Erectile dysfunction (ED) means having trouble getting or keeping an erection firm enough for sex, often enough that it bothers you. It is common, it is medical, and it is treatable. This guide explains what causes it, when it points to a bigger health issue, and what each treatment can and cannot do. If your concern is ejaculating too early rather than erections, see our premature ejaculation guide. For other topics, start from our sexual health guides.
ED is rarely one thing. A review of the condition describes it as involving organic, relational and psychological components, with blood-vessel, nerve, hormonal and medicine-related pathways all playing a part PMID: 27188339. Most men have more than one factor at work, which is why the best plan usually combines a checkup with treatment.
What causes erectile dysfunction
An erection depends on blood flowing into the penis and staying there. That needs healthy arteries, working nerves, adequate hormones and a mind that is not stuck on alarm. A problem anywhere along that chain can cause ED.
Blood flow and blood vessels
Vascular causes are the most important to know about, because ED is strongly associated with cardiovascular disease and metabolic syndrome PMID: 27188339. High blood pressure is a clear example. A meta-analysis of 18 cross-sectional studies with almost 42,000 men found hypertension was associated with a higher risk of ED, even after adjusting for weight, cholesterol, smoking and other lifestyle factors PMID: 29785046. Diabetes, high cholesterol and smoking act on the same blood vessels.
Erectile dysfunction and high blood pressure medicines
Many men worry that their blood pressure tablets are the problem. The evidence is reassuring: a network meta-analysis of randomized trials found no class of blood pressure medicine (ACE inhibitors, ARBs, beta-blockers, calcium channel blockers or thiazide diuretics) made erectile function significantly worse than placebo, although the trials were of limited quality PMID: 33945044. Untreated high blood pressure is itself a risk factor, so do not stop a blood pressure medicine on your own. If you suspect a link, ask your prescriber whether a different option makes sense.
Hormones: erectile dysfunction and testosterone
Low testosterone can reduce erections, and it usually lowers desire too. In placebo-controlled trials pooled in a meta-analysis, testosterone treatment improved erectile function in men with confirmed low testosterone, with larger gains in men with more severe deficiency and smaller gains in men with diabetes or obesity PMID: 28434676. Those results apply to men who are actually deficient. The trial evidence comes from men with low testosterone, so it does not support testosterone as an ED treatment for men with normal levels.
The Endocrine Society guideline recommends diagnosing low testosterone only in men who have symptoms and consistently low levels, measured in a fasting morning blood sample and confirmed with a repeat test PMID: 29562364. Testosterone products are FDA-approved for men with a diagnosed deficiency; the AndroGel label states that safety and efficacy in men with age-related low testosterone have not been established (AndroGel (testosterone) — DailyMed Drug Label). This site does not recommend testosterone outside that diagnosis.
If your ED comes with low energy or low desire, a blood test is a sensible first step. Hone Health LegitScript status not verified sells a finger-prick at-home hormone test that includes total and free testosterone. One low result is not a diagnosis; per the guideline above, it needs confirming with a repeat morning test. Our guide to how low testosterone is diagnosed and treated covers the tests, the causes and the risks of treatment, including to fertility.
Before you treat, test
Check for an underlying cause first
ED with low energy or low desire can signal low testosterone
Erectile dysfunction from medicines, including finasteride
Several common medicines can affect erections:
- Antidepressants. A meta-analysis found that several widely used antidepressants, including sertraline, venlafaxine, citalopram, paroxetine and fluoxetine, caused higher rates of sexual dysfunction (problems with desire, arousal or orgasm, which can include erections) than placebo, while bupropion and mirtazapine did not differ from placebo PMID: 19440080.
- Finasteride and dutasteride. In 15 placebo-controlled hair-loss trials, these 5-alpha reductase inhibitors (finasteride 1 mg is FDA-approved for hair loss; dutasteride is used off-label for it) carried about a 1.6-fold risk of sexual dysfunction; the increase was statistically significant for finasteride but not for dutasteride, which had fewer trials PMID: 30206635. Our sister site covers finasteride side effects in depth.
Never stop a prescribed medicine because of ED without talking to the prescriber first. There is often an alternative.
Erectile dysfunction from anxiety and depression
The mind matters. A review of sexual performance anxiety estimated it affects 9 to 25% of men and contributes to psychogenic ED PMID: 31447414. Depression and ED also travel together: a meta-analysis of 49 publications found depression was associated with higher odds of ED (odds ratio 1.39) and ED with higher odds of depression (odds ratio 2.92); it could not show which causes which, so the authors recommended screening for each in men who have the other PMID: 29960891. Even when ED starts with a physical cause, worry about the next attempt can keep it going. Cognitive behavioural therapy and mindfulness training are recommended for performance anxiety, though controlled studies in sexual performance anxiety are lacking PMID: 31447414.
