Why can't I get or maintain an erection?

Erectile dysfunction affects millions of men and can stem from physical causes like poor blood flow, low testosterone, or diabetes, as well as psychological factors like stress and anxiety. Treatment options range from lifestyle changes and medications to hormone testing and therapy, with most cases being highly treatable.

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Understanding Erectile Dysfunction

Erectile dysfunction (ED) is the inability to achieve or maintain an erection firm enough for sexual intercourse. While occasional difficulty with erections is normal and happens to most men at some point, persistent problems can indicate an underlying health issue that needs attention.

ED affects approximately 30 million men in the United States alone, with prevalence increasing with age. However, it's not an inevitable part of aging. About 40% of men experience some degree of ED by age 40, and this percentage increases by roughly 10% each decade thereafter.

The good news is that ED is highly treatable, and understanding the root cause is the first step toward finding an effective solution. Whether the cause is physical, psychological, or a combination of both, various treatment options can help restore sexual function and confidence.

How Erections Work

To understand why erectile dysfunction occurs, it helps to know how erections normally happen. An erection is a complex process involving your brain, hormones, nerves, muscles, and blood vessels working together in precise coordination.

The process begins with sexual arousal, which can come from physical touch or mental stimulation. Your brain sends signals through your nervous system to the blood vessels in your penis. These signals cause the arteries to relax and widen, allowing more blood to flow in.

As blood fills the two chambers of spongy tissue in your penis (called the corpora cavernosa), pressure builds up, making the penis expand and harden. The veins that normally carry blood away from the penis compress, trapping blood inside and maintaining the erection. After orgasm or when arousal ends, the blood flows out, and the penis returns to its normal state.

Physical Causes of Erectile Dysfunction

Physical causes account for about 80% of ED cases. These conditions can interfere with the blood flow, nerve signals, or hormone levels necessary for normal erectile function.

Cardiovascular Conditions

Since erections depend heavily on good blood flow, cardiovascular problems are among the most common causes of ED. These include:

  • High blood pressure (hypertension)
  • Atherosclerosis (clogged arteries)
  • High cholesterol
  • Heart disease
  • Metabolic syndrome

ED can actually be an early warning sign of cardiovascular disease. The arteries in the penis are smaller than those in the heart, so they may show signs of damage first. If you're experiencing ED, comprehensive cardiovascular testing can help identify potential heart health issues before they become more serious.

Hormonal Imbalances

Hormones play a crucial role in sexual function, and imbalances can significantly impact your ability to achieve and maintain erections. The most important hormones for male sexual function include:

  • Testosterone: Low levels can reduce libido and erectile function
  • Thyroid hormones: Both hyperthyroidism and hypothyroidism can cause ED
  • Prolactin: Elevated levels can suppress testosterone and cause ED
  • Cortisol: Chronic elevation from stress can interfere with sexual function

Regular hormone testing can help identify imbalances that may be contributing to erectile dysfunction. Understanding your hormone levels is essential for developing an effective treatment plan.

Diabetes and Metabolic Conditions

Diabetes is one of the most common causes of ED, affecting up to 75% of men with the condition at some point. High blood sugar levels can damage both blood vessels and nerves throughout the body, including those essential for erections. Men with diabetes are three times more likely to develop ED than those without the condition.

Other metabolic conditions that can contribute to ED include obesity, insulin resistance, and metabolic syndrome. These conditions often occur together and can create a cycle where each problem worsens the others.

Psychological Causes of Erectile Dysfunction

While physical causes are more common, psychological factors play a significant role in many cases of ED, especially in younger men. The brain plays a crucial role in triggering the physical events that cause an erection, starting with feelings of sexual excitement.

Common Psychological Factors

  • Performance anxiety
  • Depression
  • Chronic stress
  • Relationship problems
  • Low self-esteem
  • Guilt or shame about sex
  • Past sexual trauma

Psychological ED often develops suddenly and may be situational. For example, you might have no problem with morning erections or during masturbation but experience difficulty with a partner. This pattern often indicates a psychological rather than physical cause.

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Lifestyle Factors That Contribute to ED

Many lifestyle choices can increase your risk of developing erectile dysfunction or make existing ED worse. The good news is that these factors are often modifiable, meaning you can take action to improve them.

  • Smoking: Damages blood vessels and restricts blood flow
  • Excessive alcohol consumption: Can interfere with nerve signals and hormone production
  • Lack of exercise: Contributes to poor cardiovascular health and obesity
  • Poor diet: Can lead to cardiovascular disease and diabetes
  • Inadequate sleep: Affects hormone production and overall health
  • Drug use: Many recreational drugs can cause or worsen ED

Making positive lifestyle changes can significantly improve erectile function. Studies show that men who exercise regularly, maintain a healthy weight, and avoid smoking have a much lower risk of developing ED.

