Erectile Dysfunction

What Is Erectile Dysfunction?

Erectile dysfunction (ED) is when there is difficulty getting or keeping an erection and/or reduced sexual desire. ED can result from hormonal fluctuations (low testosterone), emotional issues, muscular and nerve problems, compromised brain functioning, and circulatory issues. In addition, stress, sleep, mental health issues, and relationship problems can also be a factor.

The most common physical issues are related to the circulatory system as the penis relies on the healthy circulation of blood to fill the penis to become and stay erect. Thus, health conditions such as heart disease, clogged blood vessels (atherosclerosis), high cholesterol, high blood pressure, diabetes, metabolic syndrome, and obesity can all impact achieving healthy erections. Other diseases can also impact erections which include Parkinson's disease, as well as multiple autoimmune diseases such as multiple sclerosis and Peyronie's disease. Even recently, erectile dysfunction has been linked to COVID.

In addition, external factors impact penile erections such as prescription medications, surgeries or injuries that affect the spinal cord, tobacco use, alcohol, illicit drugs, and medical treatments such as prostate cancer treatments and issues with an enlarged prostate.

The Structure Of The Penis

The penis is comprised of three chambers of spongy tissue; two chambers on the top (the corpora cavernosa) which extends well into the body to anchor the penis, and one underneath (the corpus spongiousm), which becomes the glans or head of the penis. The three tubes are surrounded by a sheath of skin that stretches. The arteries which feed blood to the spongy tubes are surrounded by smooth muscles fibers that are typically contracted, limiting the amount of blood entering the penis.

How An Erection Occurs

When a sight, touch, or thought causes sexual stimulation, the brain signals the muscles to relax, significantly increasing the blood flow. That is why stress will sometimes cause difficulty getting an erection. The spongy bodies fill up, making the penis enlarge and become erect. Because the veins that drain the spongy chambers pass between the chambers and the sheath of skin, an erection causes the vessels to be compressed, reducing the blood that can leave the penis. When the growth of the penis reaches the limit of the stretchable sheath of skin, the penis becomes very firm.

Erection Hardness Scale

Developed in 1998, the Erection Hardness Score (EHS) evaluates erectile dysfunction and has five categories based on the scores. Men are asked how they would rate the hardness of their erection and select one of the following options:

• 0 The penis does not enlarge.
• 1 The penis becomes larger but is not hard.
• 2 The penis is firm but not firm enough for penetration.
• 3 The penis is firm enough for penetration but not completely erect.
• 4 The penis is completely hard and fully erect.

In addition, there is the International Index of Erectile Function (IIEF), which is considered superior for assessing a man's erections. It contains 15 questions that are self-reported and evaluates five areas of sexual functioning: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall sexual satisfaction. The test scores then allow a physician to determine the severity of the ED diagnosis.

Erectile Dysfunction Concerns

Experiencing erectile dysfunction can lead to feelings of significant loss resulting from having an unsatisfying sex life, embarrassment, relationship conflicts, and infertility. These can all lead to feelings of low self-esteem, stress, and anxiety around sexual functioning. It can be overwhelming, so we have put together the following information to review potential options to assist you with ED.

Ruling Out Medical Issues

The first and most important thing one should do if experiencing erectile dysfunction is to see their physician. Specifically, a urologist can be most helpful in determining its cause. Because erectile dysfunction may be a health warning that something else is going on, it is something to take seriously. Speaking with your physician about these issues may feel intimidating, so please see our helpful guide: How To Talk To Your Doctor About Sex.

Ultrasound Option

An ultrasound can be used to check on your veins and arteries to help the doctor determine where the problem is and thus guide you to the appropriate treatment.

