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Epidemiology & Treatment of Erectile Dysfunction

Educational Resource for clinicians who treat erectile dysfunction.

Kevin Campbell, Alvaro Santamaria, SMSNA Young Clinicians Committee

Provided by SMSNA
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Take Homes for Your Practice from Princeton 4: ED, CVD, and Sexual FunctionSMSNA

I. Epidemiology

A. Epidemiology Overview

 

Epidemiology Overview
Erectile dysfunction is a highly prevalent condition that increases with age and comorbid disease burden. Population-based studies estimate that over 150 million men worldwide experience some degree of ED, with projections exceeding 300 million by 2025. The Massachusetts Male Aging Study (MMAS) remains one of the most cited epidemiologic investigations, demonstrating that approximately half of men between 40 and 70 years experience some degree of erectile difficulty. Prevalence is strongly associated with cardiovascular disease, diabetes, obesity, and smoking - highlighting ED as both a quality-of-life concern and a potential early marker of systemic vascular disease.

 

Key Epidemiologic Points:

  • Global prevalence estimated at 150 million men in 1995, projected to rise to 322 million by 2025 (Ayta et al., BJU Int, 1999)

  • In the Massachusetts Male Aging Study, 52% of men aged 40–70 reported some degree of ED (Feldman et al., J Urol, 1994)

  • In the European Male Ageing Study (EMAS), they found that 30% of the cohort reported moderate or severe erectile dysfunction and similarly identified that prevalence increased with age (Corona et al., 2010)

  • The National Health and Social Life Survey was a probability sample study of sexual behavior looking at critical components of sexual health and identified that their oldest cohort of men (ages 50 - 59) were 3 times more likely to experience erection problems compared to the younger cohort (ages 18-29 years) (Laumann et al., 1999)

  • The prevalence of erectile dysfunction among men with diabetes exceeds 50%, and the condition demonstrates a significant association with hypertension, hyperlipidemia, and smoking (Selvin et al., Ann Intern Med, 2007)

  • ED often precedes symptomatic coronary artery disease by 2–5 years, serving as a sentinel marker for endothelial dysfunction (Montorsi et al., Eur Urol, 2003)

  • There is a paucity of incidence data, but in an epidemiologic review, the crude incidence of erectile dysfunction has been found to be 25.9 - 65.6 cases per 1000 man years. Unsurprisingly, in these studies, incidence increased with age (Hatzimouratidis, 2007). 

 

Reference

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The Young Clinicians Committee is dedicated to supporting and promoting the needs of young clinicians in sexual medicine. It aims to improve their representation across various subspecialties within the SMSNA and encourage their active involvement in the society. Key responsibilities include facilitating the participation of young clinicians in roles such as mentors, speakers, moderators, committee leaders, and journal reviewers. The committee also supports research projects led by young clinicians through a multi-center framework. Additionally, it hosts mixers at AUA Sectional meetings to introduce young urologists to sexual medicine and SMSNA, as well as mixers at the AUA and Fall Scientific Meetings.

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I. Epidemiology
A. Epidemiology Overview

 

Epidemiology Overview
Erectile dysfunction is a highly prevalent condition that increases with age and comorbid disease burden. Population-based studies estimate that over 150 million men worldwide experience some degree of ED, with projections exceeding 300 million by 2025. The Massachusetts Male Aging Study (MMAS) remains one of the most cited epidemiologic investigations, demonstrating that approximately half of men between 40 and 70 years experience some degree of erectile difficulty. Prevalence is strongly associated with cardiovascular disease, diabetes, obesity, and smoking - highlighting ED as both a quality-of-life concern and a potential early marker of systemic vascular disease.

 

Key Epidemiologic Points:

  • Global prevalence estimated at 150 million men in 1995, projected to rise to 322 million by 2025 (Ayta et al., BJU Int, 1999)

  • In the Massachusetts Male Aging Study, 52% of men aged 40–70 reported some degree of ED (Feldman et al., J Urol, 1994)

  • In the European Male Ageing Study (EMAS), they found that 30% of the cohort reported moderate or severe erectile dysfunction and similarly identified that prevalence increased with age (Corona et al., 2010)

  • The National Health and Social Life Survey was a probability sample study of sexual behavior looking at critical components of sexual health and identified that their oldest cohort of men (ages 50 - 59) were 3 times more likely to experience erection problems compared to the younger cohort (ages 18-29 years) (Laumann et al., 1999)

  • The prevalence of erectile dysfunction among men with diabetes exceeds 50%, and the condition demonstrates a significant association with hypertension, hyperlipidemia, and smoking (Selvin et al., Ann Intern Med, 2007)

  • ED often precedes symptomatic coronary artery disease by 2–5 years, serving as a sentinel marker for endothelial dysfunction (Montorsi et al., Eur Urol, 2003)

  • There is a paucity of incidence data, but in an epidemiologic review, the crude incidence of erectile dysfunction has been found to be 25.9 - 65.6 cases per 1000 man years. Unsurprisingly, in these studies, incidence increased with age (Hatzimouratidis, 2007). 

