Erectile Dysfunction: What’s Normal, What Isn’t, and What Can Be Done

Things aren’t working the way they used to. Is this just getting older, or is something actually wrong?

One theme you’ll hear a lot from my clinic is the link between erectile dysfunction (ED) and cardiovascular health. The same way clogged heart arteries can lead to a heart attack, clogged penile arteries can lead to ED. Penile arteries are smaller, so they often show trouble first, sometimes years before a heart problem gives any other warning. Men with ED have roughly a 45% higher risk of cardiovascular disease (Stern et al., 2025).

That’s why I look for the cause before talking about treatment. At Form, we look beyond lifespan to healthspan. Not just how long you live, but how well.

What changes naturally with age

An erection at 55 won’t behave the way it did at 25. Many men need more stimulation, in the right setting, to get a good erection. It may be less firm, the wait before you’re ready to go again gets longer, and morning erections become less consistent. All of that is normal aging.

When the changes start to get in the way of sex, with a semi-rigid or absent erection or trouble keeping one, normal physiology has crossed into pathology. That’s erectile dysfunction. It’s associated with age, but age alone isn’t the explanation.

What causes ED

The textbook splits ED into four buckets. Arteriogenic is a blood flow in problem. Venogenic is a blood flow out problem. Neurogenic is when the signal from the brain doesn’t reach its target. Psychogenic is when psychosocial stress interferes with a normal arousal response.

Real life is far from the textbook. No man is an island, and these systems work together. Most of the men I see have two or three contributors stacked together. If you’re mentally focused on hoping and praying your erection gets hard enough and lasts long enough, instead of on the moment in front of you, is that an artery problem or a mental one? Often it’s both.

At its core, erections come down to plumbing. You want lots of blood flowing in and very little flowing out. Reduced inflow is one of the most common drivers. High blood pressure, high cholesterol, diabetes, smoking and excess weight all wear on the small vessels that supply erections. On the outflow side, changes in the collagen of the erectile tissue, previous surgery or trauma, and a big helping of bad luck can make it harder to trap blood, so it leaks out.

For some men it’s a nerve problem. Diabetes, pelvic surgery and spinal conditions can interrupt the signal from the brain.

Then there are hormones, especially testosterone. Despite the current cultural focus, it’s often less of a culprit than people assume, though it’s worth checking with a morning blood test.

Medications play a role too. Some blood pressure medications and antidepressants can interfere with erections. Don’t stop or change anything on your own. A medication review with your doctor is part of a proper workup.

Finally, lifestyle feeds into everything above. Poor sleep, heavy alcohol use, and stress at work and at home all affect sexual health. Stress, anxiety, depression and relationship strain can cause ED on their own, and they stack on top of physical causes. The mind-body connection is part of every assessment.

What a proper workup looks like

A medical and sexual history, a focused exam, and bloodwork: blood sugar or A1c, cholesterol, and a thorough hormonal panel including testosterone and luteinizing hormone. We also look at your cardiovascular risk, and some men should see a cardiologist.

What the options look like

Treating ED is more of a charcuterie board than a true ladder, though there is a stepwise approach in terms of risk and invasiveness. Good treatment is personalized.

The foundation is lifestyle: blood pressure and blood sugar control, better cholesterol and cardiovascular health, better sleep, more exercise, quitting smoking, cutting back on alcohol, and a healthy dose of sex therapy. There’s no pill I can give you that beats this, and it’s at the core of every plan.

From there, the usual treatments are:

• PDE5 inhibitors, such as sildenafil (Viagra) and tadalafil (Cialis), work with your arousal pathway to relax the blood vessels in the penis so more blood can flow in. They need sexual stimulation to work. They’re first-line for most men (Stern et al., 2025), but a lot of “failures” come down to timing, a heavy meal, or a dose that was never titrated. Like all medications, they have side effects and contraindications. They are not safe with nitrates, so make sure your prescriber knows your health conditions, medications and supplements.
• Injection therapy (intracavernosal injections) puts a small dose of medication directly into the penis before sex. It acts on the blood vessels themselves, so it doesn’t rely on the body’s usual arousal pathway. An erection lasting more than four hours needs urgent medical attention, which is why your doctor teaches you how to use it safely.
• Vacuum erection devices and constriction bands draw blood in mechanically and help keep it there.
• Testosterone therapy, but only when bloodwork confirms low levels and you have symptoms. Without careful monitoring it carries real risks and side effects, including lowered sperm production, higher red blood cell counts, and mood and skin changes.
• A penile implant is a surgical option when other approaches aren’t suitable or haven’t been enough.