PDE5 Inhibitors

Men who have erectile dysfunction are often prescribed a PDE5 inhibitor which is a vasodilator that helps with getting the penis erect and is better known as drugs such as Sildenafil (Viagra), Vardenafil (Levitra, Staxyn), Tadalafil (Cialis), and Avanafil (Stendra). Intracavernosal injections, as well as testosterone supplementation, may also be used to address ED. For more information about the prescriptions for ED, please see our Erectile Dysfunction Drugs Guide.

Why Viagra And Drugs Like It Are Not Marketed To Women

Pfizer, who makes Viagra, abandoned their efforts to market it for women because many women did not feel that it was effective. Interestingly, it did provide similar results on women with regard to pelvic engorgement (the equivalent of an erection in men). So even though there were the same physical results, women still lacked sexual arousal, which may indicate mental and emotional blockages were a more influential factor than anticipated. It may also explain why many men do not feel drugs like Viagra work for them. Medications like Viagra get fewer refill orders, and only two-thirds of men who use it achieve what they consider success (an erection).

Disregard For Mental & Emotional Aspects

Society focuses primarily on male sexual performance while often ignoring mental and emotional factors. Yet men's sexual experiences are very much affected by their emotions. However, many do not realize it due to the heavy social conditioning of learning to minimize them. Because there is such a strong focus on physical and sexual performance, there is a substantial disregard for the importance of men's mental and emotional needs. Raising boys with overt messages of self-worth surrounding their ability as men to have sex and perform sexually causes a great deal of unhealthy approaches to relationships, sexual health, and self-esteem.

Psychological Issues From Childhood

Boys are often brought up with unhealthy approaches to managing their emotions and perceptions around their sexuality as well as with communication. There are often shame-based parenting approaches around self-stimulation at a young age as well as expressing their emotional needs. Later in life, males are often encouraged to seek out sexual relationships based on physicality without incorporating emotional connections. They also tend to develop self-esteem issues around penis size, sexual performance concerns, pressure around their first sexual experiences, and the number of sexual relations they have.

Family dynamics are powerful and internalized in children. Any unhealthy issues demonstrated by family or peers while growing up may impact sexual functioning later in life. Struggling with mental and emotional issues around relationships and sexuality is not uncommon for men, and self-reflection and exploration into these areas is something that many men would benefit from in addressing erectile dysfunction.

For ways to explore mental and emotional resources, please see our guides:

• Sex & Mindfulness
  
  
• Improving Relationships
  
  
• Types of Therapy
  
  
• Sex Therapy & Counseling

Stress Management

Stress can adversely impact our sexual health. Finding ways to manage your stress will be helpful for a more balanced and healthy life. Prioritizing tasks and time management, exploring healthy coping mechanisms, practicing relaxation techniques, and improving your relationships personally and professionally are all ways you can reduce stress.

In addition, you can remember that we create our reality through our perceptions and how we choose to handle our stress. Here are some helpful tips for creating a more peaceful life.

• Recognize that your perceptions create your reality. Maintain a proactive approach to problems and encourage positive self-talk in your mind.
  
  
• Surround yourself with positive and driven people. Eliminate or reduce exposure to unhealthy and toxic relationships in your life.
  
  
• Accept that there are things that you cannot control and ask yourself what you can do to make things better.
  
  
• Choose to be assertive rather than aggressive. Allow yourself to speak your truth and stand up for things that are important to you without becoming angry, defensive, or passive-aggressive.
  
  
• Manage your time well. Ensure that you are practicing self-care each day by eating well, exercising, and having quality time for yourself and those you love.
  
  
• Set healthy boundaries with people and say no to things that create added stress to you.
  
  
• Take time to do things you enjoy, such as hobbies and activities that bring you happiness.
  
  
• Avoid using alcohol and drugs to numb yourself to your life or that encourage you to partake in compulsive and negative behaviors.
  
  
• Find social support to help you through stressful periods. It is courageous to face the things that cause us pain, and we are worthy of support to get us through things that challenge us.
  
  
• Get help if you need it through counseling, group therapy, or even life coaching. Explore alternative health options and work with your physician to determine what medical resources are available to you.