 

Reference

B. Risk & Etiologies

Most common comorbid conditions and conditions common in older men (diabetes, cardiovascular disease, hypertension, obesity, smoking, prostate cancer) are strongly associated with ED, which are all quite well studied and noted in the literature. Among diabetic men, prevalence is especially high: multiple papers found about 60-70% report ED symptoms.

Vascular cause (most common organic etiology)

  • ED is primarily vascular disorder; atherosclerosis and endothelial dysfunction reduce blood flow to the penis.

  • Strongly associated with cardiovascular disease, hypertension, hyperlipidemia, and peripheral artery disease.

  • ED often precedes cardiovascular symptoms by 3–5 years, acting as an early clinical marker.

 

References

Metabolic conditions

  • Diabetes mellitus is a major risk factor, associated with 2–3x increased ED risk.

  • Mechanisms include neuropathy, endothelial dysfunction, and impaired nitric oxide pathways.

  • Poor glycemic control worsens severity.

 

References

Neurological causes

  • Includes spinal cord injury, multiple sclerosis, Parkinson’s disease, stroke, and peripheral neuropathies.

  • These impair central or peripheral neural pathways essential for initiating and maintaining erections.

 

Reference

Endocrine/hormonal factors

  • Hypogonadism can reduce libido and impair erectile capacity.

  • Hyperprolactinemia, thyroid disorders, and Cushing’s syndrome may also contribute.

 

Reference

 

Guidelines

 

Consensus Statement

Psychogenic causes
  • More common in younger men and in situational ED; includes performance anxiety, depression, relationship issues, and stress.
  • Often coexists with organic factors ("mixed ED").

 

Reference

  • Shabsigh et al., J Urol, 2006
Medications and drugs

  • Common medications causing ED include antihypertensives (especially beta-blockers, thiazides), SSRIs, antipsychotics, 5alpha-reductase inhibitors, and opioids.

  • Alcohol, tobacco, recreational drugs (e.g. cocaine, marijuana) also negatively impact erectile function.

 

References

  • Corona G, Mannucci E, Mansani R, Petrone L, Bartolini M, Giommi R, Mancini M, Forti G, Maggi M. Aging and pathogenesis of erectile dysfunction. Int J Impot Res. 2004 Oct;16(5):395-402. doi: 10.1038/sj.ijir.3901225. PMID: 15164087.

  • Baumgarten et al., BMJ, 2022

Pelvic surgery or trauma
  • Radical prostatectomy, bladder surgery, or colorectal surgery can damage nerves or vasculature.
  • Pelvic radiation (e.g. for prostate cancer) also a known risk.

 

Reference

  • Nelson et al., JAMA, 2004.
Lifestyle and behavioral factors

  • Obesity, physical inactivity, smoking, and poor diet are associated with ED via vascular and hormonal mechanisms.

  • Weight loss and exercise improves erectile function.

 

Reference

 

Position Statement:

Sleep disorders

  • Particularly obstructive sleep apnea, which is linked to ED through hypoxia and hormonal disruption.

 

Reference

Peyronie’s disease

 

Peyronie’s Disease Overview

Peyronie’s disease (PD) is an acquired fibrotic disorder of the penile tunica albuginea that results in curvature, deformity, pain, and can be associated with erectile dysfunction. The condition is thought to arise from microtrauma to the penis, triggering an abnormal wound-healing response with excessive collagen deposition. PD can have significant physical and psychological effects, often coexisting with ED due to shared vascular and fibrotic mechanisms that impair penile rigidity and function.

 

Key Points:

  • Prevalence: Estimated to affect 3–9% of adult men, with higher rates among men with ED and diabetes. Furthermore, the true prevalence of Peyronie’s disease is likely underestimated, as many affected men may be reluctant to seek medical evaluation or treatment due to the sensitive and stigmatizing nature of the condition. (Mulhall et al., JUrol, 2004; Dibenedetti et al., Adv Urol. 2011).

 

  • Etiology: Typically results from microtrauma during intercourse, leading to inflammation and disorganized collagen deposition in the tunica albuginea (Gonzalez-Cadavid & Rajfer, Nat Clin Pract Urol. 2005).

