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Erectile dysfunction: The Optum Store Guide

15 minute read
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Erectile dysfunction can be a short-lived issue or an indicator of other health concerns. Understand the causes and how it can be treated — and how to get back on track. 

Jennifer Howze

By Jennifer Howze

Many men take getting an erection for granted. When you start the car, you expect the engine to begin humming automatically. But when things aren’t working the way they’re expected to, it can be worrying and frustrating. Erectile dysfunction (ED), or impotence, is not uncommon: It affects around 30 million men in the U.S., according to the National Institute of Diabetes and Digestive and Kidney Diseases. And while people often associate it with older men, it can happen at any age. Still, it does become more common at older ages. According to Johns Hopkins Medicine, more than 50% of men ages 40 to 70 experience ED at some point.

In fact, you may be surprised to learn that ED is not a normal part of aging. While ED is more common in older men, that’s mostly because older men are more likely to have some of the health issues that are linked to ED, such as high cholesterol, heart disease or diabetes.

Having problems getting or keeping an erection from time to time isn’t necessarily a cause for concern. But a recurring problem can point to underlying health issues. Thankfully, we’ve moved into a time where it’s easier to talk about ED, and there are a range of treatments available. Even so, some men find that it causes stress and anxiety — about sexual performance, wider health implications and how it can affect their relationships.

But there is help. By addressing ED early and getting advice and treatment from your doctor, you can improve not only your sex life but also your overall health and well-being. (If you’re ready for an ED consultation with a trusted professional, licensed doctors from our network are available for an assessment. Your first consult is free.)

What is erectile dysfunction?

ED is the inability to develop or maintain an erection that’s firm enough to have sex. It includes not being able to:

  • Keep an erection long enough for satisfying sex
  • Get an erection every time you want to
  • Get an erection at all

What causes erectile dysfunction?

At the most basic physical level, ED is a problem with blood flow to the penis. There’s simply not enough blood rushing into the penis and staying there to keep it erect. But there’s more to an erection than just the circulatory system.

Erections are a complex process: They also involve the brain, hormones, spinal cord, nerves, muscles and emotions. Like all sexual responses, erections rely on the body and the brain working together. That means ED can be caused by a physical issue or a psychological one.

Sometimes, several of these things come into play together: A medical condition may be causing ED, which in turn makes a man anxious about getting an erection, which then causes more ED.

What about testosterone level? It’s rarely a factor in ED, despite the sex hormone’s reputation as a virility indicator.

“Low testosterone doesn’t necessarily cause ED,” says Richard R. Augspurger, MD, a board-certified urologist. He is the founder of the Urology Center of Colorado in Denver and a Medical Director at Optum. Rather, the hormone plays a role in energy levels, mood and libido, all important factors that contribute to erectile function. Even patients whose testosterone has returned to a normal level may need further treatment for ED.

If you are struggling with ED, a doctor can take a full medical history and run diagnostic tests to determine the exact cause. The earlier you get a thorough examination and diagnosis, the better. ED can have a significant effect on quality of life. A speed bump in the bedroom can spill over into the relationship. The condition can also be a sign of an underlying and potentially serious health issue.

What are the medical causes of ED?

There are a range of conditions that can contribute to or cause ED. Here are some of the most common ones:

Heart disease. Also called cardiovascular disease, this condition is a major medical cause of ED, because erections depend on healthy blood flow, says Dr. Augspurger. Heart disease can include:

  • Coronary artery disease (narrowing of arteries, often due to plaque buildup)
  • Congenital defects (those you are born with)
  • Heart valve disease (when one or more of your heart valves doesn’t work well)
  • Arrhythmias (irregular heartbeats)
  • Hypertensive heart disease (caused by chronically high blood pressure)

By addressing ED problems right away, you can head off serious heart issues in the future. “A lot of studies show that people who have true ED — that is, ED caused by restricted blood flow — have a heart attack within 3 years,” says Dr. Augspurger.

In fact, ED may be the only obvious symptom of heart disease in some men. “Erectile dysfunction may reveal underlying cardiovascular disease risk factors in men who otherwise don’t appear to have symptoms of heart disease,” says Ryan P. Smith, MD. He is a urologist and associate professor of urology at the University of Virginia in Charlottesville. “For doctors who treat patients, the evaluation of men with vasculogenic erectile dysfunction — that is, ED that is caused by issues related to vessels, arteries and blood flow — should include identifying these risk factors in hopes of reducing the risk of future cardiovascular events, such as a heart attack.”

Diabetes. About 35% to 50% of men with diabetes experience ED, according to the Cleveland Clinic. That’s because diabetes can cause nerve damage, including those nerves in the penis that respond to stimulation.

Diabetes can also result in blood vessel damage, which interrupts penile blood flow. The good news: Men with diabetes who control their blood sugar may be able to slow the progression of ED, and having well-managed blood sugar can even help ED medications continue to work their magic.

High cholesterol. Although cholesterol is essential for many bodily functions (such as building new tissue), too much of it in the blood can lead to problems in bed. High levels of low-density lipoprotein (LDL) cholesterol can create fatty buildups. These buildups can narrow the arteries that lead to the penis, making it difficult for blood to pass through.

In other words, just as hardening of the arteries from coronary artery disease can restrict blood flow and result in a heart attack, that same buildup of fat, cholesterol and other substances inside the arteries that lead to the penis can restrict blood flow there, resulting in erectile problems.

“If you think about the arteries in your heart, they’re the size of a regular straw. The arteries to the penis are the size of a cocktail straw. It takes less plaque to obstruct the arterial flow to the penis than it does to the heart,” explains Dr. Augspurger.

In addition to a healthy diet and regular exercise, statins — a class of medications that lower cholesterol — can help get high cholesterol and ED under control. Research published in the Journal of Urology found that patients who had erectile dysfunction and high cholesterol improved both conditions after taking statins.

Antidepressants. While antidepressants can lift your mood and energy levels, they can dampen your interest in sex, resulting in low libido and erectile issues. If you’re on antidepressants and experiencing erectile dysfunction, talk to your doctor about changing your dosage or trying a different prescription.

If you’re thinking about going on antidepressants, ask your doctor about those with the fewest sexual side effects. Some medications are known to have less sexual side effects, such as:

You can also talk to your doctor about adding an ED medication that will help ease the sexual side effects of an antidepressant.

Chronic pain medications. No pain, no erection? It’s quite possible. Some research has shown a link between prescription pain medication and ED. A study in the journal Spine found that men being treated for back pain with long-term opioids were 50% more likely to fill a prescription for an ED medication (or testosterone replacement). And the use of pain medication can also coincide with other ED risk factors, such as smoking and depression.

Erectile Dysfunction

What are the psychological causes of ED?

We’ve all heard that the biggest sex organ is the brain, and your thoughts and feelings can definitely play a part in ED. Depression, anxiety, stress and other mental health issues may impact your ability to achieve and maintain an erection.

Some erections are triggered by erotic or emotional stimuli, such as the pressure of your partner’s hand, a flash of skin, an erotic memory or a fantasy. Your brain then sends out signals that result in a physical response. When those signals are interrupted — because you’re distracted or stressed out — you can have trouble getting or maintaining an erection.

Some psychological issues, such as depression, may also play into erectile dysfunction by lowering your sex drive, making it hard to get enthusiastic about sex in the first place.

Even if men suspect that the problem might be related to their mood, ED can be a harbinger of other future health issues. It should not be written off as something patients should just “get over.”

“It’s serious when it affects how you feel and function and how you live your life,” says Dr. Augspurger.

And even if the cause of your erectile dysfunction is primarily physical, there could also be a mental or emotional component. Feeling stressed out or down can affect how you perform.

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Unfortunately, ED can set up a vicious cycle in which an initial problem with an erection, even if it happens only once, can cause so much stress that it leads to more erectile problems.

“If you fail to respond one time and you’re bothered about it and are thinking, ‘Am I going to have trouble again this time?’ most likely you are going to have a problem,” says Dr. Augspurger. That, in turn, can lead to anxiety, depression, low self-esteem and a loss of intimacy with your partner, which — well, you get it. It’s another reason doctors recommend early treatment: It can help stop a negative cycle from developing.

What’s the first step if you’re experiencing ED?

“It’s important for men who experience erectile dysfunction to seek an evaluation from their health care provider,” says Dr. Smith. “Erectile dysfunction can be a manifestation of other underlying conditions, including cardiovascular disease.”

