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# Erectile dysfunction

Erectile dysfunction is the ongoing inability to get or keep an erection firm enough for sex; it is common and can be an early sign of heart and vessel disease.

Updated 2026-10-30

## Structures involved

Tap one to see what it is and open it in 3D.

- [Corpora cavernosa](https://durgical.com/en/anatomy/corpus-cavernosum-of-penis/)
- [Deep artery of penis](https://durgical.com/en/anatomy/deep-artery-of-penis/)
- [Pelvic plexus and cavernous nerves](https://durgical.com/en/anatomy/inferior-hypogastric-plexus/)
- [Internal pudendal artery](https://durgical.com/en/anatomy/internal-pudendal-artery/)
- [Dorsal veins of penis](https://durgical.com/en/anatomy/deep-dorsal-vein-of-penis-superficial-dorsal-veins-of-penis/)
- [Ischiocavernosus](https://durgical.com/en/anatomy/ischiocavernosus-muscle/)
- [Bulbospongiosus](https://durgical.com/en/anatomy/bulbospongiosus-muscle/)
- [Pudendal nerve](https://durgical.com/en/anatomy/pudendal-nerve/)
- [Prostate](https://durgical.com/en/anatomy/prostate/)

## In biochemistry

- [Nitric oxide synthase (NOS)](https://durgical.com/en/biochemistry/enzymes/nitric-oxide-synthase/)
- [Nitric oxide (NO)](https://durgical.com/en/biochemistry/molecules/nitric-oxide/)

## In physiology

- [Erection and ejaculation](https://durgical.com/en/physiology/erection-and-ejaculation/)

## Why it happens

- [Sympathetic and parasympathetic effects on each organ](https://durgical.com/en/physiology/sympathetic-and-parasympathetic-effects-on-each-organ/)

## What it is

Persistent or recurrent inability to achieve or keep an erection firm enough for satisfactory sexual activity. It is common, often has a vascular cause and can be an early sign of cardiovascular disease.

## Who gets it

Its frequency rises with age and with diabetes, hypertension, obesity, smoking and depression. In a 2020 online survey of 466 men from 17 Latin American countries during the COVID-19 pandemic, 37.55% screened positive for erectile dysfunction (not a representative sample). It is under-reported, so clinicians are encouraged to ask about it.

## Causes

- Vasculogenic (most common): atherosclerosis and endothelial dysfunction
- Neurogenic: diabetes, [spinal cord](https://durgical.com/en/anatomy/spinal-cord/) injury, multiple sclerosis, pelvic surgery that damages the cavernous nerves
- Hormonal: hypogonadism, hyperprolactinaemia, thyroid disease
- Drug-induced: some antihypertensives, antidepressants, antipsychotics, antiandrogens, alcohol and recreational drugs
- Anatomical: Peyronie disease, fibrosis after priapism
- Psychogenic: performance anxiety, depression, relationship problems

## Risk factors

- Older age
- Diabetes mellitus
- Hypertension, dyslipidaemia and cardiovascular disease
- Obesity, metabolic syndrome and physical inactivity
- Smoking and heavy alcohol use
- Radical prostatectomy or pelvic radiotherapy
- Depression and anxiety

## Pathophysiology

Sexual stimulation activates parasympathetic cavernous nerves, which release nitric oxide; cyclic GMP relaxes the smooth muscle of the [corpora cavernosa](https://durgical.com/en/anatomy/corpus-cavernosum-of-penis/), arterial inflow fills the sinusoids, and compression of venules against the tunica albuginea traps blood. Disease of arteries, nerves, smooth muscle or hormones disrupts this; PDE5 normally breaks down cyclic GMP.

## Classification

- Organic (vasculogenic, neurogenic, hormonal, anatomical, drug-induced), psychogenic or mixed
- Severity scored with validated questionnaires such as the IIEF-5

## Symptoms and signs

- Difficulty getting an erection
- Difficulty keeping an erection during sexual activity
- Reduced rigidity
- Preserved morning or nocturnal erections suggest a psychogenic component
- Reduced libido when hypogonadism is present

## Red flags

- Exertional [chest](https://durgical.com/en/anatomy/region/chest/) pain or other symptoms of coronary disease
- Sudden onset with back pain, leg weakness or bladder or bowel symptoms (neurological cause)
- Erection lasting more than four hours after treatment (priapism)
- Use of nitrates (dangerous interaction with PDE5 inhibitors)

## Diagnosis

**Clinical**
Sexual, medical, medication and psychosocial history, with a questionnaire such as the IIEF-5. Exam of the genitals, secondary sexual characteristics, blood pressure and peripheral pulses; cardiovascular risk is assessed.

