Overview
The ability to achieve and maintain erections when aroused is a common health issue for many men.[1] While women don’t experience the phenomenon in the same way, inadequate blood flow to female genitalia is also common — and sometimes related to the same phenomena.
Aging is the biggest risk factor for ED, but there are a host of other contributing factors,[2] such as diabetes, vascular disease, low testosterone,[3] and hypothyroidism.[4]
The potential causes of ED generally revolve around vasodilation — the widening of blood vessels — which allows the penis to accommodate more fluid, thus allowing it to become erect. Nitric oxide is a chemical messenger that tells blood vessels to dilate; a breakdown in signaling is a common reason for ED and high blood pressure.
Nitric oxide precursors and substances that lead to greater nitric oxide synthesis are commonly found in drugs and supplements aiming to improve erections. Sex hormones are involved in nitric oxide synthesis, and men with low testosterone are more likely to have ED. Anything that leads to dysfunction in the walls of the blood vessels, such as smoking, inactivity, and excessive body fat, can increase ED risk as well.
Sometimes ED isn’t a breakdown in vasodilation or a hormonal problem but secondary to psychological issues of anxiety and anhedonia — a diminished ability to feel pleasure. In this case, while some libido-enhancing supplements may be useful, the answer may not be found in supplements or dietary modification.
How are erections assessed?
💡 Tip: Talk to your physician
It can be a little uncomfortable speaking with a physician about sex. But if you have or are experiencing some level of ED, you should tell your physician.
ED can be a sign of other health problems, such as blockages in your blood vessels or nerve damage caused by diabetes. If you don't consult a physician, these problems may go unidentified and untreated.
A urologist, who specializes in urinary and sexual issues, is best and can assess ED through a series of medical and sexual history questions. They may also perform a mental health screening and physical exam.
During the exam, your urologist may ask you some of the following questions.
How would you rate your confidence that you can get and keep an erection?
How often is your penis firm enough for intercourse?
How often are you able to maintain an erection during sexual intercourse?
Do you have an erection when you wake up in the morning?
Do you use illegal drugs, drink alcohol, or smoke?
While it can be uncomfortable, the more accurate your answers, the better medical care your physician can provide.
What are the symptoms of erectile dysfunction?
ED can manifest itself in a few different ways, including the following.
The inability to get an erection at all
A partial erection that is insufficient for intercourse or masturbation
An initial erection that is prematurely lost during intercourse or masturbation
An intermittent and inconsistent ability to get or maintain an erection
What affects erections?
💡 Tip: Talk to your partner
Those with ED have reported feeling bad about themselves or shame regarding their condition, which can be a barrier to seeking treatment and enjoying sexual activity.
ED can be a difficult topic for partners to discuss with each other. Couples who do not openly talk to each other are more likely to have problems with sexual intimacy. Likewise, men who have trouble talking about their feelings may be unable to share their sexual concerns with their partners.
If you have trouble communicating, counseling can be very helpful. Finding a way for both you and your partner to express your feelings and desires, and then work on the issues together, can make a big difference.
Supplements
Supplements that have been shown to have a positive effect on ED mostly relate to how they can improve nitric oxide signaling and vasodilation. Some notable supplements include maca, arginine, and cocoa polyphenols.
The table below displays an analysis of human studies and indicates how supplements may affect erections.