Your doctor will ask you specific questions to help identify the cause, so don’t hold back. “You want to go into your history with your doctor,” says Dr. Augspurger. “Do you get nighttime erections? Do you have a good erection if you masturbate? Is it just occurring with one partner or all of your partners? Are there strains in the relationship?”

If, for example, you still experience satisfactory erections during the night or when you masturbate, your doctor will focus more on the psychological aspect and why you’re having difficulty in particular situations. You might be referred to a mental health professional for counseling. A therapist can help you cope with the anxiety you may be having about ED. They may also offer helpful suggestions about how to work treatments into your sex life — in ways that can improve your relationship.

If the ED problems are consistent, no matter the timing or situation, your doctor will focus on pinpointing issues with your physical health.

What should you expect from a doctor’s appointment for ED?

Your doctor will want to get an overall picture of your health to diagnose the cause. Depending on whether you are visiting a doctor in person or getting virtual care, you may or may not go through all of these steps.

1. Your doctor will take a thorough health history, exploring any previous erectile problems and other underlying health issues.

2. They’ll do a physical exam. This can include taking your blood pressure, examining the penis and testicles, and drawing blood. If your appointment is virtual, you won’t necessarily have a full physical exam.

3. They’ll run blood tests to evaluate things such as cholesterol, blood sugar, lipids and testosterone.

4. They’ll talk about treatment options. This could include counseling, medication, further tests and lifestyle changes you can make.

What medications can you take for ED?

In 1998, when sildenafil (Viagra) was approved by the U.S. Food and Drug Administration (FDA) to treat ED, it was a huge breakthrough — and huge news. The first effective oral medicine for the condition was introduced in an era with less stigma and silence around erectile dysfunction.

These days, there are a range of medications that can be prescribed, but most are in a class called oral phosphodiesterase-5 (or PDE5) inhibitors. Erectile dysfunction medications are effective for about 70% of men, according to Harvard Medical School. They all work by increasing the blood supply to the penis. They’re similar in effectiveness and require physical stimulation to work.

The ways that the medications differ, which may determine which one is right for you, include the cost, how long they’re meant to last, how you take them — swallowing a liquid or pill or placing a fast-dissolving tablet under your tongue — and your doctor’s advice.

Sildenafil (Viagra and Revatio). Viagra, the “little blue pill,” and its brother Revatio (which is also sildenafil but in a lower dosage) are still popular today, and they are effective for up to 4 hours. That’s how long they’re present in the body and will be able to work, not how long an erection will last. (Erections that last more than 4 hours can damage the tissues in the penis.) These medications will help produce an erection 30 to 60 minutes after taking them.

Interestingly, while heart problems can lead to ED, scientists have found that in some cases sildenafil can help certain heart conditions, such as congestive heart failure and hypertension.

Tadalafil (Cialis). Tadalafil stays in the body longer than sildenafil. You can enjoy its effects for up to 17 and a half hours. Women and men can also be prescribed tadalafil for hypertension, and it can help with urinary problems caused by an enlarged prostate.

Vardenafil (Levitra and Staxyn). Men can take vardenafil about an hour before they want it to start working, and it lasts for around 4 to 6 hours. Levitra comes in a pill form that you swallow; Staxyn comes as a dissolvable tablet that’s placed in the mouth.

Avanafil (Stendra). This medication is taken 15 minutes before sex and can last 3 to 5 hours.


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What are some other treatments for ED?

Although oral PDE5 inhibitors are the first-line treatments for ED, there are other medications and treatments that doctors may suggest, depending on your circumstances. Some other treatments include:

  • Injections. Men can inject a combination of vasodilator medications (such as Trimax or Bimix) into the base or side of the penis before sex to create an erection that lasts up to an hour.
  • Suppositories. A small suppository of alprostadil (Muse) is inserted into the tip of the penis before sex to produce an erection that lasts between 30 and 60 minutes.
  • Vacuum pumps. The pump is placed over the penis to draw blood into it; then a ring is placed at the base of the penis to hold it there long enough for intercourse.
  • Implants. An inflatable or bendable rod is surgically implanted into the penis.

For men experiencing heart problems, diabetes or other underlying medical conditions, getting those conditions properly treated and under control is essential for dealing with ED. That’s a win-win.

Should you talk to your partner about your ED?

