Few men notice a change in their erections early, and many wait years before they mention it. Large studies suggest the change is also useful information about the heart and blood vessels. This page sets out the published numbers, what we check when a man brings it to us, and where the evidence stops.
How common it becomes
In the Massachusetts Male Aging Study, a long-running population study of men in Massachusetts, the yearly rate of new erectile dysfunction rose with each decade of age: 12.4 new cases per 1,000 man-years at 40 to 49, 29.8 at 50 to 59, and 46.4 at 60 to 69. The risk was higher in men with diabetes, heart disease and hypertension.
The study did not ask about erections directly. It assigned each man a degree of impotence from related questions. That is a practical method for a population survey, but it is not a clinical examination.
What it is associated with
In a systematic review of cohort studies, Vlachopoulos and colleagues pooled 14 studies with 92,757 men followed for a mean of 6.1 years. Men with erectile dysfunction had a higher risk of cardiovascular events (relative risk 1.44, 95% CI 1.27 to 1.63), myocardial infarction (1.62, 1.34 to 1.96), cerebrovascular events (1.39, 1.23 to 1.57) and death from any cause (1.25, 1.12 to 1.39).
Cardiovascular death alone (1.19, 0.97 to 1.46) did not reach statistical significance. The risk was higher at younger ages and in men at intermediate cardiovascular risk. In men with diabetes, a separate meta-analysis of cohort studies also found more cardiovascular events (odds ratio 1.74, 95% CI 1.34 to 2.27).
A shared cause
Erectile function depends on blood flow, and so does the heart. Weight, activity and the habits that drive heart risk also move erections. In a randomized trial, Esposito and colleagues gave 55 obese men with erectile dysfunction an intensive program to lose 10% or more of their body weight, and 55 men general advice. At the end, 17 men in the program had an IIEF score of 22 or more, against 3 of the control men (P = .001). Changes in BMI and in physical activity were independently associated with changes in IIEF score.
The trial did not measure heart events. Its message is narrower: the lifestyle factors that matter for heart risk also moved erectile function.
What we check
- Blood pressure, cholesterol and blood sugar, and how they have changed over time.
- Waist, weight and activity, since these moved erectile function in the trial above.
- Smoking, alcohol and sleep habits.
- Every medicine and supplement you take, especially nitrates, which cannot be combined with PDE5 inhibitors.
- When there is known heart disease, whether exercise tolerance is adequate before sexual activity or erection treatment.
What the consensus says
The Princeton III consensus panel met in 2010 and was published in 2012. It recommends that men with erectile dysfunction and no known heart disease be assessed for cardiovascular risk, and that those who may need a cardiac work-up be identified early. For men with known heart disease, it addresses whether their cardiovascular status can support sexual activity. A consensus is expert opinion, not a trial result.
What this does not say
- These are associations from observational studies. Men with erectile dysfunction may differ from other men in ways the studies did not measure.
- A relative risk of 1.44 is a group average. It does not tell you your own risk, and it does not show that erectile dysfunction causes heart disease.
- The Esposito trial was single-blind and small, and it measured erectile function, not heart outcomes.
- Results vary with how erectile dysfunction was measured: questionnaires gave a higher risk estimate than a single question (1.61 versus 1.27).
How we use this
When a man tells us his erections have changed, we treat it as a question to answer, not a private embarrassment. That means a blood pressure check, basic bloodwork, a review of medicines and a conversation about heart symptoms. The findings above are the reason.
We do not use these numbers to frighten anyone. They explain why a change in performance is worth a proper look.
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- 1.Johannes CB et al. Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts Male Aging Study. J Urol. 2000;163:460-463. The Journal of Urology
- 2.Vlachopoulos CV et al. Prediction of cardiovascular events and all-cause mortality with erectile dysfunction: a systematic review and meta-analysis of cohort studies. Circulation: Cardiovascular Quality and Outcomes. 2013. Circulation: Cardiovascular Quality and Outcomes
- 3.Yamada T et al. Erectile dysfunction and cardiovascular events in diabetic men: a meta-analysis of observational studies. PLoS One. 2012;7(9):e43673. PLoS One
- 4.Esposito K et al. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial. JAMA. 2004;291(24):2978. JAMA
- 5.Nehra A et al. The Princeton III consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc. 2012;87(8):766-778. Mayo Clinic Proceedings
- 6.Kloner RA et al. Effect of phosphodiesterase type 5 inhibitors on major adverse cardiovascular events and overall mortality in a large nationwide cohort of men with erectile dysfunction and cardiovascular risk factors. J Sex Med. 2023;20(1):38-48. The Journal of Sexual Medicine