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Erectile Dysfunction: Causes, Tests and Treatment

Erectile Dysfunction: Causes, Tests and Treatment

📖 8 min read Written/reviewed by Dr. Alhad Naragude, MBBS, MS, DrNB Urology Last updated: September 3, 2026

Erectile dysfunction (ED) means repeatedly having difficulty getting or keeping an erection firm enough for satisfactory sexual activity. It is common and treatable, but it should not simply be dismissed as stress, age or “weakness.” ED may be related to blood-vessel disease, diabetes, high blood pressure, medicines, low testosterone, nerve problems, penile conditions or psychological factors. Most men can be assessed with history, examination and basic blood tests. Penile Doppler or other specialised tests are needed only in selected cases. Treatment depends on the cause and may include lifestyle changes, tablets, counselling, devices, injections or surgery.

What is erectile dysfunction?

An erection depends on the brain, nerves, hormones, blood vessels and penile tissue working together. Erectile dysfunction occurs when this process is repeatedly disrupted. A single episode after fatigue, alcohol or stress does not automatically mean ED. The concern is a persistent or recurrent difficulty that affects sexual activity or confidence.

ED can be mainly organic (physical), mainly psychogenic (psychological or situational), or mixed. In practice, mixed causes are common. For example, mild blood-flow impairment may start the problem and performance anxiety may then make it worse.

Erectile dysfunction: quick answer

Pattern What it may suggest
Good morning erections but difficulty with a partner Situational or performance-related factors may be important, although this is not proof of a purely psychological cause.
Gradual loss of erection quality in all situations A vascular, metabolic, hormonal or medication-related cause becomes more likely.
Low sexual desire with ED Low testosterone, depression, medication effects or relationship factors may need assessment.
ED with diabetes, BP, cholesterol or smoking Blood-vessel and nerve-related ED is more likely; cardiovascular risk should also be reviewed.
Painful erection or new penile curvature Peyronie’s disease or another penile condition needs examination.
ED after pelvic surgery or injury Nerve or blood-vessel injury may contribute and may need targeted evaluation.

What causes erectile dysfunction?

The cause is not always one problem. A urologist looks for reversible factors and conditions needing long-term treatment.

  • Blood-vessel problems such as diabetes, high blood pressure, high cholesterol, obesity, smoking and cardiovascular disease.
  • Nerve problems from diabetes, spinal disease, pelvic surgery, pelvic injury or neurological illness.
  • Hormonal problems, especially testosterone deficiency when symptoms and blood tests support the diagnosis.
  • Medicines such as some antidepressants, antiandrogens and certain blood-pressure medicines.
  • Psychological or situational factors such as performance anxiety, depression, stress, relationship distress or fear of failure.
  • Penile conditions such as Peyronie’s disease, previous penile trauma or anatomical problems.
  • Heavy alcohol use, recreational drugs, anabolic steroid use, poor sleep and lack of physical activity.

When should you see a urologist?

  • ED has persisted or repeatedly returned for several weeks or months.
  • You have diabetes, high blood pressure, high cholesterol, obesity, kidney disease or known heart disease.
  • You have low sexual desire, reduced morning erections, fatigue or other symptoms suggesting low testosterone.
  • There is penile pain, curvature, shortening or a palpable plaque.
  • ED started after pelvic surgery, radiation, trauma or a new medicine.
  • You are relying on unprescribed sildenafil/tadalafil, “herbal sex” tablets, testosterone or injections.
  • ED is causing major anxiety, relationship difficulty or avoidance of intimacy.

Emergency warning signs

ED itself is usually not an emergency, but treatment-related problems can be.

  • An erection lasting more than 4 hours needs urgent medical care because prolonged priapism can damage erectile tissue.
  • Chest pain, severe breathlessness, fainting or new neurological symptoms during sexual activity require emergency assessment.
  • Sudden major vision or hearing loss after an ED medicine requires urgent medical advice.
  • Do not take a PDE5 inhibitor such as sildenafil or tadalafil together with nitrate medicines or nitrate “poppers.” This combination can cause a dangerous fall in blood pressure.

Tests used to evaluate erectile dysfunction

Medical and sexual history

This is the most important part of the assessment. Your doctor may ask about erection hardness, how long erections last, morning erections, sexual desire, ejaculation, orgasm, masturbation, partner-related patterns, stress, sleep, medicines, smoking, alcohol and recreational drugs. A questionnaire such as the IIEF or SHIM may help measure severity.

Physical examination

Examination may include blood pressure, pulse, body weight or waist circumference, genital examination and signs of hormonal, vascular or neurological disease. The penis may be checked for curvature or plaques.

