Erectile Dysfunction: Causes & Treatment | Dr. Theodore Cisu

The short answer: Erectile dysfunction (ED) means having trouble getting or keeping an erection firm enough for sex. It is common, and it is very treatable. Because ED can be an early warning sign of heart disease or diabetes, a good evaluation looks at your overall health too. Treatment options range from lifestyle changes and pills to injections, devices and surgery.

Written by Theodore Cisu, MD, board-certified urologist. Based on the American Urological Association (AUA) guideline on erectile dysfunction (2018). Last reviewed November 2026.

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What is erectile dysfunction?

An erection depends on blood vessels, nerves, hormones and your state of mind all working together. When you are aroused, nerves signal the arteries in the penis to relax. Blood fills two spongy chambers, and the veins that drain them are squeezed shut. That trapped blood makes the penis firm.

ED happens when something along this chain doesn't work as it should. Trouble now and then is normal. ED usually means a problem that keeps happening and bothers you or your partner.

What causes ED?

Most of the time, more than one thing is involved.

• Blood flow problems. The same narrowing of the arteries that affects the heart can affect the penis. High blood pressure, high cholesterol and smoking all play a role.
• Diabetes. It can damage both blood vessels and nerves.
• Nerve injury. Prostate cancer surgery or radiation, other pelvic surgery, spinal cord injury and some neurologic conditions can affect erections.
• Hormones. Low testosterone can lower sex drive and weaken erections.
• Medications. Some blood pressure medicines, antidepressants and other drugs can contribute. Don't stop a medicine on your own. Talk with the doctor who prescribed it.
• Lifestyle. Smoking, heavy drinking, little physical activity, extra weight and poor sleep, including sleep apnea.
• Stress and emotions. Anxiety, depression and relationship strain can cause ED or make it worse.

ED and your heart

The AUA guideline advises that men with ED be told that ED can be a sign of heart and blood vessel disease. The small arteries in the penis may show narrowing before larger arteries cause symptoms such as chest pain. That makes ED a useful chance to check on your heart health.

In practice, this often means checking your blood pressure, blood sugar and cholesterol, and talking with your primary care doctor about your heart risk. If you have chest pain or unusual shortness of breath with activity, see a doctor promptly. If you have a heart condition, ask whether you are healthy enough for sexual activity before starting treatment.

How is ED diagnosed?

• A conversation. Your urologist will ask about your health, medications, sex life, sex drive, morning erections and stress. A short questionnaire helps measure how ED affects you and track how treatment works.
• A physical exam. This includes blood pressure and an exam of the penis and testicles.
• Blood tests. The AUA recommends checking a morning testosterone level in men with ED. Blood sugar and cholesterol are often checked too.
• Specialized testing, only when needed. A penile ultrasound with an injection to produce an erection can measure blood flow. It is usually saved for unclear cases or before surgery. Your urologist can arrange it when needed.

Most men don't need specialized testing before starting treatment.

Treatment options

The AUA guideline centers on shared decision-making. Any treatment that is safe for you can be a reasonable first choice. You don't have to move through options in a fixed order. Your partner is welcome to be part of the conversation.

Healthy habits

Regular exercise, weight loss, quitting smoking, drinking less alcohol, and good control of blood pressure and diabetes can improve erections. They also help your heart. These steps work well alongside any other treatment.

Counseling

A therapist with experience in sexual health can help with performance anxiety, depression or relationship stress. Counseling can be combined with medical treatment.

Pills (PDE5 inhibitors)

Sildenafil (Viagra), tadalafil (Cialis), vardenafil and avanafil boost the body's natural erection response. They need sexual stimulation to work. Tadalafil can also be taken as a low daily dose. Common side effects include headache, flushing, stuffy nose, indigestion and back aches.

Never take these pills with nitrate medicines such as nitroglycerin. The combination can cause a dangerous drop in blood pressure.

If pills don't seem to work, the guideline encourages a review of how they're being taken. Timing, dose, food and the amount of stimulation all matter. Many men do better after a few adjustments.

