Erectile Dysfunction (ED): Causes, Symptoms and Treatment

Erectile dysfunction (ED), sometimes called impotence, is when you regularly cannot get or keep an erection firm enough for sex. An occasional off night is normal and is not ED. It becomes worth looking into when it happens more often than not, or when it is getting worse.

It is far more common than most men think. In a Canadian study of 3,921 men aged 40 to 88 seen by family doctors, 49.4% had ED in the previous month or were taking medication for it1. It becomes more common with age, but it is not an inevitable part of getting older.

An erection depends on healthy blood vessels, and the arteries in the penis are smaller than those in the heart. Narrowing can show up there first.

In a study that followed 8,063 men for several years, those who developed ED were 25% more likely to go on to have a heart attack, stroke or other cardiovascular event than men who did not2. In the Canadian study, ED was linked with heart disease, diabetes and higher fasting blood sugar1.

That is why a doctor's visit is worth it even if you plan to manage ED yourself. A simple check of blood pressure, blood sugar and cholesterol can catch problems early.

Most ED has a physical cause, and many men have more than one. The mind plays a part too, because worry about performance can make any erection problem worse.

Start with your family doctor or a nurse practitioner. They will ask about your health, medicines and how the problem started, check your blood pressure, and usually order blood tests such as blood sugar and cholesterol. If needed, they can refer you to a urologist, a pelvic floor physiotherapist or a sex therapist.

ED is a routine conversation for doctors. Being specific helps them help you.

Most men start with lifestyle changes and pills, and add or switch to other options if those are not enough or not suitable. Many treatments can be combined.

Because ED so often comes from the same things that harm the heart, the same changes help both. In the weight loss trial above, men who cut calories and exercised more also saw their erection scores rise, while the comparison group did not3. Quitting smoking, cutting down on alcohol and treating diabetes or high blood pressure all help.

PDE5 inhibitors increase blood flow to the penis when you are aroused. They do not cause an erection on their own. They need a prescription, and they must never be taken with nitrate heart medicines such as nitroglycerin. Side effects include headache, flushing and a stuffy nose. In a large analysis of 82 trials, sildenafil was the most effective and tadalafil was the best tolerated4.

A vacuum erection device works for most causes of ED, needs no medication, and can be used as often as you like. You place a clear cylinder over the penis, pump out the air to draw blood in, then slide a soft constriction ring onto the base of the penis to hold the erection.

The evidence is strong for men who have tried other treatments. A 2025 meta-analysis of 18 studies and 1,065 men whose ED had not responded to other treatment found that 80% had successful or satisfying intercourse with a vacuum device. Success was 85% after prostate removal, 73% with diabetes and 72% after spinal cord injury5. The most common side effect is bruising, in about 1 in 4 men5.

The pelvic floor muscles at the base of the penis help trap blood during an erection. In a UK trial, 55 men did pelvic floor exercises with biofeedback. After 3 months their erection scores rose by about 7 points more than men given lifestyle advice alone, and after 6 months 40% of all the men had normal erections again and another 35% had improved6. A pelvic floor physiotherapist can show you how to find and train these muscles.

Low-intensity shockwave therapy sends gentle sound waves into the penis, which is thought to encourage new blood vessel growth. It is done in a clinic over several short sessions, with no needles or medication.

The largest review so far is encouraging. A 2025 Cochrane review of 21 randomized trials and 1,357 men found erection scores about 4 points higher than sham treatment in the first 3 months, and about 5 points higher after that, with no more side effects than sham. The reviewers rated the evidence as low certainty, so results vary from man to man7.

Read more about shockwave therapy for ED, or find a clinic that offers it.

A urologist can offer injections into the side of the penis that produce an erection within minutes, or a penile implant, which is a permanent option when other treatments have not worked. If tests show low testosterone, treating it may help, especially when desire is also low. Talking therapy or sex therapy helps when anxiety or relationship strain is part of the picture.

We think you should know. Pills have the largest body of trials behind them. The vacuum device results come mostly from studies without a comparison group, and the shockwave and pelvic floor trials are smaller, with results that vary. That is a good reason to choose treatment with a doctor who knows your health, and to give each option a fair trial before moving on.

Erection problems are common after prostate removal, because the nerves that control erections run right beside the prostate. Many urologists recommend starting penile rehabilitation early, to keep blood flowing to the erectile tissue while the nerves recover.

Vacuum devices are one of the main tools for this. In the meta-analysis above, 85% of men who used a vacuum device after prostate removal had successful or satisfying intercourse5. Ask your surgeon when it is safe to start, and see our article on using a vacuum device after prostatectomy.

Follow the instructions that come with your device. The outline below is typical.

Vacuum devices and pelvic floor trainers you can use at home, alongside your doctor's or physiotherapist's advice.

Browse all vacuum erection systems, erectile dysfunction devices and lubricants.