**Tests**
Fasting glucose or HbA1c, lipid profile and early-morning total testosterone; prolactin, thyroid tests or others when indicated.

**Imaging**
Not routine. Penile duplex Doppler ultrasound after intracavernosal injection of a vasoactive drug in selected cases, such as before surgery or with Peyronie disease.

## Differential diagnosis

- Hypoactive sexual desire
- Ejaculatory or orgasmic disorders
- Peyronie disease
- Hypogonadism
- Depression

## Goal of treatment

Restore satisfactory sexual function and treat underlying causes and cardiovascular risk factors, choosing therapy with the patient and partner.

## Treatment

**Lifestyle**
Weight loss, regular exercise, stopping smoking, moderating alcohol and control of diabetes, hypertension and lipids; review of medicines that may contribute.

**Medical**
Phosphodiesterase-5 (PDE5) inhibitors are first-line oral therapy and are contraindicated with nitrates. Testosterone therapy only for confirmed hypogonadism.

**Conservative**
Psychosexual therapy or counselling, alone or with other treatments, especially when psychological factors are important.

**Procedure**
Vacuum erection devices, intraurethral or intracavernosal vasoactive agents (such as prostaglandin E1 analogues), and low-intensity shockwave therapy in some settings (evidence varies).

**Surgical**
Penile prosthesis (malleable or inflatable) when other options fail or are unsuitable.

## Complications

- Reduced quality of life, anxiety, depression and relationship strain
- Missed or delayed diagnosis of cardiovascular disease or diabetes
- Treatment effects: headache, flushing, hypotension with nitrates, priapism or penile fibrosis with injections
- Prosthesis infection, erosion or mechanical failure

## Prognosis

Most men improve with treatment, though few causes are fully reversible. Psychogenic and lifestyle-related forms respond best; men with diabetes or after radical prostatectomy often need second-line therapy.

## Prevention

- Healthy weight, physical activity and not smoking
- Good control of diabetes, hypertension and lipids
- Nerve-sparing techniques in pelvic surgery when oncologically safe

## Test yourself

Think of the answer, then tap the question to see it.

## Which mediator released by the cavernous nerves starts erection?

Nitric oxide, which raises cyclic GMP and relaxes cavernous smooth muscle.

## Which drug group is an absolute contraindication with PDE5 inhibitors?

Nitrates, because together they can cause severe hypotension.

## Why is erectile dysfunction considered a marker of cardiovascular disease?

It shares endothelial dysfunction and atherosclerosis; penile arteries are small, so symptoms may appear before coronary events.

## What does the persistence of morning erections suggest?

That the vascular and neural pathways work and a psychogenic component is likely.

## Which hormone is measured in the early morning in a man with erectile dysfunction?

Total testosterone, to look for hypogonadism.

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## Related conditions

- [Type 2 diabetes mellitus](https://durgical.com/en/conditions/type-2-diabetes-mellitus/)
- [Arterial hypertension](https://durgical.com/en/conditions/arterial-hypertension/)
- [Atherosclerosis and dyslipidaemia](https://durgical.com/en/conditions/atherosclerosis-and-dyslipidaemia/)
- [Peripheral artery disease](https://durgical.com/en/conditions/peripheral-artery-disease/)
- [Prostate cancer](https://durgical.com/en/conditions/prostate-cancer/)
- [Peyronie disease](https://durgical.com/en/conditions/peyronie-disease/)
- [Priapism](https://durgical.com/en/conditions/priapism/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Erectile Dysfunction](https://www.ncbi.nlm.nih.gov/books/NBK562253/) (StatPearls (NCBI Bookshelf), 2024); [Interaction between the impact of the Coronavirus disease 2019 pandemic and demographic characteristics on sexual/erectile dysfunction in Latin America: cross-sectional study](https://europepmc.org/article/PMC/PMC9060173) (International braz j urol: official journal of the Brazilian Society of Urology, 2022) · adapted, [CC BY 4.0](https://creativecommons.org/licenses/by/4.0/).

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Source: https://durgical.com/en/conditions/erectile-dysfunction/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/erectile-dysfunction/