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Educational information and further resources
By Dr. Meyer Schoeman, MD — Precision Sexual Health Clinic, Calgary
Erectile dysfunction is still widely understood as a condition that affects older men. The epidemiological data tells a different story. Studies in men seeking medical care for new-onset ED show that approximately one in four patients are under 40, highlighting that ED is not limited to older men.
The clinical picture in younger men is different from what a 58-year-old with metabolic syndrome and borderline hypertension presents with. Understanding those differences matters for assessment and for treatment.
In men over 50, vasculogenic ED — impaired penile blood flow from endothelial dysfunction and atherosclerosis — accounts for the majority of cases. In men under 40, the picture is more mixed, with psychogenic factors playing a substantially larger role.
Performance anxiety is the most common driver. It often begins with a single episode of erectile difficulty — perhaps from alcohol, fatigue, stress, or a new partner — and spirals into a conditioned anxiety response that reliably reproduces the failure. The anticipatory anxiety itself becomes the mechanism: sympathetic nervous system activation increases circulating noradrenaline, promotes smooth muscle contraction in the corpus cavernosum, and inhibits the parasympathetically-driven nitric oxide release that erection requires. The man is functionally inhibiting his own erection.
Pornography-associated erectile dysfunction is increasingly recognised as a clinical entity in younger men. Regular high-speed internet pornography use can condition arousal to a stimulus environment that differs substantially from partnered sex, leading to diminished arousal, difficulty maintaining erection with a partner, or both. This is not a moral judgement, it is a neuroadaptive phenomenon with a recognised mechanism and, importantly, a reversible one.
Not all ED in younger men is psychogenic. Vasculogenic disease can present in men in their 30s, particularly those with significant cardiovascular risk factors: smoking, obesity, hypertension, type 2 diabetes, hyperlipidaemia, or a strong family history of premature coronary artery disease. In these men, ED is a serious vascular warning signal and deserves the same workup it would in an older patient.
Testosterone deficiency presenting in younger men — from primary or secondary hypogonadism — can produce ED through its effects on penile smooth muscle integrity, nitric oxide synthase expression, and libido. This is another reason that a proper hormonal assessment is part of the initial evaluation regardless of age.
Pelvic floor dysfunction is an underappreciated contributor to ED in younger men, particularly those who cycle heavily, sit for long periods, or have a history of pelvic trauma. Hypertonicity in the ischiocavernosus and bulbocavernosus muscles can impair venous occlusion and reduce erection rigidity. Targeted pelvic floor physiotherapy has evidence for improvement in ED in this subgroup.
The assessment process matters more in younger men, not less. A prescription for sildenafil handed to a 35-year-old with performance anxiety will work pharmacologically but will not address the underlying driver, and may actually reinforce the anxiety by teaching the man that he needs medication to function.
Sex therapy and psychological intervention — individually or as a couple — is often the most appropriate first-line approach for psychogenic ED. The goal is to interrupt the anxiety cycle, recalibrate the arousal response, and restore confidence in a way that generalises beyond any given encounter.
For younger men with genuine vasculogenic disease, the restorative treatments — shockwave therapy, PRP — are more likely to produce durable benefits than in older men with advanced disease, precisely because the underlying tissue has more capacity for repair. The earlier vasculogenic ED is treated, the better the prognosis.
The honest message for younger men dealing with ED is this: it is common, it is treatable, and the fact that you’re dealing with it at 35 does not mean you will be dealing with it at 45. But it does mean you should have a proper clinical assessment rather than either quietly managing it with a pill or doing nothing at all.
Dr. Meyer Schoeman is the founder of Precision Sexual Health Clinic for Men in Calgary, offering comprehensive ED assessment and treatment for men of all ages. Book a consultation at precisioncliniccalgary.ca.