When to get it checked
Occasional episodes happen to every man, at any age, and are usually linked to fatigue, alcohol, anxiety or a particular moment in life. They are not erectile dysfunction.
An evaluation makes sense when the difficulty keeps happening and has lasted for a few months, or when there has been a clear change from what was normal for you. There is no age at which the difficulty becomes "normal" and should be accepted without looking into it. What does exist is a higher frequency as men get older, and that is not the same thing.
What causes it
An erection depends on blood vessels, nerves, hormones and emotional state all working together. There is rarely a single cause.
- Vascular
- The most common cause from middle age onward. The penile arteries are narrow and are often the first to show signs of circulatory problems. That is why erectile dysfunction can be the first sign of a cardiovascular problem that has not yet caused any other symptoms, and it is the reason the evaluation includes blood pressure, blood glucose and a lipid profile.
- Hormonal
- Low testosterone and thyroid or prolactin abnormalities.
- Neurological
- Long-standing diabetes, previous pelvic surgery, spinal cord injury.
- Medication-related
- Blood pressure medications, antidepressants and other drugs taken long term have known effects on erections. There is often an alternative.
- Psychogenic
- Performance anxiety, depression, relationship issues. Common in younger men, and almost always combined with some physical component rather than occurring on its own.
How it is diagnosed
The consultation starts with your history: how long it has been going on, in which situations, whether the change was sudden or gradual, and whether you still have nighttime and morning erections. That last point helps tell a physical cause from a psychogenic one.
From there, the next steps are laboratory tests (hormonal and metabolic) and, when indicated, a penile Doppler ultrasound with a drug-induced erection, a test I also perform. It assesses how the blood vessels of the penis respond under controlled conditions. The goal is not to confirm that there is a problem. You already know that. The goal is to identify the mechanism, because the right treatment depends on it.
Available treatments and what each one can do
- Lifestyle changes and risk-factor control
- Physical activity, keeping blood pressure and blood sugar under control, cutting back on alcohol and quitting smoking have a real, measurable effect on erectile function. This is the foundation of any treatment, not generic advice.
- Oral medications (PDE5 inhibitors)
- These are the pills popularly known as the "little blue pill." They are effective and safe for most men, but they do not work for everyone: up to 50% of patients may not get a satisfactory response, and that proportion is higher when there is a significant vascular or neurological component. They require a prescription and a medical evaluation, especially if you take nitrates.
- Intracavernosal injection therapy
- Medication injected directly into the erectile tissue of the penis (the corpus cavernosum), used when oral medications do not work or cannot be used. It is highly effective, with success rates above 85%, even in men who did not respond to the pills. However, practical and psychological barriers lead many patients to give up before they ever try it. I have published research on this topic.
- Low-intensity shockwave therapy
- The evidence is still being established. Results vary from patient to patient and are not permanent. It may be an option in selected cases, but it is not the definitive treatment that commercial advertising often suggests.
- Penile prosthesis
- Indicated when the treatments above have not worked. Of all the available options, it has the highest satisfaction rate. It is also irreversible: the implant replaces the erectile tissue, and any remaining natural erections will not come back if the prosthesis is ever removed. That is why it is a decision made after the other options, not before them.
What follow-up looks like
The first treatment chosen is not always the final one. Adjusting the dose, switching to a different class of medication and reassessing are all part of the process. The initial evaluation and follow-up visits can be done by telemedicine.
Frequently asked questions
Can this be cured, or will I need medication forever?
It depends on the cause. When there is a reversible factor, whether hormonal, medication-related or lifestyle-related, treatment may be temporary. When the cause is established vascular disease, it usually means ongoing management rather than a treatment with an end date. That can only be answered after a proper evaluation.
Are erection pills bad for the heart?
PDE5 inhibitors are considered safe from a cardiovascular standpoint for most patients, including many with stable heart disease. The key contraindication is taking them together with nitrates. If you have heart disease, whether they are right for you should be assessed individually.
Can I take these medications if I have high blood pressure or diabetes?
In most cases, yes. In fact, these are the patients who most often have this complaint. The evaluation checks for interactions with what you already take and how stable your condition is.
Does shockwave therapy really work?
There is evidence of benefit in selected cases, but it is still being established. Results vary widely from patient to patient and are not permanent. It cannot replace looking for the cause.
At what age does this become normal?
At no age. It becomes more common as men get older, but that does not mean the difficulty should be accepted without an evaluation at any stage of life.
