Early Signs of Erectile Dysfunction (ED): A Self-Check List by Age Group | Doctor-Reviewed

The diagnostic criteria for ED (erectile dysfunction) require that both of the following two conditions are met.

In other words, ED includes not only cases in which “no erection occurs at all,” but also recurring cases in which the penis is not firm enough to allow vaginal penetration, the erection is lost during intercourse (loss of erection mid-intercourse), or the firmness has clearly declined compared with before.

If problems occur only “occasionally,” there is no need for concern. However, if “this state has continued recently” or “you fail more than half of the time,” it is highly likely that you are in the early stage of ED. Because ED is a progressive condition, recognizing it early is the first step toward improvement.

The following three signs are particularly frequently reported as early symptoms of ED. They often appear before erections fail entirely and are important clues for early detection.

These symptoms are easily dismissed as “just aging” or “just being tired,” but if left unaddressed, they may progress further. The moment you sense that “something seems off,” we strongly recommend that you try the self-checks in this article.

You wake up in the morning with an erection even though there is no sexual stimulation — this is what is commonly called a “morning erection.” It is in fact not just a morning phenomenon, but part of nocturnal penile tumescence (NPT) that occurs repeatedly during sleep.

Sleep alternates between REM and non-REM stages, and physiological erections occur during REM sleep. This phenomenon is unrelated to sexual dreams; normally, it occurs 3-5 times a night, each lasting 20-40 minutes. When you wake up while still erect from the last REM cycle, you experience a “morning erection.”

Check points:

The presence or absence of morning erections is an important clue for distinguishing between “psychogenic ED and organic ED.” With psychogenic ED, even when daytime intercourse does not go well, nocturnal erections often remain normal. By contrast, when morning erections have clearly declined, problems with the blood vessels or nerves may be present.

The EHS (Erection Hardness Score) is an internationally used scale that allows men to self-evaluate the firmness of their erections on a four-point scale. It was developed in the United States in 1998, and a Japanese version was prepared by Professor Koichi Nagao of Toho University. It is widely used in clinical settings to support diagnosis and to evaluate treatment effects.

Professor Nagao explains that, as a guide for the angle of an erection, “if you hold your palm vertically and spread your fingers, you can use it as a protractor for the penis.” If the erect penis rises to roughly the angle of the middle finger, there is generally no problem.

Grade 3 or higher (grapefruit to apple) is considered firm enough for intercourse. Research data also indicate a vaginal-intercourse success rate of about 60% at grade 3 and about 93% at grade 4. If grade 2 or lower persists, consider consulting a medical institution.

The IIEF-5 (International Index of Erectile Function-5) is a questionnaire that is used as a standard tool in ED care worldwide. You answer five questions about your erections over the past six months, and the total score is used to assess the presence and severity of ED.

For each question below, add up the score of the option that best applies to you.

[Question 1] How confident were you that you could get and keep an erection?

– Very low = 1 point – Low = 2 points – Moderate = 3 points – High = 4 points – Very high = 5 points

[Question 2] When you had erections with sexual stimulation, how often were your erections hard enough for penetration?

– Almost never/never = 1 point – A few times (much less than half the time) = 2 points – Sometimes (about half the time) = 3 points – Most times (much more than half the time) = 4 points – Almost always/always = 5 points

[Question 3] During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?

– Almost never/never able to maintain = 1 point – A few times = 2 points – Sometimes = 3 points – Most times = 4 points – Almost always/always = 5 points

[Question 4] During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

– Extremely difficult = 1 point – Very difficult = 2 points – Difficult = 3 points – Slightly difficult = 4 points – Not difficult = 5 points

[Question 5] When you attempted sexual intercourse, how often was it satisfactory for you?

– Almost never/never satisfactory = 1 point – A few times satisfactory = 2 points – Sometimes satisfactory = 3 points – Most times satisfactory = 4 points – Almost always/always satisfactory = 5 points

*Adapted from the Japanese Society for Sexual Medicine “Clinical Guidelines for ED [3rd edition]”

If your total score is 21 or lower, ED is suspected. However, the IIEF-5 is only a screening tool, and the final diagnosis is made by a physician. If your score was low, taking the result with you to a medical consultation will help the visit go smoothly.

