If you’re having trouble getting or keeping an erection firm enough for sex, and it’s happening repeatedly, you likely have some degree of erectile dysfunction. It’s not diagnosed from a single bad night. The key distinction is a pattern: erections that are consistently unreliable over several weeks or longer. About 39% of men experience some degree of ED by age 40, rising to 67% by age 70, so this is far more common than most people assume.
The trickier question is figuring out what’s causing it and how serious it is. Here’s how to evaluate what you’re experiencing.
Five Questions That Gauge Severity
Doctors use a simple five-question screening tool called the Sexual Health Inventory for Men (SHIM) to assess ED. You can ask yourself these same questions and rate each one on a scale of 1 (worst) to 5 (best):
- Confidence: How confident are you that you could get and keep an erection?
- Firmness: When you’re aroused, how often are your erections hard enough for penetration?
- Maintaining during sex: How often can you keep your erection after penetration?
- Difficulty sustaining: How difficult is it to maintain your erection through completion?
- Satisfaction: When you attempt intercourse, how often is it satisfactory?
Your total score falls between 5 and 25. A score of 22 to 25 indicates no ED. Between 17 and 21 is mild. Scores of 12 to 16 fall into the mild-to-moderate range, 8 to 11 is moderate, and 5 to 7 is severe. This isn’t a formal diagnosis, but it gives you a concrete way to measure what you’re experiencing and track whether it changes over time.
The Morning Erection Test
One of the simplest clues to what’s going on is whether you still get erections during sleep or when you first wake up. Your body naturally produces erections throughout the night, typically three to five times per sleep cycle. These happen automatically, without any mental arousal, and they test whether the physical plumbing (blood flow, nerves, tissue) is working correctly.
If you regularly wake up with an erection, or notice firm erections during the night, the physical machinery is almost certainly intact. That points toward a psychological or situational cause: stress, performance anxiety, relationship tension, or depression. If morning erections have disappeared or become noticeably weaker, something physical is more likely involved, such as reduced blood flow, nerve damage, or a hormonal issue.
This isn’t a perfect test. Impaired nighttime erections don’t completely rule out a psychological cause, and you may simply not notice erections that happen in earlier sleep stages. But it’s a useful starting signal.
Sudden Onset vs. Gradual Decline
How your symptoms started tells you a lot. ED that comes on suddenly, seemingly overnight, is more likely psychological in origin. A major life stressor, a new relationship, financial pressure, anxiety about sexual performance: these can all switch off arousal quickly and completely. You may notice that erections work fine in some situations (masturbation, morning, with a different partner) but fail in others.
ED that develops gradually over months or years, where erections slowly become less firm or less reliable, points more strongly to a physical cause. This pattern is typical when blood vessels narrow over time due to high blood pressure, high cholesterol, or diabetes. It tends to affect all erections equally, including nighttime and morning ones.
Many men have a mix of both. A physical issue makes erections slightly less reliable, which creates anxiety, which makes things worse. Recognizing this overlap matters because treating only one side often isn’t enough.
What ED Can Signal About Your Health
Erections depend on healthy blood flow. The arteries supplying the penis are smaller than those supplying the heart, so they tend to show the effects of cardiovascular damage earlier. Research from the American Heart Association has found that ED is an independent predictor of future cardiovascular events like heart attacks and strokes. In many cases, erection problems show up years before any chest pain or other cardiac symptoms.
This is why doctors take ED seriously beyond sexual health. It can be an early warning sign of diabetes, high blood pressure, high cholesterol, or metabolic syndrome. The combined prevalence of moderate to complete ED rises from about 22% at age 40 to 49% by age 70, and much of that increase tracks directly with the accumulation of cardiovascular risk factors.
If you’re under 50 and noticing a gradual decline in erection quality with no obvious psychological explanation, it’s worth treating that as a signal to check your cardiovascular health, not just your sexual function.
What Happens at a Medical Evaluation
If you see a doctor about ED, the visit is straightforward and less invasive than most people expect. It typically starts with a medical history and questions similar to the five listed above. The doctor will ask about medications you take (many common drugs affect erections), your stress levels, alcohol and tobacco use, and any chronic health conditions.
A physical exam checks for blood vessel and nerve function, hormonal issues, and any structural problems with the penis such as Peyronie’s disease (scar tissue that causes curvature). The doctor may check pulses in your legs and feet, which reveals how well blood is flowing through your lower body.
Blood work is the other main component. At minimum, this includes a morning testosterone level, since testosterone peaks around 8 AM and dropping levels can directly impair erections. Depending on your age and risk factors, the doctor may also check blood sugar and hemoglobin A1c (screening for diabetes), a lipid panel (cholesterol and triglycerides), and thyroid function. If testosterone comes back low, additional hormone tests help pinpoint why.
The entire process is designed to separate physical causes from psychological ones, identify any underlying health problems, and figure out the best treatment approach. For most men, no imaging or invasive testing is needed.
Patterns That Are Normal vs. Concerning
Not every erection problem is ED. Occasional difficulty is a normal part of life. Alcohol, fatigue, stress, distraction, and simply not being in the mood can all interfere with a single encounter. If it happens once or twice and then resolves on its own, that’s not a medical issue.
The line shifts when you notice a pattern. If erection problems happen more than half the time you attempt sex, persist for more than a few weeks, or are getting progressively worse, that fits the clinical picture of ED. Other signs that something beyond a bad night is going on: reduced sex drive alongside erection problems (which can signal low testosterone), needing significantly more stimulation than you used to, or losing your erection consistently at the same point during sex.
Age matters for context but not as a dismissal. While ED becomes more common with age, it’s not an inevitable part of aging. Plenty of men in their 70s have reliable erections, and plenty of men in their 30s don’t. The presence of symptoms at any age warrants attention, because the underlying cause is usually treatable.