Erectile dysfunction (ED) is an inability to achieve or maintain an erection during sex or with sexual stimulation. It can affect people at any age but becomes more common as you age.

ED affects about 9% of people assigned male at birth between 40 and 44 and up to 56% of those older than 65. Though individual results vary, ED is generally treatable.

Causes of ED include smoking or alcohol use, stress, and certain diseases and disorders. It is treated by primary care physicians, urologists (urinary system specialists), and/or therapists.

Prescribed medications are often the first line of treatment for erectile dysfunction. They work to promote blood flow to the penis, which can address symptoms of ED, including maintaining an erection. These include:

Viagra

Viagra (sildenafil) was the first prescription drug approved by the United States Food and Drug Administration (FDA) for ED. It is an oral phosphodiesterase-5 (PDE-5) inhibitor. These medications relax the cavernosal smooth muscle (the tissue that causes erections), stimulating blood flow to support an erection.

Viagra takes about 30-60 minutes to work. It is also recommended that it’s taken on an empty stomach to help its effectiveness. Common side effects include headache, flushing in the face, dyspepsia (chronic indigestion), impaired vision, congestion, muscle pain, dizziness, and rash.

Cialis

Another PDE-5 inhibitor, Cialis, begins to work 15-45 minutes after taking the drug. Cialis side effects include headache, indigestion, back pain, myalgia (muscle, ligament, or joint pain), nasal congestion, flushing, and limb pain.

Levitra

Like Viagra and Cialis, Levitra is an oral medication that inhibits PDE-5. It typically begins to work about 15-30 minutes after taking it. It also comes in different strengths.

Possible side effects include headache, flushed skin, nasal congestion, indigestion, sinus infection, flu-like symptoms, dizziness, nausea, and back pain.

Stendra

Like other PDE-5 inhibitors, Stendra begins working within 30 minutes. Side effects are similar to other PDE-5 inhibitors, including headache, flushed skin, nasal congestion, nasopharyngitis (nasal and throat infection), and back pain.

Testosterone

Low testosterone levels, a condition known as hypogonadism, can contribute to ED. Therefore, testosterone replacement therapy may be recommended. This treatment can be given through injections, pills, topical gels, or implants.

Testosterone therapy comes with risks, including acne, mood changes, and an increased risk of certain cancers.

Intraurethral Prostaglandin E1

Known as MUSE, prostaglandin E1 is delivered directly to the urethra, the tube where urine exits your body. MUSE is a rice grain-sized pellet of medication inserted into your urethral opening using an applicator device. The pellet dissolves and helps with blood flow.

Research has found MUSE to be 50-65% successful. Common side effects include burning in the urethra and inconsistent effectiveness.

Intracavernosal Injection

When PDE-5 inhibitors do not work, injections are another option. They include Caverject (prostaglandin E1), Pavacot (papaverine), Regitine (phentolamine), and AtroPen (atropine). Trimix—a mixture of Caverject, Pavacot, and Regitine—is available at some compounding pharmacies in varying strengths.

Intracavernosal injections generally begin working within 45 minutes to an hour. A potential side effect is pain in the penis after injection.

Though a great deal of supplements or products are advertised as helping with ED, it is important to be careful and to check what you are getting. Over-the-counter (OTC) products known to be effective for ED include Eroxon and L-arginine.

Eroxon

Eroxon (glyceryl trinitrate topical gel) is the only OTC ED product recommended by the FDA. This gel is applied directly to the penis before sex or sexual activity. It stimulates blood flow, which helps support an erection.

Studies found Eroxon to be 75% effective within 20 minutes after application. The response time is similar to oral PRE-5 inhibitors. More research is needed to confirm these results.

L-Arginine

There is some evidence that L-arginine, an amino acid, can help enhance sexual function.

Regularly taking L-arginine may raise levels of nitric oxide synthase, an enzyme that dilates blood vessels. This may, in turn, improve your sexual function. In a review of L-arginine for mild to moderate ED, several studies found the supplements were effective.

Surgeries and Procedures

A variety of surgeries and other approaches may be used to treat severe and more difficult-to-manage cases of erectile dysfunction. These include:

• Vacuum devices: These devices use a vacuum pump to draw blood into the penis, creating an erection. Some people maintain the erection by placing a constriction band at the base of their penis. While effective in 70-80% of cases, potential side effects include numbness, bruising, and discomfort.
• Low-intensity shock wave therapy: This newer approach uses mild electrical pulses to promote blood vessel growth and improve circulation. Early studies suggest a 40% success rate over 30 months, but further research is needed.
• Penile revascularization surgery: This procedure is usually reserved for younger individuals who have had pelvic injuries that affect blood flow to the penis. The surgery involves redirecting veins to improve circulation. However, complications such as loss of sensation, pain, and reduced penile length can occur. Therefore, this procedure is not common.
• Penile prosthesis: This surgical option is typically considered for severe ED that does not respond to other treatments. A prosthetic device is inserted into the penis, allowing the individual to control erections manually. There are two types: a semi-rigid device and an inflatable implant. Potential risks include infection, mechanical failure, and discomfort.

Erectile dysfunction can both cause and be caused by anxiety and depression. Working with a mental health counselor or therapist can help you identify the causes and lower anxiety and stress surrounding sex.

Some people work with their partner and a therapist in a couples setting. In sessions with your partner and therapist, you work to develop strategies to address any mental causes and symptoms of ED. 

You can sometimes manage erectile dysfunction by changing lifestyle factors that raise your risk. Depending on the case, strategies can include:

• Avoid or quit smoking, vaping, tobacco use, and illicit drug use
• Reduce or stop alcohol consumption, especially when planning on sexual activity
• Manage weight through dietary changes and exercise; excess weight and obesity are risk factors for ED
• Manage diabetes, high blood pressure, or mental health conditions
• Get exercise; increased physical activity reduces ED risk

While erectile dysfunction is not fatal, it can have an impact on your mental health and quality of life. In a study of people ages 18-60 assigned male at birth who had ED, 38.1% reported anxiety and about 65% had depression. ED can also affect partners, causing stress in relationships.

Erectile dysfunction can be an early warning sign of heart disease, so it’s important to treat ED as a possible sign of cardiovascular disease. Some ED medications, like Viagra, might have benefits that can help protect heart health.

Current therapies are highly effective in managing ED. For instance, researchers found oral PDE-5 inhibitors like Viagra to have a 76% success rate. With the currently available treatments, ED can be managed in most cases. 

There is no denying that ED can be frustrating, and it can have an impact on your mental health. It’s important to remember that this issue is common and that you are not alone. It is also important to remember that there’s a lot you can do to manage life with this condition and find support.

If you experience ED, seek diagnosis and treatment with a healthcare provider—typically a primary care physician or urologist. If you are taking PDE-5 inhibitors, get emergency help if you have a painful erection that lasts 2-4 hours.

It helps to be open and communicate with your partner about your condition. Joining a support group or online social media community may also help. Advocacy organizations, such as the American Urological Association or the American Association of Marriage and Family Therapy, can provide helpful information and support.