Erectile dysfunction in young men
ED is not only an older man's problem. In a clinic series of 439 men seeking help for new ED, 26% were 40 or younger, and almost half of those younger men had severe ED. The younger men had fewer other illnesses but smoked and used recreational drugs more often PMID: 23651423. A young man with persistent ED deserves the same assessment as anyone else, not a shrug.
Erectile dysfunction and heart disease: when to see a doctor
This is the most important section of this guide. ED and heart disease share similar risk factors, and ED can appear before heart problems are found PMID: 16414947.
In a JAMA analysis of more than 9,400 men aged 55 and over, men who developed ED had a higher rate of later cardiovascular events after adjusting for age, weight, blood pressure, cholesterol, diabetes and smoking. The authors concluded that ED should prompt investigation of cardiovascular risk factors PMID: 16414947. A meta-analysis of 12 prospective cohort studies (36,744 men) found ED was linked to a 48% higher risk of cardiovascular disease and a 35% higher risk of stroke, probably independent of conventional risk factors PMID: 21920268.
See a clinician if:
- ED has lasted more than a few weeks, or keeps coming back.
- You have never had your blood pressure, cholesterol or blood sugar checked, or it has been a while.
- You also have chest pain, shortness of breath on exertion, or leg pain when walking. Get these checked promptly.
- You have low desire, low energy, or reduced body hair alongside ED.
- ED started after a new medicine.
How erectile dysfunction is diagnosed
Diagnosis is mostly a conversation. A clinician asks how long ED has been present, whether erections happen at other times (for example on waking), what medicines you take, and how your mood and relationship are. A physical exam and blood pressure check follow. Because of the cardiovascular link above, ED should prompt a look at cardiovascular risk factors such as blood pressure, blood sugar and cholesterol PMID: 16414947. A morning testosterone test makes sense when there are symptoms of deficiency PMID: 29562364.
The American Urological Association guideline recommends shared decision-making: men should hear about every treatment that is not ruled out for them, including the more invasive ones, and choose with a full picture of the benefits and burdens PMID: 29746858.
Prescription tablets: the PDE5 inhibitors
Sildenafil (Viagra) and tadalafil (Cialis) are FDA-approved for erectile dysfunction. Both work by blocking the PDE5 enzyme, which helps the blood-vessel relaxation that produces an erection. An expert consensus describes these tablets as the standard of care for ED, although they do not work for every man PMID: 42696760. Neither works without sexual stimulation (Viagra (sildenafil) — DailyMed Drug Label; Cialis (tadalafil) — DailyMed Drug Label).
The main practical difference is timing. The Viagra label says it may be taken from 30 minutes to 4 hours before sex. The Cialis label says an as-needed dose improved erectile function compared with placebo for up to 36 hours, and tadalafil also has a low-dose once-daily option. Generic versions of both are sold, and the molecule matters more than the brand name. Our sildenafil vs tadalafil comparison covers timing, side effects, daily dosing and cost in detail, and our comparison of online ED services covers what Ro, Hone and Lemonaid publish about their prescriptions and prices (Hims's site could not be checked).
These medicines are not safe for everyone. Anyone who uses nitrates for chest pain must not take them, and the safety box below lists the other label warnings.
Over-the-counter erectile dysfunction treatment
Two kinds of ED treatment are sold without a prescription and have real evidence behind them.
Eroxon gel
Eroxon is a non-medicated, alcohol-and-water gel applied to the head of the penis. FDA authorized it in June 2023 as the first over-the-counter gel for erectile dysfunction, for men aged 22 and over. FDA describes it as working through a cooling then warming effect that stimulates nerve endings (FDA Roundup, June 13, 2023; FDA De Novo record DEN220078). It is a medical device, not a drug.
In the open-label pivotal trial summarized in a scoping review (48 men on Eroxon, no placebo group), Eroxon (studied as MED3000) improved erectile function scores by 5.73 points at 24 weeks, above the 4-point threshold considered clinically meaningful. The same review noted that its efficacy relative to first-line treatments remains unclear PMID: 39128025. FDA's decision summary shows that figure is a change from baseline in 48 men using Eroxon in an open-label trial with no placebo group; the trial's tadalafil arm was exploratory and was not used for comparison (FDA decision summary, DEN220078). Read our full Eroxon review, and for the trial design, its limits and the cost per use, our in-depth look at whether Eroxon works.
Vacuum erection devices
A vacuum erection device (VED) is a clear cylinder placed over the penis. A pump removes air, drawing blood in, and a constriction ring at the base holds the erection. FDA classifies these as external penile rigidity devices (Class II, exempt from premarket notification) (FDA product classification LKY).
