Erectile dysfunction isn't just a blood flow issue. Here's what to know about ED — and the best ways to treat it.

Blood flow is often blamed when it comes to erectile dysfunction, but a new medical review suggests that treatment plans shouldn’t ignore what’s also happening psychologically.

According to a recent article published in the journal Current Directions in Psychological Science, personality traits and mental health issues are among the risk factors associated with ED. However, the authors point out, researchers tend to bypass the psychological aspects of this condition in order to concentrate on the physical causes and their treatments.

ED is a common problem that happens to men of all ages. The review states that the condition affects 20% of men under the age of 30, 25% of men in their 30s, 40% of men in their 40s, 60% of men over the age of 50 and 80% of men after their 60th birthday. A medical article published in the International Journal of Impotence Research predicts that 322 million males around the world will be dealing with ED by 2025.

Here’s what causes erectile dysfunction, the psychological effects of the condition and how it’s typically treated.

What are the physical causes of ED?

The Urology Care Foundation defines ED as trouble getting or keeping an erection that is firm enough to have sexual intercourse. Although several factors can cause or contribute to symptoms of ED, it tends to be a symptom of another health-related condition.

“In many cases, ED is primarily a blood flow issue,” Dr. Jagan Kansal, a urologist and founder of Down There Urology, a center for men’s sexual health and male fertility, tells Yahoo Life. “I’ll tell men, ‘Anything that will affect your general health in terms of blood flow can affect your penis.’”

That’s because the penis contains microscopic arteries and veins, explains Kansal. So cardiovascular conditions, including high blood pressure, high cholesterol, heart disease and blood vessel disease, or type 2 diabetes can lead to ED. “This explains why ED can be an early sign of heart disease, because these microscopic arteries get attacked first, and then it will occur in the heart later on in life,” he says.

Other health issues can result in ED, such as chronic kidney disease, multiple sclerosis and Peyronie’s disease, along with injury to the penis, pelvis, prostate, spinal cord or bladder. Treatments for prostate or bladder cancer, including chemotherapy, radiation and surgery, can also lead to ED, according to the National Institutes of Health.

“The nervous system plays a vital role in erectile function, so any damage or disruptions to the nerves involved can impair erectile function,” Dr. Jamin Brahmbhatt, a urologist and fellowship-trained robotic surgeon with Orlando Health Medical Group Urology, tells Yahoo Life. “Additionally, age, the obesity epidemic and lifestyle choices, such as smoking and excessive alcohol consumption, as well as certain medications, can also contribute to ED.”

Cleveland Clinic reports that ED can also be a side effect of prescription drugs for anxiety, depression, blood pressure, seizures, Parkinson’s disease and cancer.

What are the psychological causes of ED?

Physical health is only part of the equation when it comes to what causes ED. Both Kansal and Brahmbhatt agree that psychological factors play a pivotal role in weak erections. “Stress, anxiety and depression can directly impact erectile function by hindering sexual arousal,” says Brahmbhatt. Stress can elevate cortisol levels and increase nervous system activity that can disrupt the complex erectile processes, according to the study authors in the latest research article.

“Furthermore, ED can instigate a self-perpetuating cycle of anxiety and performance pressure,” says Brahmbhatt. “Personality traits, such as perfectionism or high anxiety, might also predispose an individual to experience ED or exacerbate existing issues.”

Kansal refers to this occurrence as a snowball effect. “I use a little humor with my patients and say to them that once they start thinking about their penis, it’s not going to work,” he explains. And whether the psychological issues lead to ED or vice versa depends on the patient. “Either way, I think most guys have some degree of psychological ED, and it usually turns into a vicious cycle,” adds Kansal.

In fact, Brahmbhatt believes the largest culprit of psychological ED stems from men’s high levels of expectations after watching adult films. “The reality is it’s all produced content,” he stresses.

What are the best ways to treat ED?

Brahmbhatt says improving unhealthy habits is important. “First and foremost, nothing beats proactive lifestyle changes,” he says. “Getting regular exercise, eating a balanced diet and abstaining from smoking and limiting alcohol can be foundational in managing — and preventing — ED.”

Other treatment options include devices (such as vacuum erection devices), surgery (penile implants), testosterone replacement therapy (available as a gel, injection, patch and pellet) and prescription medications that help increase blood flow in the penis. “Surprisingly, treatments for ED over the last 20 to 30 years have not changed dramatically,” notes Kansal. “But today people know about Cialis and the little blue pill known as Viagra.”

Both he and Brahmbhatt add that generic versions of the oral medications have been extremely helpful. “More men have started taking them — and likely more at a younger age — simply because of the accessibility and affordability,” says Kansal.

While the recent medical review found that psychological treatments for ED tend to be an afterthought, both doctors said that communication about the condition is more open than in the past. “ED has become much more mainstream, and people are talking about it,” says Kansal.

In fact, Brahmbhatt points out that “the reason we are seeing more younger men asking for help with erections may be because men — and society — are more openly talking about sex. From Tinder to open access porn, a discussion on sex is less intimidating in this day and age.”

Psychological counseling or sex therapy can be beneficial, especially when ED has an emotional component, explains Brahmbhatt. “Engaging with a psychologist can provide valuable insights and strategies to manage psychological stress related to ED.”

Not only does Kansal recommend therapy to his patients dealing with ED, but his urology practice has also partnered with sex therapists. “Even though it might feel uncomfortable at first to talk about such things, keep in mind these people are trained medical professionals who specialize in sexual health. You won’t go wrong by at least speaking with one.”

Experts also suggest not to shy away from discussing any concerns with your partner. “Open dialogue with a partner about ED, and the associated emotional burden, can be a crucial step in fostering a supportive relationship with open communication,” says Brahmbhatt.

Kansal agrees, saying that normalizing talking about erectile dysfunction so it’s “not a taboo subject can be powerful for guys. And I think we have started to do that as a society.”