Erectile Dysfunction
Erectile dysfunction is the consistent inability to get or keep an erection firm enough for sex, and it becomes more common with age. Evaluation and treatment follow the AUA Erectile Dysfunction Guideline (2018).
Symptoms
Difficulty achieving or maintaining an erection, reduced spontaneous erections, and loss of confidence around sex -- occurring consistently rather than as an occasional off night.
Causes and risk
Vascular disease is the most common cause -- ED is frequently an early warning sign of cardiovascular disease, sometimes appearing years before a heart attack or stroke. Diabetes, low testosterone, medications (antidepressants, blood pressure drugs), smoking, and psychological factors (anxiety, depression, relationship stress) all contribute, often in combination.
How it is evaluated
Workup includes a history and exam, fasting glucose or A1c, a lipid panel, and morning testosterone. Because of the vascular link, we also assess cardiovascular risk using the ACC/AHA 10-year risk calculator, per the Princeton IV cardiovascular consensus.
Treatment
PDE5 inhibitors (sildenafil, tadalafil, and similar) are first-line per the AUA guideline. When those don't work well enough, options include intracavernosal injections, intraurethral alprostadil, vacuum erection devices, and eventually a penile prosthesis -- the guideline frames this as shared decision-making rather than a strict ladder, so patients can reasonably start with any appropriate option.
When to seek care
An erection lasting more than 4 hours (priapism) is a urologic emergency -- go to an emergency department immediately, since delay beyond 6-12 hours raises the risk of permanent damage.