Blood tests

Common tests include fasting glucose or HbA1c, lipid profile and an early-morning total testosterone level. Additional tests such as prolactin, LH, thyroid tests, kidney function or PSA are used only when the history or examination suggests they are relevant.

Penile Doppler ultrasound

Penile Doppler is not required for every patient. It is a second-level test used when a vascular cause is suspected, when oral treatment has failed despite correct use, after selected pelvic injuries, or when the result would change treatment planning.

Why ED can be a heart-health warning sign

The penile arteries are small and can show the effects of vascular disease before symptoms appear elsewhere. Current EAU guidance recommends cardiovascular risk assessment in men with predominantly vasculogenic ED. This is especially important with diabetes, smoking, hypertension, high cholesterol, obesity or a family history of early heart disease.

How a urologist decides treatment

Finding or situation Common approach
Mild ED with modifiable risk factors Lifestyle change plus treatment of diabetes, BP, cholesterol, smoking, sleep or weight.
Predominantly situational or anxiety-related ED Education, psychosexual therapy/CBT, partner involvement when appropriate, with or without medication.
Most men suitable for oral treatment A PDE5 inhibitor is usually first-line after checking contraindications and correct use.
Poor response to tablets Recheck diagnosis, dose/timing/use, testosterone if indicated; consider another modality or combination approach.
Patient prefers drug-free treatment Vacuum erection device can be considered.
Tablets unsuitable or ineffective Intracavernosal injection therapy may be offered after training.
Persistent severe ED despite other treatment Penile prosthesis can provide a definitive mechanical solution after counselling.

Erectile dysfunction treatment options

1. Treat reversible risk factors

Exercise, weight control, stopping smoking, reducing excess alcohol, better sleep and control of diabetes, BP and cholesterol can improve erections and cardiovascular health.

2. PDE5 inhibitor tablets

Sildenafil, tadalafil and related medicines improve the natural erection response during sexual stimulation. Incorrect timing, heavy meals with some drugs or inadequate attempts can look like treatment failure. They must not be combined with nitrates or nicorandil.

3. Psychosexual therapy or cognitive behavioural therapy

Counselling is not only for “psychological ED.” It can help reduce performance anxiety, break the cycle of repeated failure and improve communication between partners. It can be combined with medical treatment.

4. Vacuum erection device

A vacuum device draws blood into the penis and a constriction ring helps maintain the erection. It is drug-free and can be useful when tablets are unsuitable or when a patient prefers a non-invasive option. Proper instruction is important.

5. Penile injections

Intracavernosal injections can produce an erection by directly relaxing penile smooth muscle. They can work even when tablets do not, including in men with diabetes or after pelvic surgery. Training is essential because incorrect dosing can cause prolonged erection or priapism.

6. Low-intensity shockwave therapy

Low-intensity shockwave therapy may produce a modest improvement in selected men with mild vasculogenic ED. Evidence and treatment protocols are less established than for PDE5 inhibitors, and it should not be sold as a guaranteed cure.

7. Penile prosthesis

A penile implant is considered when less-invasive treatments are unsuitable or unsuccessful, or when a well-counselled patient prefers a definitive option. Inflatable and malleable devices are available.

Be careful with testosterone, PRP and “sex power” supplements

Testosterone should be used only when symptoms and properly measured levels support deficiency; unsupervised use can suppress sperm production. PRP and stem-cell “regenerative” treatments are not established routine ED therapies, and unlabelled sexual-enhancement products may contain unsafe or hidden drugs.

What to bring for consultation

  • A list or photographs of all current medicines, including BP tablets, antidepressants, hair-loss medicines, hormones and supplements.
  • Recent HbA1c or fasting sugar, lipid profile and blood-pressure records if available.
  • Any previous testosterone or hormone reports.
  • Previous cardiac reports if you have heart disease, chest pain or a history of angioplasty/bypass surgery.
  • Details of when ED started, whether morning erections are present and whether the problem is consistent or situational.
  • Information about fertility plans before starting testosterone or other hormonal treatment.

FAQs

Is erectile dysfunction normal with age?

ED becomes more common with age, but it is not considered an inevitable or “normal” part of ageing. Treatable vascular, metabolic, medication-related and hormonal factors should still be assessed.

Do I need a penile Doppler for ED?

Not routinely. Most men can be assessed with history, examination and basic blood tests. Doppler is useful when a vascular diagnosis will change management or when the case is complex.

Are sildenafil and tadalafil safe for the heart?

They are widely used in appropriately selected men, including many patients taking blood-pressure medicines. They must not be combined with nitrates or nicorandil, and men with unstable cardiac disease or uncontrolled hypertension need cardiovascular assessment before sexual activity and ED treatment.

Related reading

References

Note: This information is for educational purposes only and is not a substitute for medical advice. Please consult your doctor for any symptoms.