A 2025 meta-analysis of 18 studies in men with refractory ED, which often had not responded to PDE5 tablets, found about 80% achieved successful intercourse or satisfaction with a VED. Penile bruising was the most common side effect, at about 24% PMID: 40542251. The authors called for large randomized trials to confirm the results. After prostate surgery, a network meta-analysis ranked tadalafil plus a VED among the most effective combinations for recovering erections, though the certainty of evidence was low to very low PMID: 42557727. FDA's labeling guidance says not to use a vacuum pump if you take large quantities of aspirin or other blood thinners (FDA special controls guidance, external penile rigidity devices), and Timm Medical's safety information says men with a bleeding disorder should not use one (Timm Medical Important Safety Information, viewed October 3, 2026); check with a clinician if either applies. See our reviews of the Encore Deluxe and the Timm Medical PTV 3000, and for how to use one safely, use after prostate surgery and Medicare coverage, our guide to vacuum erection devices.
What to avoid: "male enhancement" supplements
FDA warns that many products sold as sexual enhancement supplements or ED treatments are likely to be contaminated with dangerous hidden ingredients, and that its list of contaminated products covers only a fraction of what is on the market (FDA sexual enhancement product notifications). This site does not link to them. For what FDA has found inside these products and what the ingredient trials show, see our guide to male enhancement supplements and FDA warnings.
Eroxon gel
Best For
Men who want a drug-free, non-prescription option they can use on demand
Works In
See the label for timing
Price
$25.97
$6.49 / count
Pros
- ✓FDA De Novo authorization as the first over-the-counter ED gel
- ✓Non-medicated: no active drug ingredient
- ✓Met the 4-point clinically meaningful threshold at 24 weeks in one open-label trial arm of 48 men (no placebo group)
Cons
- ✗Less trial data than prescription PDE5 tablets
- ✗For men aged 22 and over only
- ✗Single-use tubes add up with regular use
Encore Deluxe Vacuum Therapy System
Best For
Men who cannot take or did not respond to PDE5 tablets
Works In
See the device instructions for timing
Price
$125.00
$7.81 / ounce
Pros
- ✓Vacuum devices as a class: successful intercourse or satisfaction in about 80% of men with hard-to-treat ED across 18 studies
- ✓Drug-free and reusable
- ✓Comes with both manual and battery pumps
Cons
- ✗Penile bruising in about a quarter of users
- ✗A learning curve and some preparation time
- ✗Not for men who take large quantities of aspirin or other blood thinners (FDA labeling guidance), or who have a bleeding disorder or bruise easily (maker's safety information)
Timm Medical PTV 3000
Best For
Men who would rather press a button than pump by hand
Works In
See the device instructions for timing
Price
$399.00
$399.00 / count
Pros
- ✓Battery pump needs no hand pumping
- ✓Same device-class evidence as manual vacuum devices
- ✓Drug-free and reusable
Cons
- ✗About three times the price of the Encore Deluxe, which includes both a manual and a battery pump
- ✗Penile bruising in about a quarter of vacuum device users
- ✗The maker says to limit each ring use to 30 minutes, and not to use it with decreased hand strength
- ✗Not for men taking large quantities of aspirin or other blood thinners, or with a bleeding disorder (FDA guidance; maker's safety information)
Amazon prices retrieved from the Amazon Product Advertising API on . Prices and availability are accurate as of that time and may change.
Can erectile dysfunction be reversed with lifestyle changes?
For many men, yes, at least partly. In a two-year randomized trial of 110 obese men with ED, those coached to lose weight and exercise more improved their erectile function scores, while the control group did not; about a third of men in the intervention group reached normal function PMID: 15213209.
The wider evidence points the same way:
- Exercise. A meta-analysis of seven randomized trials found physical activity improved erectile function scores, particularly moderate-to-vigorous aerobic exercise PMID: 27707739.
- Diet and exercise together. A 2026 meta-analysis of 16 randomized trials found diet and exercise programs produced a modest but significant improvement in erectile function, with moderate-certainty evidence PMID: 42143598.
- Stopping smoking. In a trial of 719 smokers with ED, men who reported quitting at six months were more likely to see their ED improve PMID: 20709257.
- Pelvic floor exercises. In a small randomized trial of 55 men with ED, pelvic floor exercises with clinic-based biofeedback improved erectile function scores more than lifestyle advice alone, but the evidence is limited PMID: 15527607. Our guide to Kegel exercises covers how to do them.
Lifestyle changes work slowly and help most when ED is linked to weight, inactivity or smoking. They combine well with any of the treatments above, and they also lower the cardiovascular risk that ED can signal.