonly sorted into physical, psychological and mixed types, but that this split should be used with caution because most cases are of mixed cause [9].

Blood Vessel and Circulation Problems

The ADA explains that if blood vessels are not working properly or an artery is blocked, not enough blood reaches the penis, which makes it difficult to get an erection [14]. NIDDK includes heart and blood vessel diseases among the most common conditions that can lead to ED, such as atherosclerosis (hardening and narrowing of the arteries), high blood pressure and stroke [5]. The NHS says that if ED happens often, it may be caused by a condition such as high blood pressure or high cholesterol [1]. The ADA adds that lifestyle choices that contribute to heart disease and vascular problems also increase the chances of ED [13].

Nerve Damage and Nerve Conditions

The ADA says the brain must communicate with the nerves to bring blood into the penis and hold it there [14], so nerve problems can affect both getting and keeping an erection. NIDDK gives multiple sclerosis, spinal cord injuries and damage from pelvic surgery as examples [5]. The EAU adds Parkinson's disease and surgery or radiotherapy to the pelvis, including treatment for prostate cancer [9]. Diabetes can also damage nerves [8]. For more on that, see Diabetic Neuropathy and the Diabetic Foot: Prevention and Care.

Hormone Problems

The NHS lists hormone problems among the conditions that can cause ED [1]. NIDDK gives low testosterone and thyroid imbalance as examples [5]. NIDDK also says men with diabetes, especially those who are older and overweight, are more likely to have low testosterone [8].

Other Health Conditions and Medicines

NIDDK lists other long-term conditions linked with ED, including chronic kidney disease, obesity and overweight, and chronic obstructive pulmonary disease (COPD) [5]. The EAU also reports links with atrial fibrillation, inflammatory bowel disease and sleep disorders [9].

Problems of the male reproductive system can play a part as well. NIDDK names an enlarged prostate and Peyronie's disease, a condition in which scar tissue makes the penis curve when erect [5][8]. The EAU says ED is frequently associated with other urological conditions, including benign prostatic hyperplasia (BPH) [9]. For prostate and urinary symptoms, see Benign Prostatic Hyperplasia (BPH): Symptoms, Causes, and When to See a Doctor.

Some medicines can cause ED as a side effect [1][5].

Mental Health, Emotions and Relationships

NIDDK says some mental health or emotional issues can either cause ED or make it worse, including anxiety, depression or stress, feeling isolated or lonely, and low self-esteem, lack of confidence or negative body image [5]. The NHS also lists depression and anxiety among the possible causes when ED happens often [1].

The EAU says mental health problems are frequently found alongside ED, and that feeling emotionally disconnected from a partner has been related to erection difficulties [9]. In contrast, intimacy was found to be a protective factor [9].

Lifestyle Factors

NIDDK lists not getting enough physical activity, drinking too much alcohol, smoking cigarettes and using recreational and illicit drugs as lifestyle behaviors that may contribute to ED [5]. The ADA also names being overweight [13].

The NHS says healthy lifestyle changes can sometimes help with erectile dysfunction [1]. Its suggestions are to lose weight if you are overweight, stop smoking, eat a healthy diet, exercise daily and try to reduce stress and anxiety [1]. For UK readers, the NHS also advises not drinking more than 14 units of alcohol a week, and not cycling for a while if you cycle for more than 3 hours a week [1]. The EAU says regular exercise and a lower body mass index (BMI) can improve erectile function [9].

ED as an Early Warning Sign for Heart Health

The EAU says ED shares common risk factors with cardiovascular disease [9], and the CDC says ED can be a warning sign of blood vessel problems [15]. According to the EAU guideline, ED significantly increases the risk of cardiovascular disease, coronary heart disease and stroke [9]. It concludes that ED should be considered a precursor of cardiovascular disease, and that more severe and longer standing ED carries greater risk [9].

In 2018, American Heart Association News reported on a study in the AHA journal Circulation that followed nearly 2,000 men with an average age of 69 and no heart disease or stroke. Over about four years, men with ED had more than twice as many heart attacks, cardiac arrests or strokes, even after other risk factors were taken into account [11]. The study had limits: ED was self-reported, and follow-up was relatively short [11]. An expert quoted in the report said, "Patients should be aware of the potential implications of ED and inform their provider" [11].