Psychogenic ED is a type in which, despite the physical capacity for an erection being intact, psychological factors interfere with achieving an erection. It is frequently seen in younger men in their 20s and 30s.

Common causes include stress at work or in personal relationships, problems with one’s partner, anxiety or pressure surrounding sexual performance (performance anxiety), and past sexual trauma. A vicious cycle in which “anxiety from a previous failure leads to fear of failing again next time” (anticipatory anxiety) is also a typical pattern of psychogenic ED.

A characteristic feature of psychogenic ED is that morning erections and erections during masturbation occur normally, but problems arise only during sexual activity with a partner. Because there is no underlying physical abnormality in this case, a combination of ED medication and psychological approaches is effective.

Organic ED is a type in which physical causes impair erectile function. It increases from the 40s onward, and is often associated with age-related vascular changes and underlying medical conditions.

A characteristic feature of organic ED is that morning erections decrease or disappear. Because erectile function itself declines independently of the sexual setting, the morning-erection check described above is an important point of differentiation.

Drug-induced ED is a type in which ED develops as a side effect of a medication that the patient is currently taking. This is surprisingly often overlooked, but quite a number of medications can potentially cause ED.

If drug-induced ED is suspected, do not stop taking the medication on your own judgment. Be sure to consult your prescribing physician and discuss the possibility of switching to an alternative medication or adjusting the dose.

In actual clinical practice, many ED patients develop the condition through a combination of multiple causes rather than a single one. Examples include “vascular impairment due to diabetes (organic) plus anxiety about the disease (psychogenic)” and “side effects of antihypertensives (drug-induced) plus age-related vascular deterioration (organic).”

In cases of mixed ED, addressing only one cause may not lead to sufficient improvement, so a comprehensive diagnosis by a physician and a multifaceted approach are important.

ED in the 20s is overwhelmingly psychogenic. Even when men are physically healthy, psychological factors prevent erections. The representative causes are as follows.

Performance anxiety: Pressure such as “Can I do it well?” or “Can I satisfy my partner?” Often triggered by intercourse with a new partner or by past failure experiences.

Excessive pornography use: Long-term, excessive exposure to internet pornography can result in cases where men no longer feel sufficient arousal during real sexual activity with a partner. In recent years, this has attracted attention as a contributing factor in the rising prevalence of ED among young men.

Stress at work or in personal relationships: There are also many cases in which workplace environments and interpersonal stress after entering the workforce affect sexual function.

Because ED in the 20s is mainly psychogenic, it is characterized by relatively easy improvement once the cause is addressed or ED medication is used. It is important not to assume that “I’m too young to have ED” and instead take action early.

The 30s is an age group where, in addition to psychogenic ED, the impact of disrupted lifestyle habits begins to appear. As work becomes busier, sleep deprivation, lack of exercise, increased alcohol intake, and smoking can pile up, and the health of blood vessels and nerves gradually deteriorates.

Common early signs of ED in the 30s are “loss of erection mid-intercourse” and “reduced firmness.” “I used to do this without any problem, but lately something feels off.” That is the characteristic experience of this age group. Because it is too early to dismiss the changes as “just aging,” reviewing your lifestyle and using self-checks is especially important. For more details on the relationship between ED and lifestyle, click here.

The 40s is an age group in which the prevalence of ED rises sharply, with about one in five men reportedly affected. In this age group, “mixed ED”, in which workplace stress (psychogenic) and age-related vascular changes (organic) overlap, becomes more common.

The early signs that stand out in the 40s are “fewer morning erections” and “reduced stamina.” A clear decrease in the frequency of morning erections may also indicate that arteriosclerosis is starting to develop. From this age group onward, ED medications are highly effective, and an early medical consultation is recommended.

From the 50s onward, organic ED becomes the central type, with prevalence reaching 40-60%. The progression of arteriosclerosis, lifestyle-related diseases such as diabetes, hypertension, and dyslipidemia, declining testosterone, and the influence of treatments for prostate disease can all become entangled in this age group.