Medications That Can Cause ED

Certain medications can interfere with erectile function as a side effect. If you started experiencing ED after beginning a new medication, it's worth discussing with your healthcare provider. Common culprits include:

  • Blood pressure medications (especially beta-blockers and diuretics)
  • Antidepressants (particularly SSRIs)
  • Antihistamines
  • Acid reflux medications
  • Opioid pain medications
  • Some prostate medications
  • Anti-anxiety medications

Never stop taking prescribed medications without consulting your doctor. Often, alternative medications or dosage adjustments can help resolve ED while still treating your underlying condition.

When to See a Healthcare Provider

You should consider seeing a healthcare provider about ED if:

  • The problem persists for more than a few weeks
  • ED is causing stress or relationship problems
  • You have other symptoms like pain, unusual discharge, or urinary problems
  • You have known risk factors like diabetes or heart disease
  • The problem started after beginning a new medication
  • You're experiencing other symptoms of low testosterone

Remember that ED can be an early warning sign of serious health conditions. Getting evaluated can help identify and treat underlying problems before they worsen.

Diagnostic Tests for Erectile Dysfunction

Diagnosing the cause of ED typically involves a combination of medical history, physical examination, and laboratory tests. Your healthcare provider may recommend:

Blood Tests

  • Testosterone levels (total and free testosterone)
  • Thyroid function tests
  • Lipid panel (cholesterol levels)
  • Blood glucose and HbA1c
  • Prolactin levels
  • Liver and kidney function tests

These blood tests can reveal hormonal imbalances, diabetes, cardiovascular risk factors, and other conditions that may be contributing to ED. For a comprehensive analysis of your results, you can use SiPhox Health's free blood test upload service to get personalized insights and recommendations.

Other Diagnostic Tests

Depending on your symptoms and initial test results, your doctor may also recommend:

  • Nocturnal penile tumescence test: Monitors erections during sleep
  • Penile Doppler ultrasound: Evaluates blood flow
  • Injection test: Medication injected to induce erection
  • Psychological evaluation: If psychological causes are suspected

Treatment Options for Erectile Dysfunction

The good news is that ED is highly treatable, with success rates exceeding 80% when the right treatment approach is found. Treatment options range from simple lifestyle changes to medications and medical devices.

Lifestyle Modifications

For many men, especially those with mild ED, lifestyle changes can significantly improve erectile function:

  • Regular exercise (especially aerobic exercise)
  • Weight loss if overweight
  • Smoking cessation
  • Limiting alcohol consumption
  • Stress management techniques
  • Improving sleep quality
  • Dietary improvements (Mediterranean diet shows particular benefit)

Medical Treatments

When lifestyle changes aren't enough, various medical treatments are available:

  • Oral medications (PDE5 inhibitors like sildenafil, tadalafil)
  • Testosterone replacement therapy (if levels are low)
  • Penile injections
  • Vacuum erection devices
  • Penile implants (for severe cases)
  • Psychological counseling (for psychological ED)

The choice of treatment depends on the underlying cause, severity of ED, overall health, and personal preferences. Many men find success with a combination of treatments.

Prevention Strategies

While not all cases of ED can be prevented, you can significantly reduce your risk by maintaining good overall health:

  • Maintain a healthy weight
  • Exercise regularly (at least 150 minutes per week)
  • Eat a balanced diet rich in fruits, vegetables, and whole grains
  • Manage chronic conditions like diabetes and high blood pressure
  • Limit alcohol and avoid smoking
  • Manage stress through relaxation techniques or counseling
  • Get regular health checkups and blood work

Regular monitoring of key health markers can help you catch potential problems early. Tracking biomarkers like testosterone, blood glucose, and cardiovascular health indicators can provide valuable insights into your risk factors for ED.

The Path Forward: Taking Action

Erectile dysfunction can be frustrating and emotionally challenging, but remember that it's a common medical condition with many effective treatments. The key is to take action rather than suffering in silence.

Start by having an honest conversation with your healthcare provider. They can help determine whether your ED has physical or psychological causes and develop an appropriate treatment plan. Don't be embarrassed—healthcare providers regularly help patients with these concerns.

Consider getting comprehensive testing to understand your overall health status. Many cases of ED are linked to underlying conditions that, once identified and treated, can lead to significant improvements in both sexual function and overall health.

Most importantly, be patient with yourself. Finding the right treatment approach may take time, but with persistence and the right medical support, most men with ED can regain satisfactory sexual function and confidence.

