Erectile Dysfunction

Common, treatable, and often the first warning sign of a cardiovascular problem — which is why it's worth evaluating properly.

Why it is worth bringing up

Erectile dysfunction is common and becomes more so with age, but it is not simply an inevitable part of aging. It is usually a symptom of something identifiable — and often treatable.

The most important point: erections depend on healthy blood vessels, and the arteries supplying the penis are small. Vascular disease frequently shows up there before it shows up in the heart. New erectile dysfunction can precede a cardiac event by several years. Bringing it up is not embarrassing; it is a genuinely useful piece of medical information.

Common causes

Vascular disease, diabetes, high blood pressure, high cholesterol, obesity, and smoking are the leading contributors. Low testosterone plays a role in some men. Neurologic conditions and prior pelvic surgery or radiation can be factors.

Medications are a frequent and reversible cause — certain blood pressure agents, some antidepressants, and others. Psychological factors including stress, depression, relationship difficulties, and performance anxiety are real contributors, often intertwined with physical ones. Sleep apnea is underrecognized here.

Evaluation

Evaluation begins with a history, a review of your medications, and an examination. Blood work typically includes testosterone, glucose or A1c, and a lipid panel. The pattern matters: erections that are absent in all circumstances, including on waking, point toward a physical cause, while preserved morning erections with difficulty in specific situations suggest a larger psychological component.

Treatment

Lifestyle change is not a throwaway recommendation here. Exercise, weight loss, smoking cessation, and better diabetes control produce measurable improvement in erectile function.

Oral medications (PDE5 inhibitors such as sildenafil and tadalafil) are effective for most men. They require sexual stimulation to work — they are not automatic — and some need dose adjustment or a few attempts before working well. They cannot be used with nitrates.

Other options include vacuum erection devices, injectable medication, urethral suppositories, and — for men in whom other treatments fail — a penile implant, which has among the highest satisfaction rates of any treatment in this area. If testosterone is genuinely low, replacement may help. Counseling is valuable when psychological factors are significant.