Sexual Dysfunction – Symptoms
Conditions · Sexual dysfunction · Symptoms and stages
Erectile dysfunction symptoms and stages: how to tell if you have ED, and how far it has gone
Erectile dysfunction rarely starts with an erection that will not come at all. It starts with one that is a little slower, a little softer, that fades during intercourse or is no longer there in the morning, and men explain those away for years. This page lists the early signs most men ignore, the stages the condition passes through, the symptoms that usually come with it and point to its cause, and a five-question check you can do now.
Symptoms at a glance
The early signs of erectile dysfunction
Slower to come
More stimulation is needed, for longer, before the erection is usable. Fantasy alone no longer does it.
Softer than it was
Firm enough for penetration but not as hard as a year ago: the “semi” erection men describe, rigid at the tip or the base but not both.
Shorter-lived
It comes, but it goes: during foreplay, while changing position, when putting on a condom, or a minute or two into intercourse.
Less reliable
Good one night, poor the next, with no obvious reason. Men blame tiredness, drink or the partner; the pattern is the message.
Needs a specific situation
Works alone or in one position but not in another, or works in the morning but not at night.
Anxiety arrives
The first failure makes the second more likely. Watching the erection instead of enjoying sex is itself a symptom of the stage the problem has reached.
Morning erections: the early warning most men notice and ignore
Healthy men have several erections during sleep every night and wake with one most mornings. They have nothing to do with desire; they are the erectile system exercising itself, and they depend on the nerves, arteries and tissue of the penis working properly. This makes them the best free test there is. A man who still wakes with firm erections but fails with a partner has, in most cases, a psychological or situational problem. A man whose morning erections have become rarer, softer or have disappeared has an organic one, whatever his age and whatever his bloods say.
The loss is usually gradual, over months, which is why it is missed. It often starts alongside two other quiet changes: a shorter time to ejaculation and a slight urinary symptom, and that combination, in our experience, points straight at the prostate. How an inflamed prostate weakens erections.
Why the erection is lost during intercourse
An erection is kept by two things: a steady nerve signal that holds the arteries open, and healthy erectile tissue that compresses the veins and traps the blood. When the tissue has begun to fibrose, or the nerve signal is weakened by a strangled cavernous nerve, the trap leaks: the erection can be achieved with strong stimulation but cannot be held once the stimulation becomes steady, so it fades during penetration, while changing position or with any pause. Anxiety adds an adrenaline surge that closes the arteries further. Losing the erection during sex is therefore not a sign that “the mind wandered”; it is usually the earliest sign of venous leak and fibrosis, and the stage at which treatment of the cause gives the best results.
The stages of erectile dysfunction
Erectile dysfunction is graded by how hard the erection gets and how often it is good enough. Knowing the stage matters, because the treatment differs.
Stage 1: mild
Erections are achieved and usually maintained, but they are less firm and less reliable than before; morning erections are fewer; more stimulation is needed. Most men at this stage have not told anyone. The cause is usually fully reversible now, and the erectile tissue is intact.
Stage 2: moderate (the semi-rigid stage)
The erection is hard enough for penetration only sometimes, or only at the beginning; it is lost during intercourse in many attempts; a pill is often being used. Fibrosis of the erectile tissue has begun, and the venous trap leaks. Treating the cause is still the priority, but the tissue now needs help too.
Stage 3: severe
The erection is rarely or never hard enough for penetration, even with pills; it may swell but not stiffen. Fibrosis is established and the arteries and nerves are significantly damaged. Rehabilitation of the erectile tissue (injections, vacuum, shockwaves, PRP) is needed alongside treatment of the cause, and results take longer.
Stage 4: complete
No erection under any circumstances, including sleep. Usually after surgery, radiotherapy, spinal injury or decades of untreated disease. Function can still often be restored for intercourse with injections; the earlier rehabilitation starts, the more tissue is saved.
Doctors also grade a single erection on a four-point hardness scale: 1, larger but not hard; 2, hard but not enough for penetration; 3, hard enough for penetration but not fully rigid; 4, fully rigid. Most men who consult us are living at grade 2 to 3 and calling it “a bit weaker”.
Symptoms of ejaculation and desire that go with it
Premature ejaculation
Coming sooner than you used to, with less control, sometimes before penetration. In a man who used to last, it is a strong sign of an irritated, hypersensitive prostate. Ejaculation problems explained.
Weak or reduced ejaculation
Less semen, less force, a dribble instead of a spurt; yellowish or clumped semen. The seminal vesicles and prostate provide the volume and the push, and inflammation takes both away.
Burning after ejaculation
A sting in the urethra, perineum or testicles during or after orgasm. Textbook prostatitis; never normal.
Delayed or absent ejaculation
Taking a very long time, or not managing it at all, often with a semi-rigid erection. Nerve irritation, antidepressants and low testosterone are the usual causes.
Loss of desire
Not thinking about sex, not wanting it, avoiding it. Often blamed on testosterone; in younger men more often a consequence of sex that has become disappointing or uncomfortable.