The study's senior author called this "a wonderful opportunity to identify otherwise undetected high-risk cases for developing cardiovascular disease" [11]. For more on how these conditions connect, see Diabetes and Heart Disease: The Cardiovascular Connection.

It also helps to know the signs of a heart attack. In the UK, the NHS says to call 999 if you get sudden pain or discomfort in your chest that does not go away, because you could be having a heart attack [3]. In the US, the American Heart Association says: "Call 911 if you have heart attack warning signs" [12].

The Link Between ED and Diabetes

High blood sugar can damage the nerves and blood vessels needed to have an erection [8][15]. The CDC says men with diabetes are 3 times more likely to have ED [15], and NIDDK puts the figure at more than 3 times [8]. NIDDK also says men with diabetes may develop ED 10 to 15 years earlier than men without diabetes [8].

The link works in both directions. NIDDK says changes in sexual function may be a sign that you have diabetes [8], and the ADA says many men with ED later learn that they have diabetes [14]. If you already have diabetes, NIDDK says sexual problems may be signs that you need to manage your diabetes in a different way, so it is worth raising them with your health care team [8].

What Happens When You See a Doctor

In the UK, the NHS says the doctor or nurse may ask about your lifestyle and relationships, take your blood pressure, and examine your genitals to rule out any obvious physical cause [1]. If you have symptoms like needing to pee more often than usual, you may also have an examination of your prostate [1].

NIDDK says health care professionals use your medical, sexual and mental health history, a physical exam, and lab and other tests to diagnose ED [6]. They may also ask your partner about your relationship [6]. The exam often checks for blood vessel and nervous system issues, hormone problems, and physical problems with the penis, and blood tests may include thyroid and prostate tests [6].

The EAU guideline says patients with ED should have their blood pressure and heart rate measured, and blood tests for blood sugar, cholesterol and an early morning hormone level, unless these have been checked recently [9]. These checks may not reveal the exact cause, but the EAU says they are an opportunity to find other health conditions [9].

When to See a Doctor

Where to go depends on where you live.

In the UK (NHS): see a GP or go to a sexual health clinic if erection problems keep happening, because it might be a sign of a health condition that can be treated [1]. Sexual health clinics can provide the same treatment you would get at your GP surgery, and many offer a walk-in service [1].

In the US (CDC): the CDC says it is not uncommon to have trouble getting an erection sometimes, but if it gets worse, happens often, or prevents you from living the life you want, it is time to get it checked out [15].

It is normal to find this hard to bring up. NIDDK says health care professionals are trained to speak with people about every kind of health problem [8], and the ADA says your healthcare provider is there to help you, not judge you [13].

When to Get Urgent Help

A long-lasting erection (priapism) can be a medical emergency.

In the UK (NHS): call 999 or go to A&E if you have an erection that lasts more than 3 to 4 hours, or if you have sickle cell disease and a painful erection that lasts for more than 1 hour [2]. The NHS says an erection that lasts this long needs to be treated in hospital as soon as possible to avoid permanent damage to the penis. "Do not drive to A&E. Ask someone to drive you or call 999 and ask for an ambulance" [2].

In the US (NIDDK): treatment for ED can have side effects, including erections that last longer than 4 hours, known as priapism. NIDDK says to call your health care professional right away if this happens [7].

Can Erectile Dysfunction Be Treated?

Yes. The NHS says treatment can usually help improve erectile dysfunction, and there are also treatments for some of the causes [1]. NIDDK says health care professionals treat the underlying cause when possible [7], and the EAU says related conditions such as diabetes and high blood pressure should always be well controlled as the first step [9].

When ED is linked to emotional or mental health problems, the NHS says counselling and therapy can help [1], and NIDDK notes that a counselor may suggest bringing your partner to sessions [7]. Choosing an ED treatment is a personal decision, and NIDDK says that if you have a partner, you may want to talk together about treatments [7]. The CDC says almost all men with ED can be successfully treated [15].

Conclusion

Erection problems are easy to put off, but raising them can lead to checks that matter for your wider health [9]. Before an appointment, it may help to note how often the problem happens, whether it is getting worse, and any other emotional or physical changes you have noticed [13][15]. The ADA also suggests asking your provider about treatment options [13], and the EAU says patients should be fully counselled about all available options [9].

Medical Disclaimer

This article is for general information and does not replace advice from a qualified health professional. If you think you need urgent medical care, get emergency help straight away.