What Causes Erectile Dysfunction? A Urologist Explains

An increase in ads for Viagra and similar erection-inducing medications has gotten more men thinking about the dreaded day when their penis may malfunction. Urologists have seen the impact first hand, with more and more men in their thirties and forties coming into their offices concerned about erectile dysfunction, or ED. The influx has made it difficult for doctors to determine if ED is on the rise or if more men are seeking out help because it’s less stigmatized. So now no one really knows how many men actually have ED — or how many otherwise healthy men just fear having it.

It doesn’t help that ED can manifest in so many different ways.

“Erectile dysfunction is just defined as an inability to obtain or maintain an erection satisfactory for intercourse,” says urologist James Rosoff, M.D. “It could even be drinking a lot of alcohol or being nervous about their first time with a new partner.”

Simply put, a young guy who cannot get it up with his new girlfriend because he drank too much and an older man who cannot get an erection without penile implant both technically have erectile dysfunction, but there’s a vast difference between the types. Organic ED involves a specific physiological cause like high blood pressure or certain medications that treat depression, hypertension, and prostate cancer. Psychogenic ED, in contrast, does not happen all the time, and men often can still manage to get nocturnal erections as well.

This wide range shows up in the research. Depending on what study, prevalence rates of ED are anywhere from 3% to 76.5%.

Rosoff cannot say for sure if it’s on the rise, but research shows the use of medication certainly is. Since Viagra was approved by the FDA in 1998, prescriptions for it have by increased 312% for men between the ages of 18 to 45. It’s been the fastest-growing drug to reach $1 billion in annual sales to date. To be fair, this could be more a reflection of effective marketing exploiting male insecurities than increased prevalence. These rates are muddied further by individual study design; although some research is based on clinical data, other studies rely on self-reported surveys.

“Men are notorious for underestimating their sexual difficulties in self-report surveys. When speaking to a doctor, however, they are more likely to be truthful,” says clinical psychologist Daniel Sher.

Age is another important consideration. Although men 50 and older are more likely to experience organic ED, younger men tend to be more prone to psychogenic ED — though there’s plenty of overlap between both camps.

Likewise, a decline in testosterone as a result of fatherhood and aging, along with the stress and sleep deprivation that comes with raising children, may play a role in dads, but not necessarily. Rosoff notes that there are plenty of guys with low testosterone who have healthy erections and plenty of guys with higher testosterone levels who struggle to maintain them.

ED in younger men might also be a result of weight gain and smoking, which can be resolved with healthy lifestyle changes.

But beyond that, the biggest cause of erectile dysfunction for men in their thirties and early forties appears to be worrying about erectile dysfunction. “The strongest anti-erection agent is adrenaline. So if you get anxious and adrenaline is released, that’s been known to cause your erection to go away,” Rosoff warns. “That comes evolutionarily from our fight or flight response. If you need to run away from a predator, your energy needs to be focused on that and not procreating.”

Still, it’s not practical or responsible to suggest that men should stop worrying about their erections. ED has a significant and negative impact on men’s physical and mental health, as well as their relationships and overall well-being. Men with ED experience higher rates of depression, lower self-esteem, and higher rates of anxiety. A new study of over 52,000 men worldwide found that ED was linked with lower productivity at work and lower quality of life. ED can also be a symptom of underlying heart problems, so if sexual anxieties are what get men to the doctor sooner than later, this is mostly upside.

But when men worry about ED to a point where it becomes a self-fulfilling prophecy, then they’re kind of shooting themselves in the dick. So try not to overthink it and become a statistic. Those are messy enough without another guy contributing.