The complete guide to ED treatment: causes, medicines and online care

At a glance

Erectile dysfunction (ED) is a common condition: about 1 in 3 adult men in Japan experience it.

Its main causes fall into three groups: physical ones such as blood-vessel problems and diabetes, psychological ones such as stress and anxiety, and lifestyle. First-line treatment with PDE5 inhibitors (sildenafil, tadalafil, vardenafil) can be expected to help many men, and you can now get a prescription from home through online care. This article covers it all, from causes to a comparison of medicines, costs and how to use online care. Results vary.

1What is ED? The definition, and the picture in Japan

ED (erectile dysfunction) is defined as “the persistent inability to get or keep an erection firm enough for satisfactory sexual intercourse”.¹ It includes not only being unable to get an erection at all, but also erections that aren’t firm enough, or that fade partway through.

How common ED is in Japan

A national survey by the Japanese Society for Sexual Medicine in 2023, the first in 25 years, found that 30.9% of Japanese men aged 20 to 79 have ED (by the Erection Hardness Score), an estimated 14 million men.² That is about 2.7 million more than the previous survey in 1998 (about 11.3 million).³

Notably, a decline in sexual function has been reported even in young men aged 20 to 24.² ED isn’t “an older man’s problem”: it can happen to men of any age.

Even so, very few men see a doctor about it. Embarrassment, or the belief that “it’s just my age”, gets in the way. But in many cases ED is a condition that can be expected to improve with the right treatment.

2Causes: body, mind and lifestyle

The causes of ED fall into three broad groups. Often, several overlap.

Physical (organic) causes

An erection depends on blood vessels, nerves and hormones working together, so conditions that affect any of them are risk factors for ED.

• Vascular problems (atherosclerosis): the most common physical cause, where not enough blood reaches the penis.⁴
• Diabetes: damages both blood vessels and nerves. ED rates of 35–75% have been reported in people with diabetes.⁵
• High blood pressure: raises the risk of ED by impairing the lining of the blood vessels.⁴
• Dyslipidaemia: speeds up atherosclerosis and affects the small blood vessels of the penis too.
• Cardiovascular disease: ED can be an early warning sign of a cardiovascular event.⁶
• Neurological conditions: such as spinal cord injury, multiple sclerosis and Parkinson’s disease.
• Low testosterone: the age-related fall in male hormones (LOH syndrome).

A study of middle-aged Japanese men found that heart disease, diabetes, chronic kidney failure and high blood pressure significantly raised the risk of ED.⁵

Psychological causes

Especially in younger men, psychological factors are often the main cause.

• Stress and overwork: pressure from work and relationships upsets the balance of the autonomic nervous system.
• Performance anxiety: “what if it doesn’t work?” starts a vicious circle.
• Depression and anxiety disorders: the conditions themselves can cause ED, and so can side effects of their treatment.
• Relationship problems: not enough communication, or a sexual mismatch.

A typical sign of psychological ED: morning erections are normal, or the problem shows up only in certain situations.

Lifestyle

Everyday habits play a big part in ED. Put the other way round, improving them may help improve ED.

• Smoking: damages the lining of the blood vessels and raises the risk of ED about 1.5 to 2 times.⁷
• Heavy drinking: chronic heavy drinking lowers testosterone and causes nerve damage.
• Too little exercise: a lack of aerobic exercise feeds directly into poorer blood-vessel function.
• Obesity: a higher BMI goes with a higher rate of ED.⁸
• Too little sleep: affects how much testosterone you make.

3Types of ED: organic, psychogenic, mixed and drug-induced

ED is classified into four types by how it develops. Getting the type right matters for choosing the right treatment.

• Organic ED: caused by a physical problem with blood vessels, nerves or hormones. It increases with age and is common from the 40s on. Vascular ED from atherosclerosis is the most common.⁴
• Psychogenic ED: there’s no physical problem, but psychological factors make erections difficult. Relatively common in men in their 20s and 30s, and caused by stress, anxiety or trauma.
• Mixed ED: both physical and psychological factors are involved. In real clinical practice, this mixed type is said to be the most common.⁹ For example, mild vascular problems plus performance anxiety.
• Drug-induced ED: ED as a side effect of a medicine you take.

These medicines are known to be linked to ED:⁹

• Blood pressure medicines (especially beta-blockers and thiazide diuretics)
• Antidepressants (SSRIs and tricyclic antidepressants)
• Anti-androgens
• Psychotropic medicines
• Some stomach medicines (such as H2 blockers)

4ED medicines compared: sildenafil, tadalafil, vardenafil

The first-line medicines for ED are PDE5 inhibitors. Three are approved in Japan, and all of them help an erection when there is sexual stimulation.¹⁰ Several meta-analyses show that PDE5 inhibitors significantly improve erectile function compared with placebo.¹¹ ¹²

Comparison table

• Sildenafil (Viagra®): approved doses 25mg and 50mg. Starts working in about 30–60 minutes and lasts about 4–5 hours. A high-fat meal delays absorption. The longest track record.
• Tadalafil (Cialis®): approved doses 5mg, 10mg and 20mg. