Erectile Dysfunction (ED): Causes
A comprehensive, clinician-grade reference to etiologies of ED. Includes vascular, neurogenic, endocrine, psychogenic, structural, iatrogenic/medication-induced, sleep/circadian, systemic illness, and substance-related causes, plus risk predictors, red flags, and a cause→workup map.
ED is most often multifactorial. The big three buckets are vasculogenic (arterial insufficiency or veno-occlusive dysfunction), neurogenic (central/peripheral), andendocrine (hypogonadism and other hormonal disorders). Psychological/relationship factors commonly coexist. Medications, substances, structural penile disease, systemic illness, sleep apnea, aging, and post-surgical states all contribute.
Medical disclaimer
- Diabetes mellitus (duration & control strongly predictive)
- Metabolic syndrome, central obesity, dyslipidemia
- Hypertension, smoking, sedentary behavior
- Cardiovascular disease or strong family history
- Depression/anxiety; relationship stress
- Hypogonadism, thyroid disorders, hyperprolactinemia
- CKD/ESRD, chronic liver disease, COPD/OSA
- Medication classes listed above; alcohol/cannabis (heavy)
- Pelvic surgery/radiation; pelvic/penile trauma
- Age, frailty, low physical fitness
- Penile fracture or severe perineal trauma
- New-onset severe penile pain, rapidly progressive curvature, or painful priapism history
- Acute neurologic deficits (weakness, numbness, incontinence)
- Systemic symptoms (fever, weight loss) suggesting malignancy/infection
- Symptoms of acute coronary syndrome or unstable angina
- Hyperprolactinemia symptoms (galactorrhea, visual field defects) suggesting pituitary mass
Initial assessment always includes sexual/medical history, medication/substance review, focused exam (CV, GU, endocrine, neuro), blood pressure, BMI/waist, and mental health/OSA screening. Targeted labs and tests follow suspected etiology.
| Suspected Cause | Key Clues | Tests (typical) |
|---|---|---|
| Vasculogenic | Gradual onset; CVD risks; ↓ morning/nocturnal erections | Fasting glucose/HbA1c, lipid panel; consider penile duplex Doppler after intracavernosal agent; +/- CAC in select |
| Neurogenic | Neuro deficits; post-prostatectomy; ↓ genital sensation | Neuro exam; diabetes screen; consider sacral reflexes; specialized testing if indicated |
| Endocrine | Low libido, fatigue; gynecomastia; infertility | Two separate 8–11 a.m. total testosterone; if low → LH/FSH, prolactin; TSH; consider SHBG, estradiol as indicated |
| Psychogenic | Situational; preserved nocturnal/masturbatory erections; sudden onset | IIEF-5/SHIM; PHQ-9/GAD-7; relationship/sexual history; screen for trauma |
| Medication/Substances | Temporal relation to med start/dose ↑ | Medication review; consider alternatives or dose changes; check prolactin if antipsychotics |
| Sleep/OSA | Loud snoring, daytime sleepiness, obesity | STOP-Bang; sleep study if high risk; consider testosterone impact |
| Structural | Curvature, penile pain, palpable plaques | GU exam; penile ultrasound if Peyronie’s suspected |
Younger
- Psychogenic/situational, performance anxiety
- Substances/recreational drugs
- Congenital curvature/Peyronie’s early
- Post-traumatic injury
Middle-aged
- Metabolic syndrome/vascular risk accumulation
- Medication-related; depression/anxiety
- Sleep apnea; declining testosterone in subset
Older
- Vasculogenic predominance
- Polypharmacy and comorbid illness burden
- Neurodegenerative disease; post-surgical states
Validated Screens & Indices
- IIEF-5 / SHIM: symptom severity.
- PHQ-9, GAD-7: mood/anxiety comorbidity.
- STOP-Bang: OSA risk.
- AUDIT-C, DAST-10: alcohol/drug screening.
- Low desire (hypoactive sexual desire) ± normal erectile capacity
- Ejaculatory disorders: premature, delayed, anejaculation
- Anorgasmia: orgasmic dysfunction with or without erection
- Peyronie’s disease with painful/unstable deformity
- Priapism sequelae causing veno-occlusive dysfunction
References & Guideline Anchors
This page synthesizes recommendations consistent with major urology/endocrine guidelines and large reviews (AUA guideline on Erectile Dysfunction; EAU Sexual & Reproductive Health Guidelines; Endocrine Society guidance on testosterone therapy and evaluation of hypogonadism; cardiometabolic risk statements). Local practice may vary.