Is ED a normal part of aging?

ED becomes more common with age — roughly 50% of men in their 50s and 60% of men in their 60s experience some degree of it — but it is not an inevitable or untreatable consequence of getting older. In many older men, ED is driven by correctable factors: cardiovascular disease, low testosterone, diabetes, or medication side effects. Many men in their 60s, 70s, and beyond maintain satisfying sexual function with appropriate management.

Can psychological issues cause ED?

Yes. Performance anxiety is one of the most common contributors to ED in younger men — fear of not achieving an erection creates a self-reinforcing cycle that itself impairs function. Depression, relationship difficulties, and significant life stress all contribute. Psychological ED is often distinguished by the presence of normal morning erections alongside difficulty during partnered sexual activity. Psychosexual therapy is effective and, in some provinces, is partially covered under extended health benefits.

Do PDE5 inhibitors (like Viagra or Cialis) work for everyone?

PDE5 inhibitors are effective in approximately 70–80% of men with ED, but they require sexual stimulation to work and do not increase libido. They are less effective in men with severe vascular disease or significant nerve damage. If one agent fails, switching to another or adjusting dose and timing is worthwhile before concluding the class is ineffective. They are contraindicated with nitrate medications used for heart disease, a combination that can cause a dangerous drop in blood pressure.

Is ED linked to heart disease?

Yes — the relationship is well established. ED and cardiovascular disease share common risk factors, and ED often precedes cardiac symptoms by three to five years because the smaller penile arteries show the effects of atherosclerosis earlier than the larger coronary arteries. Current guidelines recommend that ED in men over 40 without another obvious cause should prompt a cardiovascular risk assessment, including blood pressure, fasting lipids, and glucose.

Is ED treatment covered by provincial health insurance in Canada?

The diagnostic workup — bloodwork, physical exam, and specialist referral — is covered under provincial health plans. However, PDE5 inhibitors such as sildenafil and tadalafil are not listed on most provincial formularies and are typically paid out of pocket or through private drug benefits; costs range from roughly $10–$30 per dose for brand-name products, with generic sildenafil considerably cheaper. Testosterone replacement therapy, when medically indicated and prescribed, is covered under some provincial plans and many private benefit plans. Patients should confirm coverage with their insurer or pharmacist.

Erectile dysfunction — Glossary

What it is

Erectile dysfunction (ED) is the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity, affecting an estimated 40% of men by age 40 and approximately 70% by age 70. Also called impotence, ED is formally defined as the consistent or recurrent failure to attain or sustain a rigid erection adequate for intercourse — a distinction from the occasional difficulty that most men experience at some point and that does not, on its own, warrant medical concern.

ED is not an inevitable consequence of aging. In Canada, where roughly 3 million men are estimated to live with the condition, it is increasingly recognized as a potential early marker of cardiovascular disease, low testosterone, or diabetes — conditions that are independently treatable and that Canadian primary care guidelines recommend screening for when ED presents without an obvious cause. Because penile arteries are smaller than coronary arteries, atherosclerosis often shows up as ED three to five years before a man develops chest pain or a cardiac event.

Causes and mechanism

ED arises when any part of the erection pathway — vascular, neurological, hormonal, or psychological — is disrupted. In most men, more than one factor is present.

Vascular causes are the most common overall. Atherosclerosis reduces arterial blood flow to penile tissue; hypertension, dyslipidemia, diabetes, and smoking are the leading contributors.

Hormonal causes account for a meaningful subset:

Hormonal factor	Mechanism	Approximate prevalence in men with ED
Low testosterone (hypogonadism)	Reduces libido, impairs erectile tissue health	~30%
Elevated prolactin	Suppresses testosterone and sexual drive	Less common; important to exclude
Thyroid dysfunction	Both hypo- and hyperthyroidism impair erectile function	Variable
Excess estrogen (often obesity-related)	Suppresses testosterone via aromatization	Increasingly recognized

Neurological causes include autonomic neuropathy from diabetes, multiple sclerosis, spinal cord injury, and pelvic surgery.

Psychological causes — performance anxiety, depression, stress, and relationship conflict — are especially prominent in men under 40 and often interact with physical factors to worsen severity.