Less sensation, less pleasure
A duller orgasm, numbness of the glans, sex that “does not feel like it used to”. Nerve-related, and one of the symptoms that improves most when the pelvic nerves are freed.
The symptoms that point to the cause
Erectile dysfunction seldom comes alone, and the company it keeps is the best clue to what is causing it. When it comes with chest pain on exertion, leg pain on walking or a diagnosis of diabetes, the vessels are the first suspect. When it follows a new tablet, the tablet is. When it began the week of a divorce, and morning erections are intact, the mind is. And when it comes with any of the following, which it does in most of the men we see, the prostate is: going to the toilet more often than you used to; a weaker or hesitant stream, or dribbling at the end; getting up at night; a feeling of not emptying; burning or stinging in the urethra, especially after ejaculation; an ache or heaviness in the perineum, the testicles, the groin or the lower back, worse after sitting; recurrent “urinary infections”, urethritis or epididymitis; a yellowish or thick semen.
Men rarely mention these at a consultation for erectile dysfunction, because they do not see the connection and because the urinary symptoms are mild. Ask yourself the questions before you go. The complete list of chronic prostatitis symptoms.
A man with soft erections, quicker ejaculation and a slightly weaker stream at 38 has, in our experience, chronic prostatitis until proven otherwise, and a normal testosterone and a normal ECG do not prove otherwise. Examined now, his erectile tissue is intact and his prognosis is excellent. Told it is stress and given a pill, he comes back at 45 with fibrosis, an enlarging prostate and a rising PSA.
A five-question self-check
Doctors use a five-question score (the IIEF-5) to grade erectile dysfunction. Answer honestly for the last six months, scoring each question from 1 (almost never or very low) to 5 (almost always or very high).
- Confidence. How confident are you that you can get and keep an erection?
- Hardness. When you have erections with sexual stimulation, how often are they hard enough for penetration?
- Keeping it. During intercourse, how often are you able to keep the erection after penetration?
- To the end. How often can you keep it to the end of intercourse?
- Satisfaction. When you attempt intercourse, how often is it satisfactory for you?
A total of 22 to 25 is normal; 17 to 21 is mild erectile dysfunction; 12 to 16 mild to moderate; 8 to 11 moderate; 5 to 7 severe. Any score below 22, or any loss of morning erections, is a reason to be examined, and the lower the score, the less time there is to lose.
When to be seen
Now, if
The erection fails or fades in most attempts over more than a few weeks; morning erections have faded; ejaculation has become premature, weak or painful; or there is any urinary symptom or pelvic pain alongside.
Soon, if
You have started using a pill to have sex, whatever your age; you have diabetes, high blood pressure or high cholesterol and erections have changed; or you are under 50 and the change has lasted more than three months.
Urgently, if
An erection has lasted more than four hours (priapism), the penis has bent suddenly or a hard lump has appeared in the shaft, or there is blood in the urine or semen with the erectile problem.
Recognise the pattern?
Softer, slower, shorter, and something not quite right with urination or ejaculation: that is the pattern we see every day, and it is treatable. Tell us how yours began.
Frequently asked questions
What are the first signs of erectile dysfunction?
An erection that takes longer and more stimulation to come, is less firm than it used to be, fades during intercourse or is unreliable from one night to the next, and morning erections that are rarer or softer. Quicker ejaculation and a mild urinary symptom often appear at the same time.
What does a “semi” erection mean?
An erection that swells and is partly hard but not rigid enough for confident penetration, or is hard at the base but soft at the tip. It is the middle stage of erectile dysfunction, when the erectile tissue has begun to fibrose and the venous trap leaks, and it is the stage at which most men first use a pill.
What are the stages of erectile dysfunction?
Mild (softer, less reliable erections, fewer morning erections), moderate or semi-rigid (hard enough only sometimes, lost during intercourse), severe (rarely hard enough even with pills) and complete (no erection at all, including in sleep). The cause is treatable at every stage; the tissue needs more repair at the later ones.
Why do I lose my erection during sex?
Because the erectile tissue cannot hold the blood once stimulation becomes steady: early fibrosis and a leaking venous trap, often with a weakened nerve signal from a strangled cavernous nerve. Anxiety adds an adrenaline surge that closes the arteries further. It is usually the earliest organic sign, not a sign of a wandering mind.
Why have my morning erections stopped?
Night and morning erections depend on healthy nerves, arteries and erectile tissue, not on desire. Losing them gradually means an organic problem is developing. In younger men the commonest cause we find is chronic prostatitis; in older men vascular disease and diabetes join it.
Can erectile dysfunction come and go?
In the early stages, yes: good nights and bad nights with no obvious pattern. Fluctuation is typical of an inflamed prostate, whose congestion varies with sitting, alcohol, sexual activity and stress. It does not mean the problem is psychological.
How do I know if my erectile dysfunction is physical or psychological?
Psychological ED usually starts suddenly after a life event, with normal erections in sleep, on waking and in masturbation, failing only in the anxious situation. Physical ED comes on gradually, affects morning erections too, and often brings changes in ejaculation or urination. Most men have a physical problem with anxiety layered on top; a penile Doppler and an examination of the prostate settle it.
