What to Do About Erectile Dysfunction

Erectile dysfunction is more common than one might think. More than half of men over 40 will experience some kind of erectile problem, and the prevalence increases with age (though men in their 20s and 30s can be affected, too).

The experience can have a devastating effect on a man’s well-being. Yet a shocking number of men don’t seek help. One industry survey suggests that just 51 percent of men with erectile dysfunction had discussed the issue with their doctor, and even fewer had spoken to their own partners about it.

There is “not a medical condition that I’m aware of that affects more men’s lives,” said Dr. Mohit Khera, a urologist and the president of the Sexual Medicine Society of North America.

But there are effective treatments, he added, beyond well-known medications like Viagra. These can include vacuum pumps, injections, implants, lifestyle modifications, testosterone-replacement therapy and sex therapy. Some combination of these options, experts said, almost always improve erections, even in the most severe cases.

However, before men go anywhere near a pill or pump (or the “natural” male supplements commonly sold at gas stations), they should get a health exam to understand the causes of the dysfunction, which might point to a more serious health issue.

“The penis can be seen as a barometer for the whole health of the person,” said Dr. Rachel Rubin, a urologist and sex medicine specialist in Maryland.

Why Erections Sometimes Fail

When men are aroused, the brain releases chemicals that lead muscles to relax and blood to flow to the penis, causing it to harden. Many factors can cause this process to break down. Clogged arteries and high blood pressure can reduce blood circulation; diseases like multiple sclerosis and Parkinson’s can disrupt neurological pathways; and pelvic trauma from surgeries, radiation therapy or injuries can damage penile tissues.

The frequency and severity of erectile dysfunction can vary widely, too. Some men experience problems periodically, while around 5 percent of men 40 and older have complete erectile dysfunction. Some men may wake up with morning erections, or can achieve them during masturbation, but struggle to stay erect during penetrative sex.

Finding the Right Treatment Plan

There is a “growing appreciation that individuals may have very different expectations” for their erections, said Dr. Petar Bajic, director of men’s health at the Glickman Urological and Kidney Institute in Cleveland. As a result, there’s no clear rule for when men should seek treatment. Some men may hope to have penetrative sex frequently; others may be satisfied with an erection strong enough for masturbation.

“If you are not maintaining an erection satisfactory enough to do what you want with it, then it’s worthwhile to talk to a physician,” Dr. Rubin said.

The first thing to consider is modifying your lifestyle. Obesity, smoking, alcohol and recreational drug use are all known contributors to erectile dysfunction. Dr. Khera said a healthy diet and regular exercise can sometimes improve the strength of erections without any other intervention.

It’s also important to examine possible psychological causes, like stress or depression, especially among younger men. In one study, such “psychogenic” dysfunction accounted for more than 85 percent of cases among men under 40.

Additionally, consider which medications you take. Several prescription drugs are known to contribute to erectile dysfunction, including certain antidepressants and finasteride, a drug that treats enlarged prostates and hair loss in men.

Keeping all these things in mind, physicians and patients can work together to develop a treatment plan that incorporates lifestyle changes and perhaps one or more of the following treatment options.

Oral Medications

There are currently four oral prescription drugs approved by the Food and Drug Administration to treat erectile dysfunction: sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanafil (Stendra). All essentially work by relaxing muscles and dilating blood vessels, allowing more blood to flow. While oral medications are highly effective, they don’t work for roughly a third of patients, typically the most severe cases.

Cheaper, generic versions of Viagra and Cialis make up the bulk of erectile dysfunction prescriptions in the United States. Viagra works better on an empty stomach and lasts for three to four hours, while Cialis must be taken with food and stays in the system up to 36 hours. Smaller doses of Cialis can also be prescribed for daily use.

Telehealth sites like Hims and Roman have become an increasingly common way for men to access oral medications — at least in part because men can skip awkward in-person conversations with their doctors and opt for a package in the mail.

Though prices are often inflated, sourcing medications through these sites can be fine, Dr. Rubin said, as long as men also establish a relationship with a doctor familiar with their medical history. A 2020 study found some direct-to-consumer companies only partly adhere to the American Urological Association’s screening guidelines, meaning underlying physical and mental health contributors can go undetected.

