Definition

An erection problem occurs when a man cannot get or keep an erection that is firm enough for intercourse. You may not be able to get an erection at all. Or, you may lose the erection during intercourse before you are ready. Erection problems do not usually affect your sex drive.

Erection problems are common. Almost all adult men have trouble getting or keeping an erection at one time or another. Often the problem goes away with little or no treatment. But for some men, it can be an ongoing problem. This is called erectile dysfunction (ED).

If you have trouble getting or keeping an erection more than 25% of the time, you should see your health care provider.

Alternative Names

Erectile dysfunction; Impotence; Sexual dysfunction - male

Causes

To get an erection, your brain, nerves, hormones, and blood vessels all need to work together. If something gets in the way of these normal functions, it can lead to erection problems.

An erection problem is usually not "all in your head." In fact, most erection problems have a physical cause. Below are some common physical causes.

Disease:

• Diabetes
• High blood pressure
• Heart or thyroid conditions
• Clogged arteries (atherosclerosis)
• Depression
• Nervous system disorders, such as multiple sclerosis or Parkinson disease

Medicines:

• Antidepressants
• Blood pressure medicines (especially beta-blockers)
• Heart medicines, such as digoxin
• Sleeping pills
• Some peptic ulcer medicines

Other physical causes:

• Low testosterone levels. This can make it difficult to get an erection. It can also reduce a man's sex drive.
• Nerve damage from prostate surgery.
• Nicotine, alcohol, or cocaine use.
• Spinal cord injury.

In some cases, your emotions or relationship problems can lead to ED, such as:

• Poor communication with your partner.
• Feelings of doubt and failure.
• Stress, fear, anxiety, or anger.
• Expecting too much from sex. This can make sex a task instead of a pleasure.

Erection problems can affect men at any age, but are more common as you get older. Physical causes are more common in older men. Emotional causes are more common in younger men.

If you have erections in the morning or at night while you sleep, it is likely not a physical cause. Most men have 3 to 5 erections at night that last about 30 minutes. Talk with your provider about how to find out if you have normal nighttime erections.

Symptoms

Symptoms may include any of the following:

• Trouble getting an erection
• Trouble keeping an erection
• Having an erection that is not firm enough for intercourse
• Less interest in sex

Exams and Tests

Your provider will perform a physical exam, which may include:

• Taking your blood pressure
• Examining your penis and rectum to check for problems

Your provider will also ask questions to help find the cause, such as:

• Have you been able to get and keep erections in the past?
• Are you having trouble getting an erection or keeping erections?
• Do you have erections during sleep or in the morning?
• How long have you had trouble with erections?

Your provider will also ask about your lifestyle:

• Are you taking any medicines, including over-the counter medicines and supplements?
• Do you drink, smoke, or use recreational drugs?
• What is your state of mind? Are you stressed, depressed, or anxious?
• Are you having relationship problems?

You may have a number of different tests to help find the cause, such as:

• Urinalysis or blood tests to check for health conditions such as diabetes, heart problems, or low testosterone
• A device you wear at night to check for normal nighttime erections
• Ultrasound of your penis to check for blood flow problems
• Rigidity monitoring to test how strong your erection is
• Psychological tests to check for depression and other emotional problems

Treatment

The treatment may depend on what is causing the problem and how healthy you are. Your provider can talk with you about the best treatment for you.

For many men, lifestyle changes can help. These include:

• Getting exercise
• Eating a healthy diet
• Losing extra weight
• Sleeping well

If you and your partner have trouble talking about your relationship, it may cause problems with sex. Counseling can help both you and your partner.

Lifestyle changes alone may not be enough. There are many treatment options.

• Pills you take by mouth, such as sildenafil (Viagra), vardenafil (Levitra, Staxyn), avanafil (Stendra), and tadalafil (Adcirca, Cialis). They work only when you are sexually aroused. They usually start to work in 15 to 45 minutes.
• Medicine inserted into the urethra or injected into the penis to improve blood flow. Very small needles are used and do not cause pain.
• Surgery to place implants in the penis. The implants may be inflatable or semi-rigid.
• A vacuum device. This is used to pull blood into the penis. A special rubber band is then used to keep the erection during intercourse.
• Testosterone replacement if your testosterone level is low. This comes in skin patches, gel, or injections into the muscle.

ED pills you take by mouth can have side effects. These can range from muscle pain and flushing to heart attack. Do not use these drugs with nitroglycerin. The combination can cause your blood pressure to drop.

You may not be able to use these drugs if you have any of the following conditions:

• Recent stroke or heart attack
• Severe heart disease, such as unstable angina or irregular heartbeat (arrhythmia)
• Severe heart failure
• Uncontrolled high blood pressure
• Uncontrolled diabetes
• Very low blood pressure

Other treatments also have possible side effects and complications. Ask your provider to explain the risks and benefits of each treatment.

You may see many herbs and supplements that claim to help sexual performance or desire. However, none have been proven to successfully treat ED. Plus, they may not always be safe. Do not take anything without talking with your provider first.

Outlook (Prognosis)

Many men overcome erection problems with lifestyle changes, treatment, or both. For more severe cases, you and your partner may have to adjust to how ED affects your sex life. Even with treatment, counseling can help you and your partner overcome the stress ED may put on your relationship.

Possible Complications

An erection problem that does not go away can make you feel bad about yourself. It can also harm your relationship with your partner. ED may be a sign of health problems such as diabetes or heart disease. So if you have an erection problem, do not wait to seek help.

When to Contact a Medical Professional

Call your provider if:

• The problem does not go away with lifestyle changes
• The problem begins after an injury or prostate surgery
• You have other symptoms, such as low back pain, abdominal pain, or a change in urination

If you think any medicine you are taking may be causing erection problems, talk with your provider. You may need to lower the dose or change to another drug. Do not change or stop taking any medicine without first talking to your provider.

Talk to your provider if your erection problems have to do with a fear of heart problems. Sexual intercourse is usually safe for men with heart problems.

Call your provider right away or go to an emergency room if you are taking ED medicine and it gives you an erection that lasts for more than 4 hours.

Prevention

To help prevent erection problems:

• Quit smoking.
• Cut back on alcohol (no more than 2 drinks per day).
• Do not use illegal drugs.
• Get plenty of sleep and take time to relax.
• Stay at a healthy weight for your height.
• Exercise and eat a healthy diet to keep good blood circulation.
• If you have diabetes, keep blood sugar well-controlled.
• Talk openly with your partner about your relationship and sex life. Seek counseling if you and your partner have trouble communicating.

References

American Urological Association website. What is erectile dysfunction? www.urologyhealth.org/urologic-conditions/erectile-dysfunction(ed). Updated June 2018. Accessed January 16, 2022.

Burnett AL, Ramasamy R. Evaluation and management of erectile dysfunction. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia, PA: Elsevier; 2021:chap 69.

Burnett AL, Nehra A, Breau RH, et al. Erectile dysfunction: AUA guideline. J Urol. 2018;200(3):633-641. PMID: 29746858 pubmed.ncbi.nlm.nih.gov/29746858/.