Erectile dysfunction (ED) is the inability to get and sustain an erection firm enough for sex. To meet the diagnostic criteria, symptoms must be present for at least six months, be causing significant distress, and not be better explained by another condition.

ED is a very common medical condition that nearly all men experience at some point in their lifetime. It affects approximately 30 million men in the United States,¹ with nearly a quarter of them under the age of forty.² Approximately 12 million men have persistent ED symptoms.³ When moderate ED symptoms are included in the statistics, about half of men over the age of 50 are affected by ED. This number increases with age.

Erectile function is essential to sexual health and can indicate cardiovascular disease. Blood vessel, neurological, psychological, or hormonal factors can cause ED.³ The first step to finding a solution for ED symptoms is to better understand its causes, symptoms, and treatments.

Physical Symptoms Of Erectile Dysfunction

The physical symptoms of ED are fairly straightforward. However, ED can be associated with other medical conditions that may cause symptoms. When assessing erectile function, a single question may be used:

Impotence means not being able to get and keep an erection that is firm enough for satisfactory sexual activity. Which of the following would you use to describe your symptoms?⁴

1. Not impotent: able to get and sustain an erection
2. Minimally impotent: usually able to get and sustain an erection
3. Moderately impotent: sometimes able to get and sustain an erection
4. Completely impotent: never able to get and sustain an erection

The American Urological Association recommends using validated questionnaires to assess ED symptoms and track treatment responses.⁵

Little To No Sexual Desire 

People with ED will often also experience decreased libido. The sexual response in men has three phases: interest/libido, the ability to obtain and sustain an erection, and ejaculation/climax. A lack of interest or libido is a cause and effect of ED. Decreased libido is common with age and may be a sign that your hormone levels are changing. Most men experience a steady decline in testosterone levels by their mid-to-30s. Researchers estimate the decline is about 1% per year or 10% per decade.⁶

The link between ED symptoms and decreased testosterone levels is unclear. Data shows that healthy older men tend to have little or no drop in testosterone, while men with multiple health problems like diabetes have the biggest drops. ⁷

Trouble Getting An Erection 

An erection occurs when blood flows into the penis and is trapped in cavities called the corpora cavernosa. As blood fills these cavities, pressure builds inside them. This increased pressure causes the penis to stiffen. Although this process appears straightforward, it is a multi-step process involving the brain, cardiovascular, and nervous systems. Getting an erection also involves a psychological response. The presence of nighttime or early-morning erections can suggest that there is a psychological component to ED symptoms.⁵

About half of men with ED have blood vessel damage. ED can be an early indicator of cardiovascular disease.⁸ This is why the American Urological Association stresses that men presenting with symptoms of ED should undergo a thorough medical, sexual, and psychological history, a physical exam, and selective laboratory testing.⁵

Trouble Maintaining An Erection 

Getting and maintaining an erection depends on blood flow. As blood enters the penis and fills the corpora cavernosa, the penis becomes erect. The ischiocavernosus muscle contracts to support the erection. If blood slowly leaks from the penis, the erection will deflate, making it difficult to maintain an erection. Penile erection requires an integrative, synchronized action by the lining of blood vessels, smooth muscles controlling blood flow, and psychological, neural, and hormonal factors controlling blood vessel activity.⁹

Damage to small blood vessels entering the penis and leaving the penis increases the risk of ED. Smokers have a 1.5 times higher rate of ED than nonsmokers.⁹

Mental Health Signs Of Erectile Dysfunction

ED is a common disorder that can negatively affect a man’s mental health, relationships, and overall well-being.⁵ Penile erection occurs in response to auditory, visual, olfactory, tactile, and imaginative stimuli.⁹ These sensory responses can be blunted when a person is dealing with mental illness. Sexual health and intimacy are affected by mental and emotional health. There is a strong connection between intimacy and mental health.

Mental illness can be both the cause and effect of ED. ED can cause symptoms associated with mental illness, including poor self-esteem, depression, anxiety, and relationship problems.

Depression    

ED can have a significant negative quality of life impact on men and their partners.¹⁰ While it is unclear whether depression causes ED or ED causes depression, or both. The incidence of depression is higher in men with ED than in men without.^9,11 Because of the close relationship between ED and depression, after completing an analysis of multiple scientific studies, researchers suggested that men presenting with ED should be screened for depression, and men diagnosed with depression should be screened for ED.¹⁰

How depression is associated with ED is not completely understood.¹² Some potential explanations include the following:^10,13,14

• The connection may be behavioral in that men with depression may have performance anxiety.
• It may also be biological in that depression causes excess catecholamine release, which leads to poor cavernosal muscle relaxation and decreased penile stiffness.
• Medication used to treat depression is associated with an increased ED risk.
• Low testosterone may contribute to both ED and depression.

Low Self-Esteem

Self-concept reflects one’s experiences in life. It is expressed in how people perceive, evaluate, and define themselves. Self-esteem is a self-assessment of how positive a person’s self-concept is rated. Self-esteem changes over time.¹¹ Negative thoughts, depression, and low self-esteem increase performance anxiety, which can contribute to ED.