Even from the 50s onward, ED medications can be expected to be highly effective. There is no need to give up by saying, “I’m just too old now.” By managing underlying conditions in parallel with ED treatment, it is fully possible to maintain and improve the quality of one’s sex life.

Many studies show that metabolic syndrome (visceral obesity, hypertension, hyperglycemia, and dyslipidemia) and lifestyle-related diseases are linked with ED. Specifically, the following conditions are risk factors for ED.

It is also known that ED is often accompanied by depressive symptoms and that, conversely, depressive symptoms make men more prone to ED. Treating ED has been reported to alleviate depressive symptoms (and vice versa), which makes ED a problem that affects not only sexual activity but also overall quality of life (QOL).

Why can ED be a precursor to cardiovascular disease? The reason lies in the caliber of blood vessels.

The diameter of the penile arteries is approximately 1-2 mm, which is much smaller than the coronary arteries of the heart (about 3-4 mm) or the cerebral arteries. When arteriosclerosis progresses throughout the body, it is therefore natural that symptoms appear first in the smallest blood vessels of the penis.

In fact, research reports indicate that the period from the onset of ED to a major cardiovascular event such as myocardial infarction or stroke is on average 3-5 years. In other words, recognizing the early signs of ED is also an opportunity to prevent serious cardiovascular disease in the future.

Rather than leaving ED unaddressed because it feels embarrassing, it is important to view it as an opportunity to reassess your overall health and to consult a medical institution early.

To improve ED, the first step is to reconsider your lifestyle. Effects are further enhanced when combined with ED medication. For more details on ED and lifestyle improvement, click here.

The most rapid-acting and widely effective option in ED treatment is the class of medications known as PDE5 inhibitors. The three main types approved in Japan are compared below.

None of these medications work by “automatically producing an erection once taken.” Instead, they support the achievement of an erection when sexual stimulation is present. ED medications require a physician’s prescription, and combination with cardiac medications (nitrates) is contraindicated. Choose the medication that suits you in consultation with a physician. For details and pricing of ED medications, click here.

ED treatment can be received at a urology department or a clinic specializing in ED. Many patients feel anxious, thinking, “It’s embarrassing” or “I don’t know what they will do,” but the actual consultation is straightforward.

Men’s Care Clinic is a men-only clinic, so there is no concern about meeting female patients in the waiting room. We also support online consultations, so even patients who find it difficult to visit in person or who live far away can receive ED treatment.

At Men’s Care Clinic, we can prescribe three types of ED medication — Viagra, Cialis, and Levitra — starting from a single tablet. Please feel free to visit one of our clinics via the access information below.

ED is not an embarrassing condition; it is a disorder that can be improved with appropriate treatment. The moment you sense that “something seems off” is the best time to start taking action. Please feel free to consult us first.

Q. What kinds of early signs does ED have?

A. The early signs of ED are not limited to a complete inability to achieve an erection. The three representative early signs are (1) loss of erection during intercourse (inability to maintain an erection during sexual activity), (2) reduced firmness of the erection compared with before, and (3) decreased frequency of morning (nocturnal) erections. If these symptoms recur, ED is a possibility. Early detection and early treatment are the key to improvement.

Q. Are there ways to check for ED on my own?

A. There are three self-check methods for ED: (1) observe the frequency of your morning erections, (2) self-grade the firmness of your erections from 1 to 4 using the EHS (Erection Hardness Score), and (3) answer the IIEF-5 questionnaire (5 questions); a total of 21 points or fewer suggests possible ED. All of these are simply rough guides, and an accurate diagnosis requires a medical consultation.

Q. What is the IIEF-5 and how is it used?

A. The IIEF-5 (International Index of Erectile Function-5) is a five-item questionnaire used worldwide for diagnosing ED. You answer questions about your confidence in achieving erections, firmness, stamina, difficulty maintaining the erection, and satisfaction over the past six months on a scale of 1 to 5, and the total score is used for assessment. Scores of 22-25 are considered normal, 17-21 mild ED, 8-16 moderate ED, and 5-7 severe ED.

Q. What is the EHS (Erection Hardness Score)?

A. The EHS (Erection Hardness Score) is a four-point scale used to evaluate the firmness of an erection. It is classified into grade 1 (about as firm as konjac jelly), grade 2 (about as firm as a mandarin orange), grade 3 (about as firm as a grapefruit), and grade 4 (about as firm as an apple). Grade 3 or higher is considered firm enough for intercourse, while grade 2 or lower may indicate ED.

