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Clinical Subject Page

Erectile Dysfunction (ED)

Erectile Dysfunction (ED) is the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity. It is a common condition and may result from vascular, neurological, hormonal, psychological, or medication-related causes

Also called

Impotence — older term, now less preferred

ICD-10

N52.9

Specialty

Urology

Onset

Chronic

Reviewed

August 2026
On This Page

Overview

-Normal erection requires coordinated:

  • Arterial blood flow
  • Relaxation of penile smooth muscle
  • Intact neurological pathways
  • Adequate hormonal function
  • Appropriate psychological stimulation

 

-Erectile Dysfunction (ED) may be:

  • Organic: vascular, neurological, hormonal, anatomical, or medication-related
  • Psychogenic: primarily associated with psychological factors
  • Mixed: involving both organic and psychological factors

Etiology & Risk Factors

-Etiology

Common causes include:

  • Vascular disease
  • Diabetes mellitus
  • Neurological disorders
  • Hypogonadism
  • Psychological factors
  • Medication adverse effects
  • Pelvic surgery or trauma

 

-Risk Factors

  • Increasing age
  • Diabetes mellitus
  • Hypertension
  • Smoking
  • Dyslipidemia
  • Obesity
  • Cardiovascular disease

Pathophysiology

Sexual stimulation → neural nitric oxide release → increased cyclic guanosine monophosphate (cGMP) → relaxation of cavernosal smooth muscle → increased arterial blood flow → venous compression → erection

Vascular, neurological, hormonal, psychological, or medication-related dysfunction → impaired erectile response → Erectile Dysfunction (ED)

Clinical Presentation

–Symptoms

  • Difficulty achieving an erection
  • Difficulty maintaining an erection
  • Reduced rigidity of erections
  • Reduced spontaneous or morning erections
  • Reduced sexual confidence
  • Associated reduced libido in hormonal or psychological disorders

 

-Signs:

  • Physical examination may be normal.

    Relevant findings may include:

    • Reduced peripheral pulses
    • Features of vascular disease
    • Penile deformity
    • Testicular abnormalities
    • Features suggesting testosterone deficiency
    • Neurological abnormalities
Erectile Dysfunction (ED) Overview
Erectile Dysfunction (ED) Overview

History Taking

-Ask about:

  • Onset and duration
  • Sudden or gradual onset
  • Ability to achieve versus maintain erections
  • Presence of morning or spontaneous erections
  • Libido
  • Ejaculatory function
  • Relationship or psychological stress
  • Symptoms of depression or anxiety
  • Diabetes mellitus
  • Hypertension and cardiovascular disease
  • Neurological disease

Physical Examination

-General Examination

  • Blood pressure
  • Body habitus
  • Signs of cardiovascular disease
  • Features suggesting hormonal abnormalities

 

-System-Specific Examination:

  • Peripheral vascular examination
  • Focused neurological examination when indicated
  • Examination of the penis for deformity
  • Testicular examination when clinically indicated

Investigations

-Biochemistry / Specific Tests

Evaluate according to suspected cause:

  • Fasting glucose or glycated hemoglobin (HbA1c)

  • Lipid profile

  • Morning total testosterone

  • Additional hormonal testing when testosterone deficiency is suspected

  • Serum prolactin when clinically indicated

 

-Imaging

Not routinely required.

Penile Doppler ultrasound may be considered when a vascular cause is suspected or before selected procedural treatment.

 

-Special / Confirmatory Tests

There is no single confirmatory laboratory test for Erectile Dysfunction (ED).

Validated questionnaires, such as the International Index of Erectile Function (IIEF), can assess severity and response to treatment.

Diagnosis

-Diagnosis is primarily clinical and based on a persistent difficulty achieving or maintaining an erection sufficient for satisfactory sexual activity.

Assessment should determine:

  • Severity and duration
  • Organic versus psychogenic features
  • Medication-related causes
  • Cardiovascular risk
  • Hormonal abnormalities when suspected
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Management

1. Definitive Treatment

Treat the underlying cause whenever possible:

  • Improve cardiovascular risk factors

  • Optimize diabetes and hypertension management

  • Treat testosterone deficiency when confirmed and appropriate

  • Address psychological or relationship factors

  • Review medications contributing to ED

 

2. Medical Treatment

Phosphodiesterase type 5 (PDE5) inhibitors are first-line pharmacological treatment for many patients.

Examples include:

  • Sildenafil

  • Tadalafil

  • Vardenafil

  • Avanafil

Important alternatives for selected patients include:

  • Intracavernosal injections

  • Intraurethral therapy

 

-PDE5 inhibitors must not be combined with nitrates because of the risk of severe hypotension.

 

3. Surgical / Procedural Treatment

For refractory cases:

  • Vacuum erection devices

  • Penile prosthesis implantation

Vascular surgery is rarely used and is limited to selected cases.

 

4. Supportive Management

  • Smoking cessation

  • Regular physical activity

  • Weight management

  • Control of diabetes, hypertension, and dyslipidemia

Complications

  • Psychological distress
  • Anxiety
  • Depression
  • Relationship difficulties
  • Reduced quality of life
  • Reduced sexual confidence
  • Adverse effects of treatment

Prognosis

The prognosis depends on the underlying cause. Many cases improve with lifestyle modification, treatment of underlying disease, psychological support, and appropriate medical therapy. Erectile Dysfunction (ED) caused by reversible factors may improve substantially, while severe vascular or neurological disease may require long-term treatment

Key Points / Clinical Pearls

  • Erectile Dysfunction (ED) is the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity.
  • It may be organic, psychogenic, or mixed.
  • Vascular disease and diabetes mellitus are major organic causes.
  • ED can be an early marker of cardiovascular disease.
  • Reduced morning erections may suggest an organic cause.
  • Situational ED with preserved spontaneous erections may suggest a psychogenic component.
  • History is the most important part of assessment.
  • Physical examination should focus on vascular, neurological, hormonal, and genital abnormalities.
  • Investigations should identify reversible causes and cardiovascular risk factors.
  • Morning testosterone testing is appropriate when testosterone deficiency is suspected.
  • PDE5 inhibitors are first-line drug treatment for many patients.
  • PDE5 inhibitors must not be used with nitrates.