References

  1. Shamloul R, Ghanem H. Erectile dysfunction. Lancet. 2013;381(9861):153-165.[Link][DOI]
  2. Yafi FA, Jenkins L, Albersen M, et al. Erectile dysfunction. Nat Rev Dis Primers. 2016;2:16003.[Link][PubMed][DOI]
  3. Gandaglia G, Briganti A, Jackson G, et al. A systematic review of the association between erectile dysfunction and cardiovascular disease. Eur Urol. 2014;65(5):968-978.[PubMed][DOI]
  4. Corona G, Rastrelli G, Maggi M. Diagnosis and treatment of late-onset hypogonadism: systematic review and meta-analysis of TRT outcomes. Best Pract Res Clin Endocrinol Metab. 2013;27(4):557-579.[PubMed][DOI]
  5. Maiorino MI, Bellastella G, Esposito K. Diabetes and sexual dysfunction: current perspectives. Diabetes Metab Syndr Obes. 2014;7:95-105.[PubMed][DOI]
  6. Hatzimouratidis K, Giuliano F, Moncada I, et al. EAU Guidelines on Erectile Dysfunction, Premature Ejaculation, Penile Curvature and Priapism. European Association of Urology. 2019.[Link]

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Frequently Asked Questions

How can I test my testosterone at home?

You can test your testosterone at home with SiPhox Health's Men's Essential Hormone Panel. This CLIA-certified test includes total testosterone, free testosterone, SHBG, albumin, and DHEA-S, providing comprehensive insights into your hormonal health from the comfort of your home.

Is erectile dysfunction a normal part of aging?

While ED becomes more common with age, it's not an inevitable part of aging. Many older men maintain healthy sexual function, and ED at any age often indicates underlying health issues that can be treated. Age-related changes may require adjustments, but satisfactory sexual function is possible at any age.

Can ED be cured permanently?

Whether ED can be permanently cured depends on the underlying cause. If ED is due to reversible factors like obesity, smoking, or psychological issues, addressing these can lead to complete resolution. For other causes, ongoing treatment may be needed, but most men can achieve satisfactory results with proper management.

How quickly do ED medications work?

Oral ED medications typically work within 30-60 minutes, though timing varies by medication. Sildenafil and vardenafil work fastest (30-60 minutes), while tadalafil may take up to 2 hours but lasts much longer (up to 36 hours). These medications require sexual stimulation to be effective.

Can stress cause erectile dysfunction?

Yes, stress is a common cause of ED, especially in younger men. Chronic stress increases cortisol levels, which can interfere with testosterone production and sexual function. Stress also affects the nervous system signals needed for erections. Managing stress through exercise, meditation, or counseling often improves ED symptoms.

This article is licensed under CC BY 4.0. You are free to share and adapt this material with attribution.

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View Details
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Pavel Korecky, MD

Director of Clinical Product Operations

Director of Clinical Product Operations at SiPhox Health with a background in medicine and a passion for health optimization. Experienced in leading software and clinical development teams, contributing to patents, launching health-related products, and turning diagnostics into actionable tools.

View Details
Paul Thompson, MD

Paul Thompson, MD

Advisor

Paul D. Thompson is Chief of Cardiology Emeritus of Hartford Hospital and Professor Emeritus at University of Connecticut Medical School. He has authored over 500 scientific articles on cardiovascular risk factors, the effects of exercise, and beyond. He received National Institutes of Health’s (NIH) Preventive Cardiology Academic Award, and has received NIH funding for multiple studies.

Dr. Thompson’s interests in exercise, general cardiology and sports cardiology originated from his own distance running: he qualified for the 1972 Olympic Marathon Trials as a 3rd year medical student and finished 16th in the 1976 Boston Marathon. Dr. Thompson publishes a blog 500 Rules of Cardiology where he shares lessons and anecdotes that he has learned over his extensive career as a physician, researcher and teacher.

View Details
Robert Lufkin, MD

Robert Lufkin, MD

Advisor

Physician/medical school professor (UCLA and USC) and New York Times bestselling author empowering people to take back their metabolic health with lifestyle and other tools. A veteran of the Today Show, USA Today, and a regular contributor to FOX and other network news stations, his weekly video podcast reaches over 500,000 people. After reversing chronic disease and transforming his own life he is making it his mission to help others do the same.

His latest book, ‘Lies I Taught In Medical School’ is an instant New York Times bestseller and has re-framed how we think about metabolic health and longevity. In addition to being a practicing physician, he is author of over 200 peer reviewed scientific papers and 14 books that are available in fourteen languages.

