Erectile Dysfunction Causes: What Is Linked to ED and Which Clues Matter

Erectile dysfunction (ED) usually has more than one cause, and most are physical or medical rather than "all in the head." The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) groups them into diseases and conditions, medicines, mental health and emotional issues, and lifestyle behaviors.¹ In a community survey of men aged 40 to 70, age was the factor most strongly linked to ED, and after adjusting for age, heart disease, hypertension, diabetes and some medications were each linked to a higher chance of it.² This page sorts the causes by how common and how well documented they are, and explains which clues point toward which cause.

What are the main causes of erectile dysfunction?

An erection needs healthy blood vessels, working nerves, normal hormones and a calm mind at the same time. A problem in any one of those can be enough. NIDDK lists the following.¹

The groups overlap. Diabetes damages both blood vessels and nerves, a long-term illness can bring depression, and some blood pressure medicines carry their own risk. That is why a single "cause" is the exception.

Which cause is most common?

Age comes first in the data, but age alone is not a cause you can change. In the Massachusetts Male Aging Study, a random community sample of men aged 40 to 70, the combined prevalence of minimal, moderate and complete impotence was 52%, and complete impotence tripled from 5% to 15% between ages 40 and 70. Age was the variable most strongly associated with it.² After adjusting for age, ED was more likely in men with heart disease, hypertension, diabetes, associated medications, and higher indexes of anger and depression, and less likely with higher HDL cholesterol.²

The study was done in 1987 to 1989 around Boston, so the exact percentages may not match today's men. The pattern, though, is the one NIDDK still describes: vascular and metabolic disease, medicines and mood sit behind most cases.¹ Our piece on how common ED is at 40 goes through the age data.

Can ED be a sign of heart disease?

It can be an early warning. In the placebo group of the Prostate Cancer Prevention Trial, 8,063 men aged 55 and older had no cardiovascular disease at the start, and 3,816 of them (47%) already had ED. Of 4,247 men without ED at entry, 2,420 (57%) reported new ED within five years. After adjustment for age, blood pressure, lipids, diabetes, smoking and more, new ED was linked to a hazard ratio of 1.25 for later cardiovascular events, and 1.45 for men with either new or existing ED. The authors compared that risk to the range seen with current smoking or a family history of heart attack, and concluded that ED should prompt investigation of cardiovascular risk factors.³

This is an association in one trial population, not a prediction for an individual man. It is the reason a clinician usually checks blood pressure, blood sugar and cholesterol when ED shows up, not just the sex-specific questions.

Could a medicine be the cause?

Possibly, and it is one of the more fixable causes. NIDDK names antidepressants, blood pressure medicines and diuretics, antihistamines, sedatives, some pain relievers and several others.¹ The Massachusetts study also found medications associated with ED after adjustment for age, although it could not separate the drug from the condition it treats.² Someone taking one of these should not stop it alone: stopping a blood pressure or antidepressant medicine can be harmful. The useful step is to bring the full list, including over-the-counter products and supplements, to a clinician and ask whether any could be involved. Our guide to questions to settle before an online ED prescription covers what to have ready.

Do stress, anxiety and depression cause ED?

They can cause it or make it worse. NIDDK lists anxiety, depression, stress, loneliness, low self-esteem and negative body image as contributors.¹ In the Massachusetts study, higher anger and depression indexes were each linked to ED after adjusting for age.² The direction runs both ways: ED itself can produce worry about performance, which makes the next attempt harder. A mental health cause does not rule out a physical one, and a physical cause often brings a mental one along with it.

Does lifestyle matter?

NIDDK names too little physical activity, heavy drinking, smoking and recreational drugs.¹ In the Massachusetts study, cigarette smoking was linked to a greater probability of complete impotence in men who already had heart disease or hypertension.² Alcohol is its own topic: see alcohol and ED medication for how it interacts with prescription treatment.

What clue do morning erections give?

Erections during sleep are a rough check that the plumbing and the hormones are working. In 3,888 men attending an outpatient ED clinic in Italy, 63.6% reported reduced sleep-related erections. After adjusting for testosterone and other factors, reduced sleep erections were still linked to higher body mass index, glucose and triglycerides and a higher 10-year cardiovascular risk score, and to depressive traits. The authors concluded that asking about them can help a clinician decide whether to look for an endocrine, organic or psychiatric background.⁴ That is a clinic population, not the general public, and a reduction in morning erections cannot diagnose a cause by itself. For the basics, see what morning wood is and whether it is unhealthy to not get it.

When is low testosterone the cause?

Less often than its reputation suggests. NIDDK lists low testosterone as one hormone cause among many.¹ Trials of testosterone treatment show clearer gains in desire than in erections, which we cover in is ED related to low testosterone.

What should happen next?

1. Write down when it started, whether it is every time or only some situations, and whether morning erections have changed.
2. List every medicine and supplement taken.
3. See a clinician for blood pressure, blood sugar, cholesterol and, where symptoms suggest it, a morning testosterone test. Our piece on which doctor to see for ED explains the options.
4. Do not rely on a quiz or an ad to name the cause. Several causes can be present at once.

Limits of the evidence

The prevalence figures come from a 1980s survey of men in one region, the heart-risk finding from men aged 55 and older in a prostate trial, and the sleep-erection finding from men already seeking ED care. Observational studies show association, not proof that fixing one factor restores function in a given man. NIDDK's list is a summary of what is known to contribute, with no ranking by frequency.

Your questions

What is the most common cause of erectile dysfunction?

There is rarely one. Age is the factor most strongly linked in a community survey, and after adjusting for age, heart disease, hypertension, diabetes, some medications and depression were each linked to more ED.

Can stress and anxiety cause ED?

Yes. NIDDK lists anxiety, depression, stress and low self-esteem as contributors, and ED can also create worry that makes the problem worse.

Which medicines can cause erectile dysfunction?

NIDDK lists antidepressants, blood pressure medicines and diuretics, antihistamines, sedatives, some pain relievers and others. Do not stop a medicine without asking the prescriber.

Can ED be a sign of heart disease?

It can be an early warning. In a trial of men aged 55 and older, new ED was linked to a higher risk of later cardiovascular events, so clinicians usually check blood pressure, blood sugar and cholesterol.

Do morning erections tell you the cause?

They are a clue, not a diagnosis. In a clinic study, reduced sleep-related erections were linked to higher glucose, BMI and cardiovascular risk and to depressive traits.

Read next

Part of our guide: Everyday ED Questions: Age, Alcohol, Testosterone and Myths

• Erectile Dysfunction in Young Men: How Common It Is, What Causes It and What to Do
• What Is Morning Wood? Why It Happens and What It Says About Sleep and Health
• Is It Unhealthy to Not Get Morning Wood? What Fewer Morning Erections Can Mean
• Is ED Related to Low Testosterone? What the Trials Show