What doctors wish patients knew about erectile dysfunction

A growing number of men are facing a common yet often unspoken health issue that impacts their quality of life, confidence and relationships: erectile dysfunction (ED). While erectile dysfunction is not often discussed openly, this condition can signal deeper concerns such as heart disease or diabetes. But the narrative is changing. 

With advancements in medical treatments, lifestyle interventions, and a deeper understanding of its psychological and physiological causes, it is important for men to seek help to break the stigma and engage in open conversations about erectile dysfunction to improve both personal and relational well-being.

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Amanda R. Swanton, MD, PhD, a urologist at University of Iowa Health Care, discusses what patients need to know about erectile dysfunction.

University of Iowa Health Care is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

Erectile dysfunction is “the inability to get and maintain an erection rigid enough for satisfactory sexual intercourse,” said Dr. Swanton. As to “what causes it? There are many, many things. It is multifactorial.”

“There’s a vascular component to erectile function that can be related to cardiac function, vascular health, diabetes,” she explained. Then there is a “nerve component to erectile dysfunction that can be impacted by diabetes or neurological disorders. Hormones also play a role.”

Additionally, “there are iatrogenic causes such as medications, surgeries or radiation,” Dr. Swanton said. “Trauma can also play a role such as penile fracture. And then there is also psychological input as well. Anxiety, relationship issues, trauma or poor sexual experiences in the past all can impact sexual function.”

“Most men will experience some degree of erectile dysfunction at some point in their lives,” Dr. Swanton said, explaining that “onset may start in the 40s and 50s, but can be earlier for some men. And it does increase with age.”

“About 40% of men in their 40s experience erectile dysfunction. This rate increases by about 10% for each subsequent decade of life,” she said. “The majority of men after 50 years old are experiencing some degree of erectile dysfunction.”

“Not because every person who is above 70 has erectile dysfunction, but because of a lot of the comorbidities that come along with aging, such as worsening cardiovascular health, diabetes and obesity also increase with age,” Dr. Swanton said. Beyond age, “some of the other big major factors are smoking because that contributes to poor cardiovascular health, coronary artery disease, hypertension, hyperlipidemia, diabetes, obesity—anything that plays into metabolic syndrome.”

“Neurological disorders such as multiple sclerosis or Parkinson’s disease may place you at risk,” she said. Also, “sometimes people will have hormone issues. Low testosterone is something we see in the media a lot these days and testosterone decreases with age. 

“Not that all ED is caused by low testosterone, but especially people who have had prostate cancer treatment and are on an androgen deprivation therapy,” Dr. Swanton said. “Their testosterone levels are incredibly low as a method of cancer control, which can certainly have an impact.”

Prostate cancer, colorectal cancers or radiation to those areas can also be risk factors, she explained. But beyond these conditions, “sometimes people can have penile fractures that aren’t treated and can result in longer lasting erectile dysfunction.”

“Another cause that patients may not often hear about as much is Peyronie’s disease. That is abnormal fibrosis and scar tissue development in the tunica albuginea, which is the covering of the erectile chambers and can often start around the same time as erectile dysfunction.

There are some misconceptions about erectile dysfunction that patients should keep in mind. 

“First, there can be an element of denial,” Dr. Swanton said. For example, “a man may say, ‘Well, this couldn’t be that. Maybe I’m just not in the mood.’ Or the partner will say, ‘Maybe he’s not interested in me anymore.’”

“The one thing I want people to know is that there may be an anatomic or physiologic basis for this disease just like any other,” she said. “It is just like how your knees may not be like they were when you were 20. Well, your erections may not be either and people don’t always recognize that.”

“Most of the time, erectile dysfunction can be diagnosed based on history—increasing difficulty with erections,” Dr. Swanton said. “And usually, the first step is to try oral medications. We talk about other treatment options too, but oral medications are generally easy to take and relatively low risk.”

“If patients are managed with oral medications, that’s fine, but some people may require further workup,” she said. “In my practice, I will do penile ultrasounds to get a sense of the blood flow to the penis and try to get a better idea of what’s going on hemodynamically, though not all physicians offer that.”

“We may also try injection therapy in the office. Injections can be a treatment for erectile dysfunction, but also can—to some degree—can be diagnostic by seeing how people respond to it,” Dr. Swanton said. 

But diagnosis of erectile dysfunction is largely history and “sometimes people will notice that it’s situational that they’re having issues. That is why I will have patients try oral medications because for most people there’s very little harm and if this helps, that’s great,” she said. “If not, we may move on to one of those other treatments such as injections.” 

What doctors wish patients knew

Subscribe for the answers to the latest questions patients are bringing to the exam room.

Subscribe Now

“There are five treatments that are recommended by the American Urological Association for erectile dysfunction. By far the easiest for most patients is the oral phosphodiesterase type 5 [PDE5] inhibitors,” Dr. Swanton said. These are marketed as “Viagra, Cialis and Levitra. The generics would be sildenafil, tadalafil and vardenafil.