The answer to this is an unequivocal yes, according to Dr. Augspurger: “Every time you discuss it with your partner, it’s going to help you,” he says. That’s because ED affects not only your emotional state but theirs.

A frank conversation can help remove worries of “it’s me” or “I don’t turn him on.” Talking about the problem openly helps your partner understand the causes and treatments and reduces the amount of stress for you both. 

How much does lifestyle matter when it comes to ED?

A lot. Getting treatment for ED from a doctor is important, but you can also do things on your own to reduce the risk and frequency of it. Doctors recommend making these lifestyle changes:

  • Stop smoking. Heavy smoking is a risk factor for ED in younger men, and it’s dangerous for your health overall. Because smoking predisposes someone to vascular disease, hardening of arteries and narrowing of blood vessels (all issues that have to do with blood flow), it also increases the risk of erectile problems.
  • Get more exercise. Sweaty is sexy. Whether you enjoy a brisk walk or a challenging game of tennis, keeping fit benefits your cardiovascular health and lowers your risk of diabetes, which can help improve or prevent ED. Exercise can also increase sex drive, which can help restore your confidence.
  • Reduce alcohol intake. Yes, alcohol can be a buzzkill in the bedroom. Here’s why men may have trouble maintaining an erection after a heavy night on the town: Erections are a 3-part process, says Dr. Augspurger. The first is the reflex and response to stimulation of touch. Second, the brain comes into play, reinforcing those signals and perhaps responding to other stimuli, such as a visual cue or a mental image. The train is leaving the station and you’re feeling excited and turned on. Then, blood flows to the penis, where it becomes trapped, producing and sustaining the erection. Alcohol, which depresses your central nervous system, can interfere with the brain and hijack those reinforcing signals.

Will it get better?

Science says yes. Most men who seek treatment for ED experience improvement, whether it’s by taking medication, addressing underlying health issues, making lifestyle changes or going to counseling (or some combination of these treatments). Even in cases where ED isn’t completely cured, its symptoms can be greatly reduced, and you can enjoy a satisfying sex life again.

The bottom line: You don’t have to just accept ED, try to overcome it on your own or suffer in silence. There is help. It’s simply a matter of partnering with a doctor who can identify the causes of your ED. The doctor can create a plan that will treat your specific issues and bring back your confidence.

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Have a consult with a licensed doctor who can assess whether you’re a good candidate for medication.


Our expert panel

Richard R. Augspurger, MD, urologist, founder of the Urology Center of Colorado in Denver, Medical Director at Optum

Ryan P. Smith, MD, urologist, associate professor of urology at the University of Virginia, Charlottesville

Additional sources

Erectile dysfunction facts: National Institute of Diabetes and Digestive and Kidney Diseases. Definitions and Facts for Erectile Dysfunction.
Hypertension and ED: Current Opinion in Nephrology and Hypertension (2012). “New Insights into Hypertension-Associated Erectile Dysfunction.”
Prevalence of ED: Johns Hopkins Medicine. Erectile Dysfunction.
Heart disease and ED: Cleveland Clinic. Heart Disease and Erectile Dysfunction.
Diabetes and ED: Diabetes, Metabolic Syndrome and Obesity (2014). “Diabetes and Sexual Dysfunction: Current Perspectives.”
Vascular disease: Johns Hopkins Medicine. Overview of the Vascular System.
Study on statins and ED: Journal of Urology (2004). “Improvement of Erectile Function in Men with Organic Erectile Dysfunction by Correction of Elevated Cholesterol Levels.”
ED and antidepressants: Mayo Clinic. Antidepressants: Which Cause the Fewest Sexual Side Effects?
Opioids and ED: Spine (2014). “Prescription Opioids for Back Pain and Use of Medications for Erectile Dysfunction.”
The brain and sexual response: Nature Reviews Disease Primers (2016). “Erectile Dysfunction.”
History of Viagra: Harvard Medical School. Viagra and Health: Beyond ED.
Meds available for ED, and effectiveness: Harvard Medical School. Which Drug for Erectile Dysfunction?
Differences in medications: Boston University School of Medicine. Choosing the Right Pill to Treat ED.
Safety and efficacy of sildenafil: The Journal of Sexual Medicine (2016). “Efficacy and Safety of Sildenafil by Age in Men with Erectile Dysfunction.”
Additional treatments: Mayo Clinic. Erectile Dysfunction.