The Importance Of Nutrition

Maintaining good nutrition and a healthy weight are the most important ways we can take care of ourselves, and if you look at how to improve any health condition, the recommendations are always focused on plant-based nutrients.

It is important to remember that erectile dysfunction is heavily linked to circulatory issues, which means keeping blood vessels healthy and open is essential. Thus, avoiding foods that clog and damage blood vessels is crucial in addressing erectile dysfunction. In addition, because ED is significantly more common in overweight men, losing excess weight may be something you want to explore as a potentially helpful approach.

Foods that clog and damage blood vessels are animal fats (saturated fat), trans fats (manufactured partially hydrogenated oil), excess salt, and added sugars. Foods that help improve your circulation are plant-based such as greens, beans, onions, mushrooms, berries, nuts, and seeds. For more helpful information, please see our related guides:

• Nutrition Guide for Good Sex & Health
  
  
• Holistic Weight Loss For Better Health & Sex
  
  
• Natural Erectile Dysfunction Remedies

Supplements & Erectile Dysfunction

Vitamins and supplements may be helpful when addressing erectile dysfunction; however, no supplement can cure it. Please use a great deal of caution before taking any supplements for ED and review them with your physician. Some supplements that can seem harmless but can have adverse health effects and cause serious health risks in specific doses or with certain health conditions and/or medications.

Many supplement brands promise results for the treatment of ED, but none have proven to be effective or safe. In addition, some may also contain dangerous ingredients, including black-market prescription medications at overly high doses. Also, see our article on holistic marketing hype that can cause more harm than good.

Below are supplements that may help with erectile dysfunction:

Vitamin D

Vitamin D is a steroid hormone that influences cardiovascular health. Because sexual functioning relies so heavily on blood circulation in the body, it has been linked to improving sexual function. A study showed significant associations between low Vitamin D levels and the severity of erectile dysfunction.

If taking it in the form of a supplement, you will want to take Vitamin D3 as other forms such as D2 cannot be easily absorbed by the body. Because Vitamin D3 is a fat-soluble vitamin, you will need to check your levels with your physician to determine the proper dosing for your body, as overweight people tend to need more.

Red Ginseng (Panax Ginseng)

Red ginseng is sometimes referred to as herbal Viagra because it contains compounds (ginsenosides), as it may help relax the penile smooth muscle, which helps provide erections. It is thought to improve blood circulation and cardiovascular health, which in turn would improve erections.

L-arginine

L-arginine is an amino acid that increases nitric oxide production, which is essential in helping to produce an erection. While it has shown effectiveness in mild to moderate ED, it showed significant improvements in erection hardness scores (EHS). In addition, a 2020 randomized study showed that taking 2,500 mg per day of L-arginine was as effective as Tadalafil (5 mg) which is a common ED medication. Some have found that using a combination of both show increased improvements.

L-carnitine

L-carnitine is also an amino acid that supports cardiovascular health as well as fat metabolism and sperm production. Because it promotes cardiovascular health, it may improve penile blood flow. To maximize its benefits, some people combine it with L-arginine and sildenafil (Viagra). In a study conducted with 54 men with ED, there were significant improvements to their IIEF scores after taking it for three months along with Propionyl-L-carnitine, L-arginine, and niacin (vitamin B3).

Tribulus Terrestris

Tribulus Terrestris is often used in Chinese medicine and Ayurvedic medicine. Multiple double-blind studies have shown that taking 800 mg - 1,500 mg per day improved IIEF scores over a placebo within three months.

For more natural remedies for erectile dysfunction, please see our guide: Natural Erectile Dysfunction Remedies

Sex Toys For Erectile Dysfunction

Beyond basic treatments for erectile dysfunction, there are the options of using sex toys. Usually, those with ED seek out prosthetic penises (dildos), penis pumps, penis rings, or hollow dildos. However, there are so many other options that most consumers don't know about. Thus, we have put together a helpful guide outlining possible sex toys to assist you with your sexual goals. 

