How Do You Know if You Have Erectile Dysfunction (ED)?

Erectile dysfunction (ED) makes you unable to achieve or satisfactorily maintain an erection. ED can be temporary or chronic (long-lasting) and can range in severity. You might have trouble getting an erection when you want, be able to achieve an erection but have trouble maintaining it for fulfilling sex, or be completely unable to get an erection.

Erectile dysfunction isn’t a normal part of aging, but it is more common among people assigned male at birth over age 75. About 5% of males have complete ED at age 40, and this percentage rises to 30-40% in males 80 or older.

Given this prevalence and the effect ED can have on quality of life, proper diagnosis is critical. Primary care physicians and urologists—specialists in urinary tract health and diseases affecting the reproductive system—typically conduct an evaluation and make a diagnosis. They will review symptoms, screen mental health, and run clinical tests.

Erections occur when the penis becomes engorged with blood, making it rigid. A wide range of personal habits and health conditions can cause problems with erections, leading to erectile dysfunction. Your provider will ask about your habits and overall health to determine potential causes.

Using tobacco, alcohol, or illicit drugs can lead to ED. Having excess weight or obesity, type 2 diabetes, or cardiovascular (heart and blood vessel) diseases can also increase your risk for the condition.

Other habits and conditions that may raise the risk of erectile dysfunction include:

• Lack of physical activity
• Atherosclerosis, a hardening of the arteries
• Hypertension (high blood pressure)
• Chronic kidney disease
• Multiple sclerosis, a chronic autoimmune disease that attacks the nervous system
• Peyronie’s disease, a curving of the penis
• Complications of prostate cancer treatment, such as injury or radiation therapy side effects
• Physical injury to the penis, spinal cord, bladder, prostate, or pelvis
• Bladder cancer surgery complications
• Side effects of blood pressure medications, antidepressants, tranquilizers, appetite suppressants, and others
• Stress, anxiety, low self-esteem, and other mental health conditions
• Fear of sexual failure, feelings of guilt surrounding sex

Your healthcare provider will need to take a detailed medical history. Though problems with sexual function may be difficult to talk about, it’s important to open up about your sex life and symptoms with your provider. As part of an erectile dysfunction diagnosis, they may ask about:

• How confident you feel in your ability to achieve and maintain an erection
• How often you’re successfully able to have sex to completion
• How satisfied you are with sex when you have it
• Whether you have erections when waking in the morning
• Your overall desire for sex
• How often you are able to orgasm during sex or masturbation
• What treatments, surgeries, or injuries you’ve had that affect the groin area
• Any prescribed or over-the-counter (OTC) medications you’re taking
• Your dietary and exercise habits
• Any alcohol, illicit drug use, or smoking

To detect physical causes of erectile dysfunction, the healthcare provider performs a physical exam. This may involve several steps:

• Touching the penis to see whether sensory nerves are working; a lack of sensitivity indicates a nerve problem
• Visual assessment of the penis for discoloration or other signs of issues, such as curvature indicating Peyronie’s disease (scar development in part of the penis’s shaft)
• Checking your blood pressure, pulse, and heart rate for signs of blood circulation problems or other health issues
• Assessing the body for breast development or excess body hair, which can be signs of hormonal imbalances or low levels of testosterone

Along with physical causes, mental health issues like depression and anxiety can cause or contribute to erectile dysfunction. In some cases, ED can also lead to mental health issues. Given this connection, psychological and mental health assessment is often a big part of ED diagnosis.

This typically involves answering questions about your feelings and behaviors surrounding sex and in general. You may also take a specialized questionnaire that helps providers detect signs of depression or sexual dysfunction, such as the International Index of Sexual Function (IIEF-5).

Many diseases can contribute to erectile dysfunction, including type 2 diabetes, hypogonadism (insufficient sex hormone production), or kidney failure. Researchers found anywhere from 35-70% of people with type 2 diabetes experience erectile dysfunction.

To identify this type of cause, your healthcare provider may collect blood samples and send them to a clinical laboratory for evaluation. Tests they may use include:

• Fasting glucose test: This test measures glucose (sugar) levels in the blood after fasting for at least eight hours. It can help detect diabetes (an inability to break down sugars).
• Testosterone levels test: Several blood tests help providers determine levels of testosterone—the primary male sex hormone. Low levels can cause ED, reduced sex drive, infertility, and other symptoms.
• Lipid profile: This test measures levels of lipids in the blood, such as total cholesterol, low-density lipoprotein (LDL) or “bad” cholesterol, high-density lipoprotein (HDL) or “good” cholesterol, and triglycerides.

In some cases, your healthcare provider may want to perform imaging of the penis to assess blood flow. This often involves a color Doppler ultrasound, a type of imaging that relies on sound waves.

The technician, radiologist, or your provider may inject a medication to induce erection during the evaluation. They may also inject dyes to make blood flow more visible in the images. With detailed computer images, healthcare providers can detect any physical causes of the condition.

A few other tests—administered in a clinic or hospital or at home—can help healthcare providers evaluate the quality and quantity of erections. These include:

• Nocturnal erection test: This involves wearing a plastic ring or blood flow measuring device on your penis overnight. Since people assigned male at birth have, on average, 3-5 erections during sleep, changes in the ring or data in the device can measure the frequency and quality of erections.
• Intracavernosal injection: With this test, the healthcare provider injects a medication into the penis or urethra that causes an erection. They then assess how much blood flows to the penis and how long it lasts.

Erectile dysfunction (ED) occurs when you aren’t able to achieve or maintain an erection. While this issue becomes more common as you age, it isn’t a natural part of aging. A wide range of physical and mental health issues, medications, and lifestyle habits can cause or raise ED risk.

Typically performed by primary care physicians or urologists, the diagnosis of ED primarily involves a physical exam, assessment of medical history, and mental health evaluation. If the provider suspects certain physical causes, they’ll also perform various tests, including blood and imaging tests.