Medications are a frequently overlooked contributor: antihypertensives (particularly beta-blockers and thiazides), SSRIs, and antipsychotics can all impair erectile function as a side effect.

Symptoms and diagnosis

The core symptom is straightforward: difficulty getting or keeping an erection firm enough for intercourse, occurring consistently rather than occasionally. Associated features that help guide workup include:

Reduced libido, which points toward a hormonal cause
Absent morning erections, which suggests a physical rather than purely psychological origin
Sudden onset, which may indicate a psychological trigger or medication change, versus gradual onset, which is more typical of vascular or hormonal disease

A standard Canadian workup includes:

Medical and sexual history — frequency, severity, onset pattern, morning erections, libido
Hormone panel — total and free testosterone, prolactin, TSH, LH, FSH
Metabolic screen — fasting glucose, HbA1c, lipid panel, blood pressure
Psychological assessment — when anxiety, depression, or relationship factors are the primary suspected driver
Penile Doppler ultrasound — reserved for selected cases where vascular anatomy needs direct assessment

In Canada, hormone panels and metabolic bloodwork are covered under provincial health plans when ordered by a physician or nurse practitioner. LifeLabs and Dynacare both process these panels with results typically available within 24–48 hours.

Treatment options

Treatment is matched to the underlying cause and follows a stepwise approach.

Hormonal treatment: When low testosterone is confirmed on repeat testing, testosterone replacement therapy (TRT) improves libido and, in many men, erectile function directly. Hyperprolactinemia is treated with dopamine agonists; thyroid dysfunction with standard thyroid therapy.

First-line pharmacological treatment: Phosphodiesterase type 5 (PDE5) inhibitors — sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra) — are effective in approximately 70–80% of men. They work by enhancing nitric oxide-mediated smooth muscle relaxation in response to sexual stimulation; they do not produce an erection without arousal and do not increase libido. They are contraindicated with nitrate medications used for angina. In Canada, these drugs require a prescription and are not typically covered by provincial formularies, though some private benefit plans include them.

Second-line options:

Intracavernosal injections (ICI) of alprostadil or combination agents, injected directly into the penile shaft — highly effective even when oral therapy has failed
Vacuum erection devices — draw blood into the penis via negative pressure; non-pharmacological and available without a prescription
Intraurethral alprostadil (MUSE) — medication pellet delivered into the urethra

Third-line: Surgically implanted penile prostheses are reserved for refractory cases; patient satisfaction rates exceed 90% in appropriately selected men.

Lifestyle modification is effective across all severity levels: weight loss, aerobic exercise, smoking cessation, blood pressure control, and reducing alcohol intake all improve erectile function through vascular mechanisms and, in some cases, by raising testosterone.

When to see a clinician in Canada

Seek evaluation if ED is occurring in more than half of sexual attempts, has persisted for more than a few weeks, or is causing significant personal or relationship distress. New-onset ED — particularly in a man over 40 with no obvious psychological trigger — warrants cardiovascular and metabolic screening even if the sexual complaint itself seems minor.

Men under 40 with ED should be evaluated for hormonal causes; significant vascular disease is less common at this age and hormonal factors are more frequently identified. Canadian men can access initial assessment through a family physician, walk-in clinic, or virtual care platforms such as Felix, Maple, Phoenix, or Cleo, several of which offer online prescription services for PDE5 inhibitors following a clinical intake.

Limitations and open questions

Research is still emerging on several fronts. Low-intensity shockwave therapy has shown promise in early trials for vasculogenic ED, but Health Canada has not approved any device for this indication and the evidence base is not yet sufficient to recommend it outside a clinical trial. Platelet-rich plasma (PRP) and stem cell therapies are similarly investigational; men should be cautious about paying out of pocket for these outside a research setting.

The optimal testosterone threshold for initiating TRT in men with ED and borderline-low testosterone remains debated. The Endocrine Society guideline sets a biochemical threshold but acknowledges that symptom burden and individual context matter. It is also unclear whether treating ED pharmacologically reduces long-term cardiovascular risk, or whether the cardiovascular benefit comes only from treating the underlying vascular disease directly. Canadian-specific prevalence data and guideline updates from bodies such as the Canadian Urological Association are periodically revised as new evidence accumulates.

Erectile dysfunction