• The Best Sex Toys For Erectile Dysfunction
  
  

Acupuncture & Erectile Dysfunction

There is limited research in using acupuncture to treat erectile dysfunction; however, some studies have shown promise, especially with those who have psychologically induced ED. Acupuncture may stimulate the nerves, release hormones, and increase blood circulation to assist in treating ED. To learn more about acupuncture, please see our guide Sex & Acupuncture.

Disabilities, Mobility Issues & Sex

Disabilities come in many forms, such as chronic illness, injuries, mental health challenges, etc. Many disabling conditions affect sexual health and can cause problems with sexual desire, arousal, achieving orgasms, and can even make sex painful. Accidents and diseases can cause trauma to the genitals and general reproductive functioning. There can also be indirect consequences from treatments, medications, and complications.

Whether your disability is congenital, acquired, hidden, or visible, your sexual health can be profoundly affected physically, mentally, and emotionally. These factors can, in turn, affect the ability to achieve an erection. While penis pumps and penis rings are often recommended in addition to medications such as Viagra, exploring additional resources may also be helpful.

Always discuss possible treatments with your physician, as even some of the most harmless-seeming solutions and remedies may have unwanted consequences. Sometimes you simply don't know what you don't know. For example, some spinal-cord patients can experience health risks when using vibrators. This is why we have provided a variety of sexual guides for you to review to help you determine with your doctor what may be the best options for you.

• Disability, Sex & Discrimination
  
  
• Sex Toys For Disabilities
  
  
• Plus-Size Sex Education, Resources & Products
  
  
• Communication: Sex & Disabilities
  
  
• Sex & Communication
  
  
• Sex Toys For Spinal Cord Injuries
  
  
• Autoimmune Disease & Sex
  
  
• Sex With Cancer

Exercise & Kegel Exercises

Because so many causes of erectile dysfunction originate from circulatory issues, movement is an essential part of addressing it. This means that getting regular physical activity may protect against or improve ED.

A Harvard study found that just walking for 30 minutes daily was linked to a 41% drop in risk for ED. Other research suggests that just moderate exercise can help restore sexual performance in obese, middle-aged men.

In addition to general exercise, Kegel exercises (pelvic floor muscle exercises) have been strongly linked to improved erections. Kegel exercises are easy to do and are one of the first recommended treatments by physicians in improving erections.

Please see our Kegel Exercise Guides for more information:

• How To Do Kegel Exercises
  
  
• Exercises For Delayed Ejaculation

Improving Sleep

Sleep is crucial to good health, and lack of it can contribute to sexual performance issues resulting in erectile dysfunction. Studies have shown that people who have worse sleep quality are at a higher risk for ED, including conditions such as obstructive sleep apnea. Reduced sleep can lower testosterone levels and contribute to health conditions such as diabetes and high blood pressure, contributing to ED.

Doing things to improve sleep, such as sticking to a sleep schedule, creating a restful environment, limiting naps, improving diet, increasing physical activity, and controlling stress levels, can all help address sleep issues and ED.

Smoking & Vaping

Both smoking and vaping can impact your sexual health, including developing erectile dysfunction because they can damage your blood vessels. Smoking and vaping can also reduce nitric oxide availability in the body, which aids in blood flow and muscle relaxation that contribute to healthy erections. They also increase the risks of developing more severe ED.

See our guide for more information: Smoking, Vaping & Sexual Health Issues

Cycling & ED

Riding a bike may cause temporary ED. Temporary numbness can occur from riding bikes, especially where a lot of hard-core road shock occurs. In 2014 the Journal of Men's Health found that cycling did not pose a serious threat of ED or infertility.

