Erectile Dysfunction (ED)

Erectile dysfunction is ongoing difficulty getting or keeping an erection firm enough for sexual activity. Erections depend on healthy blood vessels, nerves, hormones and psychological state, so a persistent change can reflect what is happening elsewhere in the body. It is a common medical condition, it becomes more frequent with age, and it is assessed and managed like any other health concern.

What erectile dysfunction is, and what it is not

An occasional difficulty is not erectile dysfunction. What clinicians assess is a change that has been present for several months rather than now and then. It is also not, on its own, a sign that testosterone is low: hormone levels are only one of several things reviewed, and a morning testosterone test is generally ordered when the history points that way rather than as a matter of routine.

The more useful way to think about it is as a circulation and nerve signal. The Canadian Urological Association guideline states that erectile dysfunction and cardiovascular and cerebrovascular disease share the same risk factor profile, and that erectile dysfunction may serve as an early warning sign for the future development of vascular events. A British Columbia Medical Journal review reports that symptoms typically appear on average about three years before the symptoms of coronary artery disease. The Canadian guideline also notes conflicting evidence on whether erectile dysfunction predicts events independently, and states that established tools such as the Framingham risk score are superior predictors. That is why assessment in Canada includes checks for diabetes, blood pressure and cholesterol, and why cardiovascular disease often comes up in the same appointment.

Signs and symptoms

• Difficulty getting an erection
• Difficulty keeping an erection long enough for sexual activity
• Erections that are less firm than they used to be
• A change that has been present for several months rather than occasionally
• Reduced sexual desire alongside the change
• Distress, worry or avoidance related to the change
• In some cases, other signs at the same time, such as fatigue, reduced exercise tolerance or chest discomfort

Severity varies widely, and so does the mix of physical and psychological contributors in any one person.

What raises the risk

Some things cannot be changed:

• Increasing age
• Existing cardiovascular disease, which the Canadian primary care study linked to higher odds
• Neurological conditions, prostate or pelvic surgery, pelvic trauma and pelvic radiation
• Testosterone deficiency and certain other hormonal conditions

Others can often be worked on, usually with support from a health care team:

• Diabetes and blood glucose control, which carried the strongest association in the Canadian study
• Smoking, high blood pressure, abnormal cholesterol, excess weight and low physical activity
• Certain medications, alcohol and substance use, sleep loss, depression, anxiety and relationship distress

How erectile dysfunction is diagnosed in Canada

The Canadian Urological Association guideline describes a detailed history and physical examination as the cornerstone of assessment. Clinicians review medical and psychological conditions, medications, substance use, and any history of surgery or pelvic injury, and they check blood pressure, body habitus, genital anatomy and testicular volume. Laboratory tests usually include HbA1c or fasting glucose and a lipid profile, which is how undiagnosed diabetes and abnormal cholesterol are often picked up, with a morning testosterone level when symptoms suggest testosterone deficiency. Validated questionnaires such as the SHIM, IIEF and EHS may be used to describe severity. Specialised tests such as overnight tumescence monitoring or penile duplex ultrasound are rarely needed.

Treatment and day-to-day management

Clinical research for Erectile Dysfunction (ED) is enrolling. See the current studies ↓

Care in Canada usually runs on two tracks at once: something for the erections themselves, and attention to the conditions underneath. Depending on your situation and what matters to you, a health care team may discuss:

• First-line oral medication in Canada: phosphodiesterase type 5 inhibitors
• Second-line options described in the Canadian guideline: intraurethral alprostadil, intracavernosal injection therapy and vacuum erection devices
• Third-line option described in the Canadian guideline: a surgically implanted penile prosthesis
• Assessment and management of contributing conditions, including diabetes, blood pressure, lipids and testosterone deficiency
• Psychological and relationship support, including sex therapy and counselling, used alone or alongside medical options

What suits one person will not suit another. Which of these applies to you, if any, is a decision for you and your own clinician, and this page is not a recommendation about any of them.

When to talk to a doctor

• Book an appointment if difficulty getting or keeping an erection has persisted for several months, or is causing distress, since assessment includes checking for diabetes, blood pressure and cholesterol problems.
• Raise it sooner rather than later, because Canadian sources describe erectile dysfunction as a possible early sign of cardiovascular disease, with symptoms appearing on average about three years before symptoms of coronary artery disease.
• Seek emergency care for chest pain, pressure or shortness of breath during exertion or sexual activity, or for an erection lasting more than four hours, which is a medical emergency.

Why clinical research matters for erectile dysfunction

The most recent Canadian prevalence data is now about two decades old, and there is no current national estimate of how many Canadians have erectile dysfunction or how many seek care. It is also unresolved how strongly erectile dysfunction predicts future cardiovascular events independently of established risk scores, a point the Canadian Urological Association guideline explicitly flags as showing conflicting results. Research currently under way includes regenerative approaches such as low-intensity shockwave therapy and stem cell and platelet-based treatments, new oral and topical compounds, studies in men after prostate cancer treatment and in men with diabetes, and work on using erectile dysfunction as an opportunity for cardiovascular screening.

Clinical studies are how those questions get answered. Taking part is voluntary, you give informed consent before anything begins, and you can stop at any time without affecting the care you get from your own doctor. Joining a study does not mean giving up your current treatment, and no one can tell in advance whether a study will help you personally.

Learn more from Canadian sources

• Canadian Urological Association guideline on erectile dysfunction
• Sex and U, Society of Obstetricians and Gynaecologists of Canada
• Action Canada for Sexual Health and Rights: Access Line and service provider directory