Erectile dysfunction

Erectile dysfunction, also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a penile erection with sufficient rigidity and duration for satisfactory sexual activity. It is the most common sexual problem in males and can cause psychological distress due to its impact on self-image and sexual relationships. The term erectile dysfunction does not encompass other erection-related disorders, such as priapism.
The majority of ED cases are attributed to physical risk factors and predictive factors. These factors can be categorized as vascular, neurological, local penile, hormonal, and drug-induced. Notable predictors of ED include aging, cardiovascular disease, diabetes mellitus, high blood pressure, obesity, abnormal lipid levels in the blood, hypogonadism, smoking, depression, and medication use. Approximately 10% of cases are linked to psychosocial factors, encompassing conditions such as depression, stress, and problems within relationships. ED is reported in 18% of males aged 50 to 59 years, and 37% in males aged 70 to 75.
Treatment of ED encompasses addressing the underlying causes, lifestyle modification, and addressing psychosocial issues. In many instances, medication-based therapies are used, specifically PDE5 inhibitors such as sildenafil. These drugs function by dilating blood vessels, facilitating increased blood flow into the spongy tissue of the penis, analogous to opening a valve wider to enhance water flow in a fire hose. Less frequently employed treatments encompass prostaglandin pellets inserted into the urethra, the injection of smooth-muscle relaxants and vasodilators directly into the penis, penile implants, the use of penis pumps, and vascular surgery.

Signs and symptoms

ED is characterized by the persistent or recurring inability to achieve or maintain an erection of the penis with sufficient rigidity and duration for satisfactory sexual activity. It is defined as the "persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity for at least 3 months."

Psychological impact

ED often has an impact on the emotional well-being of both males and their partners. Many males do not seek treatment due to feelings of embarrassment. About 75% of diagnosed cases of ED go untreated.

Causes

Causes of or contributors to ED include the following:

Diets high in saturated fat are linked to heart diseases, and males with heart diseases are more likely to experience ED. By contrast, plant-based diets show a lower risk for ED.
Prescription drugs
Neurogenic disorders
Cavernosal disorders
Hyperprolactinemia
Psychological causes: performance anxiety, stress, and mental disorders
Surgery
Ageing: after age 40 years, ageing itself is a risk factor for ED, although numerous other pathologies that may occur with ageing, such as testosterone deficiency, cardiovascular diseases, or diabetes, among others, appear to have interacting effects
Kidney disease: ED and chronic kidney disease have pathological mechanisms in common, including vascular and hormonal dysfunction, and may share other comorbidities, such as hypertension and diabetes mellitus that can contribute to ED
Lifestyle habits, particularly smoking, which is a key risk factor for ED as it promotes arterial narrowing. Due to its propensity for causing detumescence and erectile dysfunction, some studies have described tobacco as an anaphrodisiacal substance.
COVID-19: preliminary research indicates that COVID-19 viral infection may affect sexual and reproductive health.

Surgical intervention for a number of conditions may remove anatomical structures necessary to erection, damage nerves, or impair blood supply. ED is a common complication of treatments for prostate cancer, including prostatectomy and destruction of the prostate by external beam radiation, although the prostate gland itself is not necessary to achieve an erection. As far as inguinal hernia surgery is concerned, in most cases, and in the absence of postoperative complications, the operative repair can lead to a recovery of the sexual life of people with preoperative sexual dysfunction, while, in most cases, it does not affect people with a preoperative normal sexual life.
ED can also be associated with bicycling due to both neurological and vascular problems due to compression. The increased risk appears to be about 1.7-fold.
Concerns that use of pornography can cause ED have little support in epidemiological studies, according to a 2015 literature review. According to Gunter de Win, a Belgian professor and sex researcher, "Put simply, respondents who watch 60 minutes a week and think they're addicted were more likely to report sexual dysfunction than those who watch a care-free 160 minutes weekly." A 2026 review shows that simple pornography consumption does not cause erectile dysfunction, the relationship between pornography and ED being much more complex.
In seemingly rare cases, medications such as SSRIs, isotretinoin and finasteride are reported to induce long-lasting iatrogenic disorders characterized by sexual dysfunction symptoms, including erectile dysfunction in males; these disorders are known as post-SSRI sexual dysfunction, post-retinoid sexual dysfunction/post-Accutane syndrome, and post-finasteride syndrome. These conditions remain poorly understood and lack effective treatments, although they have been suggested to share a common etiology.