Vacuum Devices

Penile vacuum devices — better known as penis pumps — are a surprisingly effective, noninvasive option as well, particularly for men who find oral medications don’t work for them. The vacuums work by helping to increase blood flow to the penis to achieve an erection, which is then maintained with the aid of a constriction ring placed at the base of the penis and scrotum.

“For about $300, men can have sex whenever they want, for however long they want,” Dr. Khera said, referring to medical grade devices. Though effective and a good solution for some of Dr. Khera’s patients, others find them cumbersome, he said, since they require “a little bit of drama” every time they want to have sex.

Injections

Two drug mixtures, known as “bimix” and “trimix,” also induce erections by improving blood flow. They are administered at home following initial in-office instruction from a doctor. However, patients have to inject them directly into the penis five to 20 minutes before intercourse.

“They’re usually like, ‘Wait, you want me to put what where, now?’” Dr. Rubin said.

But the injections have been safely and effectively used to treat erectile dysfunction since the early 1980s. However, unlike oral medications, they cause erections whether or not a man is aroused.

Testosterone Replacement Therapy

Low testosterone levels can decrease sex drive and lead to weak erections, though this is rarely the sole cause of erectile dysfunction. Over time, the hormone deficiency can cause penile tissues to atrophy, making erections even more difficult. The condition is easily treatable with testosterone replacement therapy, which can also improve the effectiveness of oral medications. But it’s important to work alongside a doctor to monitor the condition.

Implants

Penile implants, which have been around since the 1970s, were the first major treatment for erectile dysfunction. They remain an effective option for men who don’t respond to (or dislike) other treatments. Though the implants require surgery, they have a 93 percent satisfaction rate, according to one study, likely because men can achieve and maintain an erection at will, Dr. Khera said.

Penile implants use inflatable cylinders inserted by a urologist inside the penis. The cylinders are attached to a water-filled pouch that is typically implanted under the abdominal wall. The user presses a small pump device (implanted into the scrotum) to fill the penis with fluid. A release valve on this same device returns the penis to a flaccid state.

Questionable Remedies

So what about those gas station pills and social media ads promising men firmer, longer-lasting erections without a doctor’s visit or prescription drugs?

“Buyer beware,” Dr. Rubin said. These supplements, sometimes called “rhino pills,” are not regulated by the F.D.A., she said, meaning the manufacturers “put whatever they want in them.”

Federal investigations have found the “all-natural” products promised by some of these brands often contain the active ingredients in medications like Viagra and Cialis, sometimes in unhealthy amounts.

Alternative treatments for erectile dysfunction, like amino acids, ginseng and acupuncture, are popular but still lack sufficient evidence to be recommended.

There are several regenerative therapies currently undergoing extensive research, including platelet-rich plasma injections, stem cell therapy and shock wave therapy. Though some have shown promise in early trials, Dr. Khera said, “none of them are ready for prime time yet.”

Addressing Underlying Health and Psychology

If men won’t see a doctor for the sake of their penis, they should do so for their heart. Heart disease is the most common cause of erectile dysfunction, which is often a warning sign of the condition.

In one study, 15 percent of men with recurring erection issues experienced a cardiovascular event, like a heart attack or stroke, within seven years of the problem starting. Erectile dysfunction can also be an early indicator of other serious conditions like diabetes and hypertension.

Addressing these issues through lifestyle modification will not only improve overall health, it may improve erections without other interventions.

There is not “a pill on the planet stronger than diet and exercise,” Dr. Khera said. He led a 2023 meta-analysis that found aerobic exercise was as effective in treating erectile function as oral medications.

Mental health factors — like anxiety, depression, stress and relationship problems — can also drive erection problems. And erection issues, in turn, can cause depression and anxiety in men, said Dr. Daniela Wittman, a sex therapist and professor at the University of Michigan. Left untreated, the conditions can exacerbate one another, leading to performance anxiety or despondency, she added.

Sex therapy, which addresses the psychological and emotional triggers of erectile dysfunction, is often most successful when used alongside oral medications. Regardless of the cause, however, most men could benefit from learning how their “mental and sexual well-being are connected,” she added.

With such a robust toolbox available, Dr. Rubin said, most men don’t have to live with the effects of erectile dysfunction. The difficult part is getting men to walk through her door.

“It’s your job to help me understand what’s going on for you, and the kind of sex you want,” she said. Then “we can figure out the best plan.”

David Dodge is a freelance writer focusing on health, wellness and LGBTQ issues.