 

  • Phases of Disease:

    • Acute (Active) Phase: ~3-6 months; associated with penile pain and evolving penile deformity (Hussein et al., Asian J Urol., 2015, Nguyen et al., Urology, 2020)

    • Chronic (Stable) Phase: Pain subsides; curvature and deformity stabilize due to mature fibrosis (Hussein et al., Asian J Urol., 2015)

 

  • Clinical Features:

    • Penile curvature, indentation (“hourglass” deformity), shortening

    • Palpable plaque

    • Penile pain (most pronounced in acute phase)

    • Erectile dysfunction in up to 30% of patients (Mulhall et al., J Urol, 2006)

 

  • Association with Erectile Dysfunction:

    • ED and PD frequently coexist; both reflect penile vascular insufficiency and corporal fibrosis (Gonzalez-Cadavid & Rajfer, Nat Clin Pract Urol. 2005).

    • Deformity can cause mechanical difficulty with penetration and psychogenic distress, worsening erectile function

 

  • Risk Factors: Penile trauma, Dupuytren’s contracture, increasing age, diabetes, and smoking (Dibenedetti et al., Adv Urol. 2011).

 

  • Diagnosis: Primarily clinical, supported by penile ultrasound to evaluate for plaque, calcification, and vascular status

 

  • Treatment:

    • Non-surgical: Oral agents (acute phase), intralesional collagenase Clostridium histolyticum (chronic phase), and penile traction therapy

    • Surgical: Indicated for stable deformity impairing intercourse – can include plication, plaque incision/excision and grafting, or penile prosthesis for men with concurrent ED

 

Selected References

  1. Mulhall JP, Creech SD, Boorjian SA, Ghaly S, Kim ED, Moty A, Davis R, Hellstrom W. Subjective and objective analysis of the prevalence of Peyronie's disease in a population of men presenting for prostate cancer screening. J Urol. 2004 Jun;171(6 Pt 1):2350-3. doi: 10.1097/01.ju.0000127744.18878.f1. PMID: 15126819.

  2. Dibenedetti DB, Nguyen D, Zografos L, Ziemiecki R, Zhou X. A Population-Based Study of Peyronie's Disease: Prevalence and Treatment Patterns in the United States. Adv Urol. 2011;2011:282503. doi: 10.1155/2011/282503. Epub 2011 Oct 23. PMID: 22110491; PMCID: PMC3202120.

  3. Gonzalez-Cadavid NF, Rajfer J. Mechanisms of Disease: new insights into the cellular and molecular pathology of Peyronie's disease. Nat Clin Pract Urol. 2005;2(6):291-297. doi:10.1038/ncpuro0201

  4. Hussein AA, Alwaal A, Lue TF. All about Peyronie's disease. Asian J Urol. 2015;2(2):70-78. doi:10.1016/j.ajur.2015.04.019

  5. Nguyen HMT, Yousif A, Chung A, et al. Safety and Efficacy of Collagenase Clostridium histolyticum in the Treatment of Acute Phase Peyronie's Disease: A Multi-institutional Analysis. Urology. 2020;145:147-151. doi:10.1016/j.urology.2020.07.048

  6. Mulhall JP, Schiff J, Guhring P. An analysis of the natural history of Peyronie's disease. J Urol. 2006;175(6):2115-2118. doi:10.1016/S0022-5347(06)00270-9

 

Guidelines:

C. Burden of Erectile Dysfunction

Quality of Life of Impacts

  • Men with ED report significantly lower health‐related quality of life metrics than those without, including both mental and physical domains in multiple studies.
  • Partners/female partners are also affected: decreased sexual satisfaction, relationship difficulties, lower engagement in sexual activity, etc - particularly well documented in study by Burnett et al. 
  • Psychological consequences include lowered self‐esteem, emotional distress, depression, anxiety. Men often report shame, feelings of inadequacy, and strain in intimate relationships.
Mental Health Toll
  • High co‐occurrence of depression and anxiety among men with ED: one cross‐sectional study found 65% with depression and 38% with anxiety - with severity of ED being associated with worse mental health - noted by Xiao et al.
  • ED has also been shown to be significantly associated with higher odds of depression and/or anxiety, particularly in age groups 45‑55 via Sugimori et al.

 

Many men with ED do not seek treatment; stigma, embarrassment, under‐recognition, or thinking it’s a “normal” part of aging contribute. This means the burden may be under‐measured. Severity matters: more severe ED is associated with worse quality of life, more mental health issues, greater productivity loss - all of the above noted by Burnett et al. Because ED is also a marker of underlying health issues (vascular disease, diabetes, etc.), addressing ED can have upstream benefits. 

Economic Burden of Erectile Dysfunction

Work Productivity Loss

  • Men with ED show substantially higher absenteeism (missing work), presenteeism (working but impaired), and overall work productivity impairment compared to men without ED. For example, in an international survey (8 countries; men aged 40‑70), absenteeism 7.1% vs 3.2%, presenteeism 22.5% vs 10.1% overall productivity impairment 24.8% vs 11.2% - shown by Goldstein et al.
     

Overall Costs

  • If employer‐sponsored insurance plans exclude benefits for penile prosthesis implantation, that exclusion could cost U.S. employers $9.3 billion/year in lost productivity due to ED (Burnett et al.)