“Of those, Viagra and Cialis tend to be cheaper, so they are the medications we typically use in my practice. These might be taken either as an as needed or a once daily,” she added. “As an oral medication, they are systemically absorbed, and some fraction of that medication makes its way to the penis where it exerts its effect.” 

These oral medications “tend to be better for patients with more mild disease. It’s a first step,” Dr. Swanton said, noting that “some patients may try oral medications and that’s all they need for their whole lives.”

“Just because you start oral medications doesn’t mean that the erectile dysfunction will progress,” she said. “However, many people find that eventually they stop working and the reason for that is because erectile dysfunction tends to worsen over time. Patients may then need to move on to something else.”

Another medical option for erectile dysfunction are intraurethral suppositories or gels. “Many compounding pharmacies will make gels that can be instilled through the urethra using a syringe.” The benefit here is that there are no needles. medications.

A third option is injectable medications delivered through the skin in the side of the penis. 

“People typically use a small insulin syringe to instill medication directly into the corpus cavernosum, which is the erectile chamber,” said Dr. Swanton. “This is usually a mixture of three medications colloquially called trimix.”

There are other therapies such as “vacuum erection devices which are external devices that are placed over the penis and use a vacuum to cause penile engorgement,” said Dr. Swanton. “But to keep the blood there, you need to have a tight constriction band, which many people don’t like.

“All of these options have pluses and minuses,” she added. “Another option is a penile prosthesis, which is a surgical device—either inflatable or malleable—that is implanted to provide internal rigidity to the penis.”  

“One thing you can do to mitigate erectile dysfunction is to try to remove offending medications,” Dr. Swanton said. “Certain psychiatric medications or blood-pressure medications can worsen erections. There’s a long list of medications that can impact erections, even medications for benign prostatic hyperplasia and urination can cause it to some extent.

“But I always caution people to make sure that they’re talking about their medications with their primary doctor or psychiatrist before making any changes,” she added.

“Being as healthy as possible is always best,” Dr. Swanton said, noting that conditions such as “metabolic syndrome, obesity, diabetes, high blood pressure and cholesterol can—to some extent—often be mitigated with lifestyle factors.

“Having a more active lifestyle can decrease the risks of some of the conditions that are risk factors for erectile dysfunction,” she added. “Exercise and physical activity promote good cardiovascular health, which decreases the risk of erectile dysfunction.”

It is also important to eat healthy food such as “fruits, vegetables, less ultraprocessed foods and saturated fats. This is better for your overall health and can reduce some of the risk,” Dr. Swanton said, emphasizing that “if you can maximize your health, you’ll maximize your erections.”

“Smoking is a major risk factor for erectile dysfunction specifically, but not only tobacco. Other things like marijuana or alcohol use can also contribute,” she said. “Lifestyle factors certainly play a role and living a healthy lifestyle can promote good erectile function, hopefully maintain erectile function longer, and decrease the severity of erectile dysfunction.”

Erectile dysfunction “certainly can have effects on relationships,” said Dr. Swanton. “For many men, there’s a decrease in self-confidence. This can lead them to be depressed or less likely to initiate sexual activity because they get frustrated when they’re not able to perform.

“Sometimes this can cause the partner to feel hurt and feel like there is a lack of attraction,” she added. “So, there can be these relationship signals that aren’t necessarily true, rather this is an underlying disease.”

Additionally, “it can lead to resentment, and you can have problems with intimacy or connecting with the partner,” Dr. Swanton said. That is why “understanding that there is a disease present and then being able to communicate about it is important. It’s very helpful for the male patients in my practice to have an understanding partner that are sensitive to these issues; it does affect both people.”

“If they’re having trouble getting on the same page or just want a third party, either partner individually or partners together can go see a sex therapist to talk through some of these things,” she said.

“The outcome, what the end goal is, depends on the person,” Dr. Swanton said, noting that “different treatments are for different people and that just depends on their priorities. 

“Some people are needle phobic—they don’t want to do injections. Some people are not very frequently active and just decide it’s not worth it for them. But all those decisions are very personal,” she added. “I encourage all patients to involve their partners in those conversations to keep communication open. If possible, I encourage them to have their partners come to the appointments so they can hear all the same information.”

“Erectile issues are something that men should bring up if they’re concerned about it,” Dr. Swanton said. “Many men won’t bring it up unless they’re asked, so it would be great if more physicians asked about it directly as well.”

“In our cancer patients that we see in urology, we try to make sure that somebody is asking them these questions because many patients won’t bring it up or don’t know to bring it up,” she said. “There’s a lot of shame and sometimes denial that goes along with this.”

“I encourage patients to bring up any erectile concerns because there are treatment options. Patients may be less familiar with some of the options, but they exist and the only way to get them to the right place would be to talk about it with their physician,” Dr. Swanton said.