These treatments manage the problem, but they don’t necessarily address the root cause. The next set of options looks at underlying contributors like the pelvic floor, psychosocial factors, and regenerative therapies that are still being studied.

• Pelvic floor physiotherapy. A certified pelvic floor physiotherapist can assess the muscles involved in supporting erections, identify weakness, tightness or imbalance, and build a plan around it. Emsella, a chair that uses HIFEM technology to stimulate those same muscles, is one tool we use alongside it.
• Regenerative and energy-based therapies, including low-intensity shockwave therapy (we use the Alma Duo) and radiofrequency (the InMode Apex M). Both are newer and the research is still evolving. We consider them after a proper assessment, match them to what’s actually going on, and tailor the protocol to each patient rather than running a template.

What’s still debated

Men’s health is an evolving field, with as much art as science. It also asks men to talk about things most of us don’t say out loud to someone we’ve just met. That takes trust, and trust only works when your doctor is straight with you about what’s known, what isn’t, and what a treatment can realistically do. When you’re worried and looking for answers, that honesty matters more than a confident pitch.

• Shockwave therapy is an active area of research, and guidelines don’t all describe it the same way (Schoofs et al., 2019). Many trials show statistically significant gains on erection questionnaires, but statistically significant isn’t the same as meaningful to the man. A 2026 pooled analysis of 19 randomized trials found significant improvements, yet most of the individual studies fell short of the minimal clinically important difference, the smallest change a patient would actually notice (You et al., 2026). An earlier pooled analysis was more encouraging (Sokolakis et al., 2019). So the honest answer is that it depends on the study, the protocol and the man, which is why I won’t promise a result. [The international consensus panel I sat on classifies non-approved novel therapies as experimental outside of clinical trials (Stern et al., 2025). That’s the right framing, and it’s why I walk through the evidence with every patient before we start.]

What we do is combine approaches rather than rely on any one device: lifestyle changes, oral medication, and shockwave or radiofrequency, often with a timed injection beforehand. The rationale is that better blood flow in the tissue may help it respond to the shockwave. That’s a theory, not a proven result.

• Testosterone for men with normal levels is another one. It’s unlikely to fix ED that has a vascular cause, and it can affect fertility. In men with low testosterone, treatment can improve the response to ED medications, but on its own its role in ED is limited (Pignanelli, Stern, and Brock, 2023).
• Regenerative injections into the penis, such as platelet-rich plasma (PRP) and stem cell products, are widely promoted, but the evidence behind them is still limited and evolving.

Online ED prescriptions and over-the-counter “male enhancement” supplements are mostly a safety question. Health Canada has repeatedly warned about sexual enhancement products containing undeclared prescription drugs, which matters most for men on nitrates or with heart disease. And a prescription written without a proper history and exam, from anyone, can miss the vascular warning signs and treats the symptom without looking for the cause.

None of this means avoid treatment. It means ask good questions: what’s causing this, what does the evidence say about what you’re recommending, and what happens if it doesn’t help.

When to see someone

If it’s been going on for a few months and it’s bothering you, book the visit. It’s one of the most treatable things I see, and it’s often the first sign of something worth knowing about, like blood pressure or blood sugar. Ask what’s driving it before you decide how to treat it. If ED comes with chest pain or shortness of breath on exertion, don’t wait for a clinic visit.

References

Pignanelli M, Stern N, Brock G. Does testosterone salvage PDE5i non-responders? A scoping review. Endocrines. 2023;4(1):117-127. doi:10.3390/endocrines4010011

Schoofs E, Fode M, Capogrosso P, et al. Current guideline recommendations and analysis of evidence quality on low-intensity shockwave therapy for erectile dysfunction. Int J Impot Res. 2019;31(3):209-217. doi:10.1038/s41443-019-0132-0

Sokolakis I, Hatzichristodoulou G. Clinical studies on low intensity extracorporeal shockwave therapy for erectile dysfunction: a systematic review and meta-analysis of randomised controlled trials. Int J Impot Res. 2019;31(3):177-194. doi.org/10.1038/s41443-019-0117-z

Stern N, Bajic P, Campbell J, et al. Evolving medical management of erectile dysfunction: recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024). Sex Med Rev. 2025;13(4):513-537. doi:10.1093/sxmrev/qeaf035

You CH, Kang YN, Wen YC, et al. A close look at the evidence on low-intensity shockwave therapy in erectile dysfunction: a systematic review and meta-analysis of randomized controlled trials. J Sex Med. 2026;23(4):qdag070. doi:10.1093/jsxmed/qdag070