 

In the UK in 1997/98: the socioeconomic burden of ED on society was estimated at 53 million pounds/year, of which 43.9 million pounds was NHS direct cost.  Outpatient visits were the biggest driver (65%), then GP prescriptions (25%), with smaller shares for surgeries, tests, etc. Loss of productivity accounted for a smaller share (Plumb et al.)

II. Therapeutic Options

Here, we review three commonly utilized therapeutic options:

  • PDE5 inhibitors

  • Intraurethral alprostadil (MUSE)

  • Intracavernosal injection therapy—with a focus on mechanisms of action, efficacy, patient selection, and clinical considerations.

 

Guidelines

 

Position Statement:

 

A. Phosphodiesterase Type 5 (PDE5) Inhibitors

PDE5 inhibitors are the established first-line pharmacologic therapy for ED due to their non-invasive administration and favorable safety profile. These agents—sildenafil, tadalafil, vardenafil, and avanafil—act by inhibiting the PDE5 enzyme, thereby augmenting cyclic guanosine monophosphate (cGMP) concentrations in cavernosal smooth muscle. This results in smooth muscle relaxation and enhanced penile arterial inflow in response to sexual stimulation.

 

Efficacy: PDE5 inhibitors demonstrate response rates of 60–80% in general ED populations, with slightly lower rates in diabetics and post-prostatectomy patients. Tadalafil's prolonged half-life permits daily dosing, which may be beneficial in men with LUTS or those seeking more spontaneity.

 

Considerations: All agents require intact neural pathways to the penis; thus, efficacy may be limited in neurogenic ED or after nerve-sparing surgery with incomplete recovery. Contraindications include concurrent nitrate use or severe hypotension. Counseling should emphasize the necessity of sexual stimulation and the potential need for multiple attempts before efficacy is determined.

 

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Position Statement:

B. Intracavernosal Injection Therapy (ICI)

Intracavernosal injection (ICI) therapy remains the most efficacious non-surgical option for ED, with response rates exceeding 80%, even in severe neurogenic or vasculogenic cases. Agents used include alprostadil (monotherapy) or compounded mixtures such as bimix (papaverine + phentolamine), trimix (papaverine + phentolamine + alprostadil), and quadmix (adding atropine).

 

Mechanism: These agents act via direct smooth muscle vasodilation through diverse intracellular pathways—cAMP, cGMP, and alpha-adrenergic blockade—bypassing the need for neural input. This makes ICI particularly useful in post-prostatectomy and diabetic populations.

 

Considerations: Proper patient selection and education are essential to minimize complications. Adverse effects include penile pain (particularly with alprostadil), priapism, fibrosis, and ecchymosis. Dose titration should be individualized, ideally under supervised in-office teaching. Regular rotation of injection sites and adherence to dosing frequency guidelines (no more than 3x/week) help mitigate fibrosis and scarring.

C. Intraurethral Alprostadil (MUSE) – included mostly for historic reasons

Intraurethral Alprostadil (MUSE) – included mostly for historic reasons

The Medicated Urethral System for Erection (MUSE) delivers alprostadil via a transurethral suppository. Alprostadil, a synthetic prostaglandin E1, directly stimulates adenylate cyclase, increasing intracellular cAMP and promoting smooth muscle relaxation independent of nitric oxide pathways.

 

Efficacy: Reported response rates vary, with 30–60% of men achieving erections sufficient for intercourse. MUSE may be particularly useful in patients contraindicated for systemic therapies or who prefer a non-injectable, non-oral option.

 

Considerations: Common side effects include penile or urethral discomfort, minor urethral bleeding, and a burning sensation. Systemic hypotension is rare but can occur, especially in patients with poor baseline cardiovascular status. Patients must be counseled on proper administration technique and the importance of pre-voiding to facilitate urethral absorption. This therapy has fairly low success and is increasingly challenging to find in pharmacies.

D. Summary

Treatment selection for ED should be tailored to the underlying etiology, patient preference, comorbidities, and previous therapy outcomes. While PDE5 inhibitors remain the mainstay for most men, intracavernosal therapy offers a therapeutic alternative for those with contraindications or poor response. Shared decision-making, trial and error, and patient education remain central to optimizing outcomes and adherence.

III. Assessments for ED
Digital Assessments

To support both healthcare professionals and patients, the SMSNA provides access to a collection of validated questionnaires and self-assessment apps. These tools can be used by clinicians and researchers to evaluate sexual health in clinical and research settings, and by patients who wish to better understand their own sexual function, satisfaction, and related health concerns. The following instruments are available for use. Here are a few assessments to consider in the evaluation of ED. SMSNA offers a suite of digital Sexual Medicine assessments. Visit SMSNA for a full list of available assessments.

 

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