To avoid temporary numbness, you can avoid getting saddle-shaped seats with a narrow front. Getting a gel-filled, well-padded seat may also help. Additionally, having your handlebar lower than the seat may help as it will take pressure off the testicles, perineum, and penis. Finally, recumbent bikes are easier on the penis than conventional bicycles. They were also better for back or neck pain.

Condoms & Erectile Dysfunction

Condoms that are too tight may cause a numbing sensation that decreases feeling, thus making staying aroused or climaxing more difficult. While condoms can help prolong sex, you should consider wearing a looser condom if you are struggling with ED. If you are concerned about the condom coming off during sex, you can always secure it with a penis ring at the base.

Erectile Dysfunction Injections

Penile injection therapy is one of several proven treatments for ED (impotence). Injection therapy originated in the 1980s. It was more commonly used before the introduction of newer treatments. Generally, it is less effective than drugs such as Viagra and urethral suppositories.

How Injection Therapy Causes An Erection

Injection therapy typically uses a combination of drugs prescribed by a doctor, usually a urologist. The drugs are injected into the side of the penis. The drugs relax muscles and increase blood flow to create an erection. The most common drugs are Papavarine, Phentolamine and alprostadil. The doctor may combine two of these drugs (Bimix) or all three of the medicines (Trimix). The drugs are injected directly into the penis through a fine-gauge needle. A firm erection develops in 10-15 minutes and lasts up to 60 minutes. If a prolonged erection occurs, the man should contact his prescribing physician immediately or seek medical treatment.

Who Should Not Use Injection Therapy?

Some conditions rule out the use of injection therapy:

• Allergy to alprostadil.
  
  
• Abnormally formed penis.
  
  
• Peyronie's disease or penis angulation.
  
  
• Cavernosal fibrosis.
  
  
• Diseases that might result in a prolonged erection, such as sickle cell anemia.

Injection Therapy Results

Injection therapy can be very effective. About 75-85% of those who choose this option have success. Failure often is due to extremely poor blood flow or venous leakage in the penis. Some men must combine the injection with an external vacuum device to get satisfactory results. This procedure, however, can be cumbersome and expensive. The additional time it takes tends to reduce romantic spontaneity.

Cons To Penis Injections

• Limits sexual spontaneity.
  
  
• Some may feel a sting from the needle.
  
  
• Some may feel penile pain after the injection.
  
  
• Some may develop nodules in their penis, although this may disappear after a short break from injections. In a small number of cases, permanent nodules may occur with long-term use.
  
  
• Some scarring can occur with multiple uses. This can further complicate the process of achieving an erection.
  
  
• Although rare, prolonged erection can occur. Such an erection can turn into priapism, a painful erection lasting more than four hours. If priapism occurs, immediately seek medical help.
  
  
• Injections cost about $15-25 each depending on the drugs used. Medicare does not pay for the treatment, but some insurance plans will cover the prescription cost.

Penile Implants & Penis Extenders

Penile Implants

Penile implants are used for a variety of reasons. They can treat erectile dysfunction, Peyronie's disease, deformities, traumatic injuries, ischemic priapism (when blood is trapped in the penis), phalloplasty (penis enlargement), and metoidioplasty (female-to-male sex reassignment surgery).

Penile implants offer a flexible or inflatable insert that is surgically implanted into the penis so that erections can be created when desired. Penile implants are only available through surgical means.

Penis Extenders

Penis extenders are used to assist in making new, healthier, and stronger cells in the penis. They may do this by using stretching motions, increasing blood flow to the penis. As more healthy cells are created, they can support more blood allowing for larger, firmer, longer-lasting erections. For more information about penis extenders, please see our Penis Enhancement Toys Guide.

In Closing

Erectile dysfunction happens to most men at some time in their lives. Whether it is a short-term or a chronic condition, the most essential thing you can remember is that you are much more than your ability to achieve an erection. While we understand it is frustrating, stressful, and even exhausting to deal with, please know you are not alone; we sincerely care and are here to help you find ways to nurture yourself and your sexual health.