Erectile dysfunction (ED) refers to the persistent difficulty in achieving or maintaining an erection sufficient for satisfying sexual activity. It can be temporary or chronic, mild or severe. Some individuals may find it difficult to get an erection at all, while others may achieve one but struggle to maintain it.

Although ED becomes more common with age, it is not an inevitable part of aging. Research shows that about 5% of men experience complete ED by age 40, with this number rising to 30–40% among men over 80.

Diagnosing ED is important not just for sexual well-being but also because it may point to underlying health issues. Medical professionals, particularly urologists and primary care physicians, evaluate ED by assessing sexual health history, physical health, and mental well-being.

Medical and Sexual History

Erections are a result of increased blood flow to the penis. When this process is interrupted—by lifestyle choices or health conditions—ED can develop. A comprehensive look at your lifestyle, habits, and overall health helps pinpoint potential causes.

Common contributors to ED include:

  • Tobacco and alcohol use

  • Illicit drug use

  • Obesity

  • Type 2 diabetes

  • Cardiovascular conditions

Other risk factors:

  • Lack of physical activity

  • High blood pressure or atherosclerosis

  • Kidney disease

  • Multiple sclerosis

  • Peyronie's disease (penile curvature)

  • Past pelvic surgeries or trauma

  • Side effects from certain medications

  • Psychological issues such as stress, low self-esteem, and anxiety

Your provider will also explore your sex life by asking questions like:

  • How confident are you in your ability to get and keep an erection?

  • Do you have morning erections?

  • Are you satisfied with your sexual performance?

  • Are you able to orgasm?

These insights help differentiate between physical and psychological causes of ED.

Physical Examination

A physical examination assesses potential physical causes. Your healthcare provider may:

  • Test sensation in the penis to evaluate nerve health

  • Check for curvature or discoloration that could indicate Peyronie’s disease

  • Monitor blood pressure and heart rate

  • Look for signs of hormonal imbalance, such as breast enlargement or reduced body hair

Psychological Assessment

Mental health plays a critical role in erectile function. Emotional conditions like depression and anxiety can directly impact performance and desire. In fact, ED and mental health issues often occur together.

A provider may use validated tools such as the International Index of Erectile Function (IIEF-5) to assess psychological influences. These assessments provide context to understand whether ED is more likely physical or psychological in origin.

Laboratory and Clinical Testing

Certain medical conditions can affect hormone levels, blood flow, or nerve signals—contributing to ED. Blood tests may be ordered to check for:

  • Fasting blood sugar: High levels may indicate diabetes.

  • Testosterone: Low testosterone may result in decreased libido and erectile problems.

  • Lipid panel: Elevated cholesterol and triglycerides are risk factors for vascular issues that may impact erections.

Imaging

In some cases, providers may use imaging to evaluate blood flow to the penis. A common test is the color Doppler ultrasound, which uses sound waves to assess circulation.

During this test, a medication may be injected into the penis to induce an erection. Sometimes, a dye is used to make blood flow more visible on the ultrasound.

Additional Testing

For more detailed evaluation, your provider might use:

  • Nocturnal penile tumescence (NPT) test: This measures erections that occur during sleep, which can help differentiate physical versus psychological causes.

  • Intracavernosal injection test: A medication is injected into the penis, and the resulting erection is monitored for quality and duration.

These tests provide a clearer picture of how well your erectile system is functioning in real time.

A Quick Review

Erectile dysfunction is a complex condition influenced by physical, psychological, and lifestyle factors. While it becomes more common with age, it's not an inevitable part of aging and often signals other health concerns.

Diagnosis involves a mix of history-taking, physical examination, mental health assessment, and specific tests. Addressing ED early can improve quality of life and potentially uncover underlying health issues.