Rarely impotence can be caused by aromatase being active. See Androgen replacement therapy.
Pathophysiology

Penile erection is managed by two mechanisms: the reflex erection, which is achieved by directly touching the penile shaft, and the psychogenic erection, which is achieved by erotic or emotional stimuli. The former involves the peripheral nerves and the lower parts of the spinal cord, whereas the latter involves the limbic system of the brain. In both cases, an intact neural system is required for a successful and complete erection. Stimulation of the penile shaft by the nervous system leads to the secretion of nitric oxide, which causes the relaxation of the smooth muscles of the corpora cavernosa, and subsequently penile erection. Additionally, adequate levels of testosterone and an intact pituitary gland are required for the development of a healthy erectile system. As can be understood from the mechanisms of a normal erection, impotence may develop due to hormonal deficiency, disorders of the neural system, lack of adequate penile blood supply or psychological problems.

Diagnosis

In many cases, the diagnosis can be made based on the person's history of symptoms. In other cases, a physical examination and laboratory investigations are done to rule out more serious causes such as hypogonadism or prolactinoma.
One of the first steps is to distinguish between physiological and psychological ED. Determining whether involuntary erections are present is important in eliminating the possibility of psychogenic causes for ED. Obtaining full erections occasionally, such as nocturnal penile tumescence when asleep, tends to suggest that the physical structures are functionally working. Similarly, performance with manual stimulation, as well as any performance anxiety or acute situational ED, may indicate a psychogenic component to ED.
Another factor leading to ED is diabetes mellitus, a well known cause of neuropathy. ED is also related to generally poor physical health, poor dietary habits, obesity, and most specifically cardiovascular disease, such as coronary artery disease and peripheral vascular disease. Screening for cardiovascular risk factors, such as smoking, dyslipidemia, hypertension, and alcoholism, is helpful.
In some cases, the simple search for a previously undetected groin hernia can prove useful since it can affect sexual functions in males and is relatively easily curable.
The currentas of 2025edition of the Diagnostic and Statistical Manual of Mental Disorders lists Erectile Disorder as a diagnosis. According to the DSM, it "is the more specific DSM-5 diagnostic category in which erectile dysfunction persists for at least 6 months and causes distress in the individual." The ICD-10, to which the DSM refers regarding Erectile dysfunction, lists it under Failure of genital response. The latest edition of the ICDnamely, the ICD-11lists the condition as Male erectile dysfunction.

Ultrasonography

with doppler can be used to examine the erect penis. Most cases of ED of organic causes are related to changes in blood flow in the corpora cavernosa, represented by occlusive artery disease, most often of atherosclerotic origin, or due to failure of the veno-occlusive mechanism. Before the Doppler sonogram, the penis should be examined in B mode, in order to identify possible tumors, fibrotic plaques, calcifications, or hematomas, and to evaluate the appearance of the cavernous arteries, which can be tortuous or atheromatous.
Erection can be induced by injecting 10–20 μg of prostaglandin E1, with evaluations of the arterial flow every five minutes for 25–30 min. The use of prostaglandin E1 is contraindicated in patients with predisposition to priapism, anatomical deformity of the penis, or penile implants. Phentolamine is often added. Visual and tactile stimulation produces better results. Some authors recommend the use of sildenafil by mouth to replace the injectable drugs in cases of contraindications, although the efficacy of such medication is controversial.
Before the injection of the chosen drug, the flow pattern is monophasic, with low systolic velocities and an absence of diastolic flow. After injection, systolic and diastolic peak velocities should increase, decreasing progressively with vein occlusion and becoming negative when the penis becomes rigid. The reference values vary across studies, ranging from > 25 cm/s to > 35 cm/s. Values above 35 cm/s indicate the absence of arterial disease, values below 25 cm/s indicate arterial insufficiency, and values of 25–35 cm/s are indeterminate because they are less specific. The data obtained should be correlated with the degree of erection observed. If the peak systolic velocities are normal, the final diastolic velocities should be evaluated, those above 5 cm/s being associated with venogenic ED.