Erectile dysfunction — what's actually happening and what actually works.

What's actually happening during an erection

An erection requires three things working together: nerves (signaling), blood vessels (filling), and hormones (driving desire). Problems with any of the three can cause ED, and many men have issues with two or all three simultaneously.

When something goes wrong, it's usually one or more of:

• Vascular — blood vessels can't deliver enough blood (or can't keep it trapped). Most common cause in men over 40. Usually tied to broader cardiovascular health.
• Neurogenic — nerve signaling is impaired. Diabetes, prior pelvic surgery (prostatectomy), spinal cord injury.
• Hormonal — low testosterone, thyroid issues, high prolactin.
• Psychogenic — anxiety, depression, relationship issues, or performance anxiety. Often coexists with physical causes.
• Medication-related — blood pressure meds, antidepressants, opioids, among others.

Why ED matters beyond sexual function

ED is strongly associated with cardiovascular disease. In many men, ED precedes a heart attack by 3–5 years. The penis's small arteries clog before the heart's arteries do — so ED is sometimes the canary in the coal mine. This is why the first step in ED evaluation is often a look at the whole cardiovascular picture.

The workup

History and physical

We ask about:

• Onset (sudden vs. gradual)
• Morning erections (present or absent)
• Erections with masturbation (present or absent)
• Libido
• Specific symptoms: curvature (Peyronie's disease), pain, premature ejaculation
• Overall health: diabetes, heart disease, blood pressure, sleep
• All medications

A sudden-onset ED with preserved morning erections often has a psychogenic component. A gradual loss of morning erections typically points to vascular or hormonal causes.

Labs

• Morning testosterone (see our low T guide)
• Hemoglobin A1c — to screen for diabetes
• Lipid panel
• TSH (thyroid)
• Prolactin if other hormones are abnormal

Sometimes additional testing

For selected patients: penile duplex ultrasound (blood flow studies), nocturnal penile tumescence testing, or cardiology referral for stress testing.

The treatment ladder

Step 1: Lifestyle and health optimization

Often underestimated. The following genuinely improve ED:

• Weight loss — even 10% improves ED in many men.
• Exercise — especially moderate cardio 30 minutes 4–5×/week. One of the most effective single interventions.
• Smoking cessation — blood flow improvement starts within weeks.
• Blood pressure, cholesterol, and diabetes control.
• Sleep — treating sleep apnea can dramatically improve ED.
• Limit alcohol — chronic heavy use impairs erections.

Step 2: Oral medications (PDE5 inhibitors)

The "little blue pill" family:

• Sildenafil (Viagra) — take 30–60 minutes before. Lasts 4–6 hours.
• Tadalafil (Cialis) — can be taken as-needed or daily at lower dose. Longer lasting (up to 36 hours).
• Vardenafil (Levitra), Avanafil (Stendra) — similar mechanism, different timing profiles.

Effective in 60–70% of men with ED. Don't work if there's no libido or if vascular damage is severe. Critical caveat: these drugs interact dangerously with nitrates (heart medications). Always tell your urologist and cardiologist what you're taking.

Step 3: Vacuum erection devices

A plastic tube with a pump that draws blood into the penis, followed by a constriction ring to maintain the erection. Cheap, non-invasive, effective for the right patient. Mechanical rather than medical, so it works even when pills don't.

Step 4: Penile injections (intracavernosal injection therapy)

Self-administered injection of alprostadil or a combination medication directly into the side of the penis. Works within 5–15 minutes. Effective in 80–90% of men. Sounds worse than it is — most men find it very tolerable after the first few tries. This is the most effective non-surgical option.

Step 5: Urethral suppositories (MUSE)

A small pellet of alprostadil inserted into the urethra. Less effective than injections but avoids needles.

Step 6: Penile implants (prostheses)

For men who fail or can't tolerate the other options, a penile implant is a permanent, highly satisfying solution. Most common type is the three-piece inflatable prosthesis: a pump in the scrotum activates when you want an erection. Satisfaction rates exceed 90%. This is a surgery, typically outpatient.

Common questions

Do supplements work?

The evidence for most over-the-counter supplements is weak to nonexistent. Some (like yohimbe) have modest effects but also side effects. Others are adulterated with actual PDE5 inhibitors without disclosure — which is dangerous if you're on nitrates. Stick with evidence-based treatments.

What about testosterone?

Low testosterone can contribute to ED, but ED is almost never purely a testosterone problem. Testosterone replacement primarily restores libido; it usually doesn't fix the erection itself unless testosterone is very low.

Will this ever get better on its own?

Psychogenic ED can resolve with time and addressing the underlying stressor. Physical-cause ED rarely reverses without intervention — but it's highly treatable at every stage.