View Details
Ben Bikman, PhD

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Advisor

Benjamin Bikman earned his Ph.D. in Bioenergetics and was a postdoctoral fellow with the Duke-National University of Singapore in metabolic disorders. Currently, his professional focus as a scientist and professor (Brigham Young University) is to better understand the role of elevated insulin and nutrient metabolism in regulating obesity, diabetes, and dementia.

In addition to his academic pursuits, Dr. Bikman is the author of Why We Get Sick and How Not To Get Sick.

View Details
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Health Programs Lead, Heart & Metabolic

Dr. Natasha Milinkovic is part of the clinical product team at SiPhox Health, having graduated from the University of Bristol Medical School. Her medical career includes rotations across medical and surgical specialties, with specialized research in vascular surgery, focusing on recovery and post-operative pain outcomes. Dr. Milinkovic built her expertise in emergency medicine as a clinical fellow at a major trauma center before practicing at a central London teaching hospital throughout the pandemic.

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View Details
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Health Programs Lead, Health Innovation

Dr. Tsogbayar leverages her clinical expertise to develop innovative health solutions and evidence-based coaching. Dr. Tsogbayar previously practiced as a physician with a comprehensive training background, developing specialized expertise in cardiology and emergency medicine after gaining experience in primary care, allergy & immunology, internal medicine, and general surgery.

She earned her medical degree from Imperial College London, where she also completed her MSc in Human Molecular Genetics after obtaining a BSc in Biochemistry from Queen Mary University of London. Her academic research includes significant work in developmental cardiovascular genetics, with her thesis publication contributing to the understanding of genetic modifications on embryonic cardiovascular development.

View Details
Pavel Korecky, MD

Pavel Korecky, MD

Director of Clinical Product Operations

Director of Clinical Product Operations at SiPhox Health with a background in medicine and a passion for health optimization. Experienced in leading software and clinical development teams, contributing to patents, launching health-related products, and turning diagnostics into actionable tools.

View Details
Paul Thompson, MD

Paul Thompson, MD

Advisor

Paul D. Thompson is Chief of Cardiology Emeritus of Hartford Hospital and Professor Emeritus at University of Connecticut Medical School. He has authored over 500 scientific articles on cardiovascular risk factors, the effects of exercise, and beyond. He received National Institutes of Health’s (NIH) Preventive Cardiology Academic Award, and has received NIH funding for multiple studies.

Dr. Thompson’s interests in exercise, general cardiology and sports cardiology originated from his own distance running: he qualified for the 1972 Olympic Marathon Trials as a 3rd year medical student and finished 16th in the 1976 Boston Marathon. Dr. Thompson publishes a blog 500 Rules of Cardiology where he shares lessons and anecdotes that he has learned over his extensive career as a physician, researcher and teacher.

View Details
Robert Lufkin, MD

Robert Lufkin, MD

Advisor

Physician/medical school professor (UCLA and USC) and New York Times bestselling author empowering people to take back their metabolic health with lifestyle and other tools. A veteran of the Today Show, USA Today, and a regular contributor to FOX and other network news stations, his weekly video podcast reaches over 500,000 people. After reversing chronic disease and transforming his own life he is making it his mission to help others do the same.

His latest book, ‘Lies I Taught In Medical School’ is an instant New York Times bestseller and has re-framed how we think about metabolic health and longevity. In addition to being a practicing physician, he is author of over 200 peer reviewed scientific papers and 14 books that are available in fourteen languages.

View Details
Ben Bikman, PhD

Ben Bikman, PhD

Advisor

Benjamin Bikman earned his Ph.D. in Bioenergetics and was a postdoctoral fellow with the Duke-National University of Singapore in metabolic disorders. Currently, his professional focus as a scientist and professor (Brigham Young University) is to better understand the role of elevated insulin and nutrient metabolism in regulating obesity, diabetes, and dementia.

In addition to his academic pursuits, Dr. Bikman is the author of Why We Get Sick and How Not To Get Sick.

View Details
Tash Milinkovic, MD

Tash Milinkovic, MD

Health Programs Lead, Heart & Metabolic

Dr. Natasha Milinkovic is part of the clinical product team at SiPhox Health, having graduated from the University of Bristol Medical School. Her medical career includes rotations across medical and surgical specialties, with specialized research in vascular surgery, focusing on recovery and post-operative pain outcomes. Dr. Milinkovic built her expertise in emergency medicine as a clinical fellow at a major trauma center before practicing at a central London teaching hospital throughout the pandemic.

She has contributed to global health initiatives, implementing surgical safety standards and protocols across rural Uganda. Dr. Milinkovic initially joined SiPhox Health to spearhead the health coaching initiative and has been a key contributor in the development and launch of the Heart and Metabolic program. She is passionate about addressing health disparities by building scalable healthcare solutions.

View Details