Q. Does losing morning (early-morning) erections mean I have ED?

A. A decrease in morning erections is one possible sign of organic ED, but it is not enough on its own to confirm a diagnosis of ED. Morning erections are a physiological phenomenon that occurs during REM sleep, and they may decrease due to fatigue or sleep deprivation as well. However, when morning erections that used to be frequent have clearly decreased, this may suggest a problem with the blood vessels or nerves, so a medical consultation is recommended.

Q. Can men in their 20s also have ED?

A. Yes, ED can also occur in men in their 20s. ED in the 20s is mainly psychogenic (due to psychological factors), with causes including pressure regarding the partner, work-related stress, and desensitization to sexual stimulation due to excessive pornography use. Surveys in Japan suggest that about 8% of men in their 20s have experienced ED. Because the underlying cause in younger men is mainly psychogenic, early treatment tends to lead to easy improvement.

Q. What is the relationship between ED and lifestyle-related diseases?

A. ED is closely related to lifestyle-related diseases such as arteriosclerosis, diabetes, hypertension, and dyslipidemia. Because the blood vessels of the penis are smaller than the coronary arteries of the heart, the effects of arteriosclerosis tend to appear there first, and ED can serve as a “precursor” of cardiovascular disease. Some studies indicate that the average period from the onset of ED to a cardiovascular event is 3-5 years, so the early detection of ED is also important for managing your overall health.

Q. Can ED be cured by yourself?

A. With mild ED, lifestyle improvements alone may reduce symptoms. Specifically, sufficient sleep (7 or more hours), aerobic exercise (150 or more minutes per week), smoking cessation, moderate alcohol intake, and a balanced diet are effective. However, in cases of moderate or more severe ED or organic ED, combining these with medication is more effective. Rather than leaving the condition unaddressed on your own judgment, a medical consultation is recommended.

Q. What types of ED medications are available?

A. The main ED medications approved in Japan are three: (1) Viagra (sildenafil), with a rapid onset and a duration of 4-5 hours; (2) Levitra (vardenafil), which is less affected by food; and (3) Cialis (tadalafil), which lasts up to 36 hours and offers flexible timing. All are PDE5 inhibitors and require a physician’s prescription.

Q. Which department should I see for an ED consultation?

A. ED treatment can be received at a urology department or a clinic specializing in ED. The consultation centers on a medical interview, and there is generally no palpation or painful examination. Blood tests may be performed as needed. Men’s Care Clinic also offers online consultations, allowing men who find it difficult to visit in person to receive ED treatment.

Q. From what age do the early signs of ED start to appear?

A. The early signs of ED can appear regardless of age, but statistically, the prevalence rises sharply from the 40s. Japanese epidemiological surveys indicate that about 20% of men in their 40s, about 40% in their 50s, and about 60% in their 60s have ED. However, psychogenic ED is not unusual in men in their 20s and 30s either, and consultations from younger men are reportedly increasing in today’s stressful society.

Q. Is loss of erection during intercourse an early sign of ED?

A. Yes, loss of erection during intercourse (a state in which the erection cannot be maintained during sexual activity) is one of the representative early signs of ED. ED is not limited to a state of “no erection at all”; the inability to maintain “sufficient firmness” is also part of the definition. When loss of erection during intercourse recurs, it is highly likely that the patient has mild to moderate ED, and early countermeasures are effective.

References:

*1 Japanese Society for Sexual Medicine, “Clinical Guidelines for ED [3rd edition]”

*2 Translational Andrology and Urology 2017; The relationship between depression and erectile dysfunction

*3 Daito Pharmaceutical Co., Ltd., “Men’s Start-up Inspection”

*4 Daito Pharmaceutical Official Blog, “Japanese Version of the EHS (Erection Hardness Score)”

*5 Research reports by Professor Koichi Nagao of Toho University

*6 Japanese Society for Sexual Medicine, “Clinical Guidelines for ED [3rd edition],” IIEF-5 questionnaire