Signs and symptoms of low self-esteem:¹⁵

• Helplessness or low sense of control
• Poor confidence
• Worry
• Self-doubt
• Fear of failure
• Negative self-talk
• Poor outlook for the future
• Low expectations for help
• Difficulty setting boundaries
• Sensitivity to criticism
• Difficulty accepting compliments
• Shame
• Physical symptoms such as fatigue, stomachaches, headaches, and difficulty sleeping

Relationship Troubles

ED also impacts the partners of men with ED. Partners may start to feel insecure and think that ED is a sign of something wrong with them. Many men associate the ability to have erections with masculinity, an assumption often reinforced in popular culture. Having ED can negatively impact a man’s self-image, leading to low self-esteem, depression, anxiety, and guilt.

Supporting your partner with ED involves a willingness to have non-threatening, honest conversations. Dealing with ED can be isolating for both men and their partners as they try to interpret how ED will impact their relationship. However hard it is, discussing ED is essential for the health of your relationship.

Whether due to a lack of interest/libido, an inability to obtain and sustain an erection, or premature ejaculation/inability to climax, ED is treatable, and there are cures for ED. Passion+, for example, improves mood, increases blood flow into the penis, fosters intimacy, and increases libido.

Oral ED medications (sildenafil, vardenafil, tadalafil, and avanafil) are PDE5 inhibitors that support blood flow into the penis. Penile injections, such as Trimix, deliver medications directly into the corpora cavernosa. Vacuum devices and surgical options are also available.

If you have ED, or symptoms that suggest ED, talk to your doctor and your partner. An open and honest conversation with both can get you on the road to treating and overcoming ED, a medical condition.

DISCLAIMER

While we strive to always provide accurate, current, and safe advice in all of our articles and guides, it’s important to stress that they are no substitute for medical advice from a doctor or healthcare provider. You should always consult a practicing professional who can diagnose your specific case. The content we’ve included in this guide is merely meant to be informational and does not constitute medical advice.

References

1. Nunes KP, Labazi H, Webb RC. New insights into hypertension-associated erectile dysfunction. Curr Opin Nephrol Hypertens. Mar 2012;21(2):163-70. doi:10.1097/MNH.0b013e32835021bd

2. Capogrosso P, Colicchia M, Ventimiglia E, et al. One Patient Out of Four with Newly Diagnosed Erectile Dysfunction Is a Young Man—Worrisome Picture from the Everyday Clinical Practice. The Journal of Sexual Medicine. 2013;10(7):1833-1841. doi:10.1111/jsm.12179

3. Rew KT, Heidelbaugh JJ. Erectile Dysfunction. Am Fam Physician. Nov 15 2016;94(10):820-827.

4. Derby CA, Araujo AB, Johannes CB, Feldman HA, McKinlay JB. Measurement of erectile dysfunction in population-based studies: the use of a single question self-assessment in the Massachusetts Male Aging Study. Int J Impot Res. Aug 2000;12(4):197-204. doi:10.1038/sj.ijir.3900542

5. Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. J Urol. Sep 2018;200(3):633-641. doi:10.1016/j.juro.2018.05.004

6. Feldman HA, Longcope C, Derby CA, et al. Age Trends in the Level of Serum Testosterone and Other Hormones in Middle-Aged Men: Longitudinal Results from the Massachusetts Male Aging Study. The Journal of Clinical Endocrinology & Metabolism. 2002;87(2):589-598. doi:10.1210/jcem.87.2.8201

7. Hackett G. An update on the role of testosterone replacement therapy in the management of hypogonadism. Therapeutic Advances in Urology. 2016;8(2):147-160. doi:10.1177/1756287215617648

8. Montorsi F, Briganti A, Salonia A, et al. Erectile Dysfunction Prevalence, Time of Onset and Association with Risk Factors in 300 Consecutive Patients with Acute Chest Pain and Angiographically Documented Coronary Artery Disease. European Urology. 2003/09/01/ 2003;44(3):360-365. doi:https://doi.org/10.1016/S0302-2838(03)00305-1

9. Mitidieri E, Cirino G, d’Emmanuele di Villa Bianca R, Sorrentino R. Pharmacology and perspectives in erectile dysfunction in man. Pharmacology & Therapeutics. 2020/04/01/ 2020;208:107493. doi:https://doi.org/10.1016/j.pharmthera.2020.107493

10. Liu Q, Zhang Y, Wang J, et al. Erectile dysfunction and depression: a systematic review and meta-analysis. The Journal of Sexual Medicine. 2018;15(8):1073-1082.

11. Özkent MS, Hamarat MB, Taşkapu HH, Kılınç MT, Göger YE, Sönmez MG. Is erectile dysfunction related to self-esteem and depression? A prospective case–control study. https://doi.org/10.1111/and.13910. Andrologia. 2021/02/01 2021;53(1):e13910. doi:https://doi.org/10.1111/and.13910

12. Huang S-S, Lin C-H, Chan C-H, Loh E-W, Lan T-H. Newly diagnosed major depressive disorder and the risk of erectile dysfunction: a population-based cohort study in Taiwan. Psychiatry research. 2013;210(2):601-606.

13. Makhlouf A, Kparker A, Niederberger CS. Depression and erectile dysfunction. Urologic Clinics of North America. 2007;34(4):565-574.

14. Goldstein I. The mutually reinforcing triad of depressive symptoms, cardiovascular disease, and erectile dysfunction. The American journal of cardiology. 2000;86(2):41-45.

15. Don BP, Girme YU, Hammond MD. Low Self-Esteem Predicts Indirect Support Seeking and Its Relationship Consequences in Intimate Relationships. Personality and Social Psychology Bulletin. 2019;45(7):1028-1041. doi:10.1177/0146167218802837

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