Diets & foods
For both men and women, blood flow to sexual organs is one of the major features of arousal, and this is achieved with nitric oxide,[5][6] a chemical that signals blood vessels to widen, or dilate. Sildenafil (Viagra) works by increasing nitric oxide signaling but does not affect nitric oxide synthase (NOS), the enzyme responsible for producing nitric oxide.[7]
The effect of NOS can be enhanced by compounds found in a wide variety of plants,[8] and your body makes nitric oxide from the nitrate in your food or from the amino acid arginine. Some foods and supplements can help with not just male erections but also clitoral and vaginal blood flow.[6]
| NITRATE CONTENT | VEGETABLES |
|---|---|
Very high | Arugula/rocket, collard greens, dill, turnip greens |
High | Beetroot, bok choy, celeriac, celery, kale, kohlrabi, lettuce, mustard greens, parsley, radishes, rhubarb, spinach, swiss chard, turnips, watercress |
Moderate | Broccoli, cabbage, cauliflower, endive, Savoy cabbage |
Low | Chicory, eggplant, fennel, green beans, green onions, leeks, pumpkin/squash |
Very low | Artichokes, asparagus, broad beans, brussels sprouts, carrots, cucumbers, dried beans, garlic, lima beans, maize, mushrooms, onions, peas, peppers, sweet potatoes, tomatoes, white potatoes |
References: Jackson et al. Nutr Res Rev. 2017.[9] ● Hord et al. Am J Clin Nutr. 2009.[10] ● Jones. Sports Med. 2014.[11]
Lifestyle
Nicotine — cigarette smoking in particular — can reduce arousal in both men and women[12][13][14][15] For men specifically, regular cigarette smoking is a risk factor for ED[16] and may reduce fertility.[17]
Lifestyle activities that help prevent the narrowing of blood vessels all over the body, including those that supply blood to the penis, can be important for maintaining general as well as erectile health. In addition to smoking, excessive alcohol intake, lack of sleep, excessive body fat, poor mental health, and inadequate exercise can all contribute to ED.
Age
Age is a strong predictor of ED. The condition affects 18% of men over age 20 in the United States, with roughly 45% of men over 20 and 50% of men 40–70 reporting at least some issues with ED.[2]
Hormones
The sex hormones estrogen and testosterone help orchestrate nitric oxide production in the genitals.[6][18] Low testosterone is a well-known risk factor for ED. A blood test is used to assess your levels of testosterone and its components (free T, bound T, etc.). You can learn about how testosterone is assessed here.
The path to solving your sexual dysfunction may start with addressing a root cause that’s a step or two removed from the hormonal deficiency itself, such as obesity or decreased insulin sensitivity.[19]
If you don’t know where to start, talk to an endocrinologist.
Medical conditions
Most erection problems have a contributing physical cause. Below are some common medical conditions that may play a role in ED.
Clogged arteries (atherosclerosis)
Heart or thyroid conditions
High blood pressure
Low testosterone levels, which can also reduce libido
Nerve damage
Nervous system disorders (e.g., multiple sclerosis, Parkinson’s disease)
Spinal cord injury
Mental health and relationship problems can also contribute to ED. Depression, stress, and anxiety all play a role.
Drugs
Phosphodiesterase type 5 inhibitors (PDE-5) inhibitors, such as sildenafil (Viagra, Revatio), are the main pharmaceutical agent used to treat ED.[20] However, headaches, indigestion, abdominal pain, and flushing are commonly reported adverse effects of the drug.[20]
Unusually long-lasting erections, called priapism, may also occur. If an erection lasts 4 hours or longer, contact a health care professional immediately.
Other common oral drug treatments include:
Avanafil (Stendra)
Tadalafil (Adcirca, Cialis)
Vardenafil (Levitra, Staxyn)
Keep in mind that these are intended to cause erections only when you are aroused. The effect of the drugs typically occurs in 15–45 minutes and can last for several hours.
Other ED medications include drugs that are injected into the penis or tablets that can be placed into the opening of the penis (e.g., alprostadil urogenital (Caverject, Caverject Impulse, Edex, Muse)). With this treatment, an erection may occur within 5–20 minutes (depending on which delivery method is used) and last 30–60 minutes.
If you have heart disease, discuss the use of these drugs with your physician. Some ED drugs are also contraindicated for men who take nitrates.
Furthermore, these drugs don’t work for some people,[21] so there’s room for other possible therapies to improve ED.
Some drugs may cause erectile problems as well, notably:
Antidepressants
Cocaine
Blood pressure medicines (particularly beta-blockers)
Heart medicines (e.g., digoxin)
Sleeping pills
Some peptic ulcer medicines
A comprehensive list of drugs that may cause erection problems can be viewed here.
