Erectile dysfunction

What is erectile dysfunction?

Erectile dysfunction (ED) is a common male sexual disorder. It is the inability to get or keep an erection that allows for satisfying sexual activity. It can happen occasionally or regularly, with or without any clear reason. Some men with ED are not able to get an erection at all.

ED is not a life-threatening disorder, but it can have a negative impact on your quality of life and that of your partner.

How common is ED?

ED is a common condition in men of all ages and ethnicities. The risk of having ED increases with age.

What is an erection?

Getting an erection is a process that includes physical, hormonal, and psychological elements. The penis is made of soft, spongy, elastic tissue that fills with blood to make it grow in size and become rigid. Around the spongy tissue and the prostate, there are nerves that send signals so that the blood vessels supply the blood (Fig. 1). These signals are controlled by the male hormone testosterone.

Fig. 1: a) Flaccid penis b) Erect penis.
Fig. 1: a) Flaccid penis b) Erect penis.

What causes ED?

Risk factors for ED and cardiovascular disease (CVD) are similar. The most cases of ED result from a vascular disturbance of the endothelium. Risk factors are such as:

  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Low levels of testosterone
  • Neurologic diseases (e.g Parkinson’s disease, spinal cord injury)
  • Nerve damage to the penis or the pelvic area
  • Obesity
  • Pelvic surgery
  • Radiation therapy to the pelvic area
  • Smoking

Cardiovascular disease and ED

ED and cardiovascular disease share common risk factors, like obesity, smoking, high cholesterol, high blood pressure, and lack of exercise. ED can be an early sign of heart disease because problems with blood flow affect erectile function. This is why men who experience ED should go to the doctor to get checked for heart disease.

Urinary symptoms and ED

ED is often associated with urinary symptoms, such as urinary frequency, nocturia, and urgency. Often these symptoms are related to benign prostatic enlargement (BPE). It is unclear if the urinary symptoms cause ED, but generally, ED gets worse when urinary symptoms worsen.

Psychological risk factors for ED

Several psychological conditions have been associated with ED. These include:

  • Anxiety
  • Depression
  • Feelings of self-inadequacy
  • Low self-esteem
  • Inability to describe emotions
  • Stress

Social ideas of how men and women are supposed to interact can also contribute to ED. These can include unrealistic expectations about love and sexuality, and inappropriate male and female role models.

ED is sometimes the cause and sometimes the result of unsatisfying or dysfunctional relationships. It is often difficult to find out which started first.


Erectile dysfunction (ED) is a problem that needs to be diagnosed correctly, to find what causes it so that you get the appropriate treatment.

Discussing ED with your family doctor or urologist may be uncomfortable, but it is important to do so. Together you can discuss which treatment is right for you.

This section lists the different tests your doctor may need to assess your situation. It offers general information about the diagnosis of ED. Keep in mind that situations can vary in different countries.


Your doctor may ask you to fill out questionnaires, which are used to assess different aspects of your sexual health. The most common are:

  • The International Index for Erectile Function (IIEF)
  • The Sexual Health Inventory for Men (SHIM)
  • The International Prostate Symptom Score (IPSS)
  • The Clinical Depression Questionnaire

Laboratory testing

Your doctor may order laboratory tests to identify metabolic disorders underlying the ED.

Other tests

In some cases, it may be necessary to do specific diagnostic tests other tests. These may include:

  • A nocturnal penile tumescence and rigidity (NPTR) test
  • An intracavernous injection test
  • Penile Doppler Ultrasound
  • Neurological tests

These are not common tests for initial diagnosis of ED and are only necessary if your doctor needs additional information to assess your personal situation.

If necessary, your doctor may refer you to a neurologist, a psychiatrist, an andrologist, or an endocrinologist for further tests.


Erectile dysfunction (ED) is a common condition. Although it is not life-threatening, it can negatively affect your quality of life. Because it can be related to other conditions, such as heart disease, it is important that you get the right treatment. There are various treatment options for ED, discuss with your doctor which option is best for your individual situation.

This section offers general information about treatment options and situations can vary in different countries.

Education and couple assessment

An important part of treatment is understanding the condition and the consequences it may have on your intimate relationships. Your doctor will often recommend a combination of physical and psychological approaches to treat ED. In the past doctors focused mainly on treating the physical aspect of ED. Nowadays, psychological and emotional aspects of the condition are also dealt with.

Treatment that includes psychological approaches has proved to be more effective than treating only the physical symptoms. This approach has also shown to be effective in single patients, or in cases when the partner is not involved.

If you are in a committed relationship, it benefits your treatment if your partner agrees to the type of treatment, is aware of how it works, and you are able to talk about it.

Keep in mind that treatment is based on your individual situation and what may be helpful for others is not always helpful for you.

If you have other conditions that may be related to ED, your doctor will discuss referring you to a specialist for assessment and further treatment.

Lifestyle advice

Improving your general health could help improve your symptoms. Your doctor will advise you to stop smoking, drink less alcohol, and exercise regularly.

Depending on your individual situation, your doctor may recommend that you adapt your diet. It is important to discuss this with the doctor first. As a general rule, try to have a varied diet which is low on sugar, salt, and fatty foods.

Phosphodiesterase 5 inhibitors

Phosphodiesterase 5 inhibitors (PDE5Is) are a group of drugs used for the treatment of ED. These drugs relax smooth muscle in the vessels in the penis to increase blood flow. They do not cause an erection without sexual stimulation.

There are 4 approved types of PDE5Is:

  • Sildenafil
  • Tadalafil
  • Vardenafil
  • Avanafil

PDE5Is are the most commonly prescribed treatment for ED. All types of PDE5Is can be equally effective. Which drug is best for you depends on how often you want to have sexual activity, and your personal experience.

Because of the success of PDE5Is in treating ED, there are many fake pills on the market. These drugs are not approved for sale, they may be toxic and may damage your health. Always talk to your doctor or healthcare provider before using or buying medication for ED.

Interesting Fact

Sildenafil, best known by its brand name Viagra®, is the oldest and best-known drug for ED. Although new drugs have been developed, it still accounts for more than 40% of all PDE5Is sales.

This information was produced by the European Association of Urology.

  • Dr. Maarten Albersen, Leuven (BE)
  • Dr. Eduardo García-Cruz, Barcelona (ES)
  • Prof. Dr. Kostas Hatzimouratidis, Thessaloniki (GR)
  • Prof. Dr. Markus Margreiter, Vienna (CH)
  • Dr. Ege Can Serefoglu, Istanbul (TR)
  • Dr. Chaira Simonelli, Rome (IT)
  • Prof. Dr. Wolfgang Weidner, Giessen (DE)

Updated March 2018 by the EAU Patient Information Working Group

  • Dr. Mazhar Ortac, Istanbul (TR)