Erectile Dysfunction: Facts and Treatments

How does an erection work?

A normal erection requires four systems to work together: the brain and nerves (signaling), the blood vessels (delivering blood to the erectile tissue), the hormones (testosterone in particular), and the psychological state. If any one of these is impaired, the system can fail. This is why effective ED treatment starts with finding WHICH system is the problem — not just prescribing the same pill to everyone.

Roughly 30 million men in the United States are affected by ED. By age 40, around 40% of men experience some degree of it. By age 70, that figure is closer to 70%. And yet fewer than 1 in 4 men with ED ever seek treatment. If you are reading this, you are already ahead of most.

What causes ED?

ED has many possible causes, and most cases involve more than one at a time. Identifying the actual driver — not just the symptom — is the difference between a one-size-fits-all prescription and a treatment plan that actually works.

• Vascular causes — atherosclerosis, diabetes, high blood pressure, high cholesterol and metabolic syndrome, obesity, and low testosterone (hypogonadism).
• Neurological causes — nerve damage from spinal cord injury, multiple sclerosis, Parkinson's disease, or pelvic surgery — particularly radical prostatectomy.
• Psychological causes — performance anxiety is both a cause of ED and an amplifier of it. Psychological ED is especially common in younger men and almost always responds well to treatment.
• Medication-induced ED — over 200 medications list ED as a potential side effect. Common culprits include thiazide diuretics, beta-blockers, SSRIs, and antiandrogens.

Can ED be a warning sign of heart disease?

This is one of the most important — and least talked about — facts in modern urology: erectile dysfunction frequently precedes cardiovascular disease by 3 to 5 years. The penile arteries are approximately 1-2 mm in diameter — among the smallest in the body. When atherosclerosis begins narrowing blood vessels throughout the body, the smallest ones show symptoms first.

An ED evaluation at a urologist's office is not just about improving sexual function. For men over 40, it is also one of the earliest practical screens for cardiovascular disease. Dr. Lief coordinates with cardiologists and primary care physicians when an ED workup reveals underlying vascular concerns.

When should ED be evaluated promptly?

• ED that develops suddenly or worsens quickly
• ED in a man under 40, especially with no obvious psychological cause
• ED accompanied by chest pain, shortness of breath, leg swelling, or unexplained fatigue
• ED accompanied by significant urinary symptoms (possible BPH overlap)
• ED accompanied by low energy, low libido, mood changes, or muscle loss (possible low testosterone)
• ED that began after starting a new medication

Which lifestyle changes help ED?

The lifestyle changes with the strongest evidence for improving erectile function are, in order: quitting smoking, regular aerobic exercise (especially walking, cycling, or swimming most days), weight loss in men carrying excess weight, treating sleep apnea, and reducing alcohol intake. None of these replace medical treatment when ED is established — but they amplify the results of every treatment on the ladder.

The complete ED treatment ladder

Effective ED care is not one-size-fits-all. At Lief Urology, every treatment plan starts with finding the actual cause — then matches it to the lowest-intensity tier that's likely to work. Most local men's health clinics offer one or two of the options below. Lief Urology offers all six.

• Tier 1 — Oral medications (PDE5 inhibitors) such as Viagra (sildenafil), Cialis (tadalafil), Levitra, Staxyn and Stendra.
• Tier 2 — Penile injections.
• Tier 3 — Medical-grade low-intensity shockwave therapy (LiSWT).
• Tier 4 — Platelet-rich plasma (PRP), injected into penile tissue to support natural regeneration. Strongest evidence in combination with LiSWT.
• Tier 5 — Combination protocols: LiSWT + PRP, LiSWT + Emsella (pelvic floor strengthening), and customized multi-modal plans for men whose ED has more than one underlying driver.
• Tier 6 — Surgical options (penile implant), reserved for men who have not responded to other treatments.

LiSWT vs. radial wave therapy

Not all 'shockwave therapy' is the same. True LiSWT delivers FOCUSED acoustic waves at precisely calibrated low-energy levels into the penile tissue. Radial wave therapy — sometimes marketed as acoustic wave therapy — disperses acoustic energy in a spreading, radial pattern rather than focusing it. They are NOT the same modality as LiSWT, and they have not demonstrated the same clinical outcomes.

Before starting any shockwave treatment for ED — at any practice, anywhere — ask one question: What specific device do you use, and is it focused LiSWT or radial wave? Lief Urology uses medical-grade LiSWT equipment.

What to expect at your first consultation

The first visit is private, conversational, and unhurried. Patients who speak Spanish are welcome to do so — Dr. Lief is bilingual.

• Step 1 — Confidential conversation about your symptoms, their duration, and any related concerns.
• Step 2 — Focused physical exam, which typically takes only a few minutes.
• Step 3 — Diagnostic testing as needed, such as blood work to check testosterone, blood sugar, cholesterol, thyroid, PSA, and other markers.
• Step 4 — Personalized treatment plan. You leave with a plan, not a prescription pad.

Download the full patient guide

This article is drawn from Dr. Lief's patient education guide, Erectile Dysfunction: Facts and Treatments (PDF).