Testosterone, when it's truly low

If blood tests confirm low testosterone along with symptoms, treating it can improve sex drive and may help ED pills work better. Testosterone isn't a treatment for ED when your levels are normal.

Vacuum erection device

A plastic cylinder and pump draw blood into the penis. A snug ring placed at the base holds the erection. It uses no medication and costs little. Some men find it awkward, and the ring should only stay on for the time the instructions allow.

Urethral medication

A tiny pellet of alprostadil is placed in the tip of the penis. It works for some men. Side effects can include aching in the penis and burning in the urethra.

Penile injections

Medication is injected into the side of the penis with a very small needle. An erection usually follows within minutes. Injections often work for men who don't respond to pills. Your first dose should be given with a clinician watching so the dose can be adjusted safely. Your urologist can arrange this injection training. The main risk is an erection that lasts too long, which needs urgent care.

Penile implant

An implant is a device placed inside the penis during surgery. Most are inflatable, with a small pump in the scrotum. In studies, many men and partners report high satisfaction. Risks include infection and device problems that may need another surgery. Your urologist can discuss whether an implant fits your goals, and Dr. Cisu can coordinate referral to a surgeon who specializes in implants when appropriate.

Treatments still being studied

The AUA considers low-intensity shock wave therapy, platelet-rich plasma (PRP) injections and stem cell treatments investigational. They are best tried within a clinical trial. Be cautious with clinics that sell these as proven cures, often as cash-only packages.

When to see a urologist

• ED that bothers you or your partner
• Pills that haven't worked or cause side effects
• ED along with low sex drive or low energy
• ED after prostate cancer treatment or pelvic surgery
• A new curve, lump or pain in the penis
• ED at a younger age or after an injury to the pelvis

When it's an emergency

Go to the emergency room for an erection that lasts more than 4 hours, or a painful erection that won't go down. Call 911 for chest pain during or after sex. Tell emergency staff if you've taken an ED pill, because it changes which heart medicines are safe.

Seeing Dr. Cisu for erectile dysfunction

Dr. Theodore Cisu evaluates and treats ED at his clinics in Charlottesville and Fishersville. You can start with a telehealth visit from anywhere in Virginia. Our office can gather your outside records and lab results so Dr. Cisu reviews them before you talk. Second opinions are welcome, and no referral is needed. Book a visit.

Frequently asked questions

Is ED just a normal part of getting older?

ED becomes more common with age, but you don't have to accept it. It can be treated at any age, and it is worth checking for health issues behind it.

Can erectile dysfunction be cured?

Sometimes. When the cause can be reversed, such as a medication side effect, low testosterone, smoking or extra weight, erections can improve. Otherwise, ED can usually be managed well with treatment.

Which ED pill works best?

No single pill is best for everyone. They work in similar ways. They differ mostly in how fast they start, how long they last and how they interact with food. Generic versions are widely available.

Is it safe to buy ED pills or supplements online?

Be careful. The FDA has warned that some "natural" sexual enhancement products contain hidden prescription drug ingredients. Get ED medicine with a prescription from a licensed pharmacy so your doctor can check it is safe with your other medicines.

Does low testosterone cause ED?

It can contribute, especially with low sex drive. That's why the AUA recommends checking testosterone in men with ED. Still, most ED is related to blood flow, nerves or stress.

Can I talk about ED through a telehealth visit?

Yes. Much of the evaluation starts with a conversation, and labs can often be drawn close to home. An in-person exam is arranged when it's needed.

Sources

• American Urological Association. AUA releases new clinical guideline for diagnosis and treatment of erectile dysfunction (2018).
• Burnett AL, et al. Erectile Dysfunction: AUA Guideline. Journal of Urology, 2018 (summary via UroToday).

This article is for general education and isn't a substitute for medical advice. If you have an erection lasting more than 4 hours, go to the nearest emergency room. If you have chest pain, call 911.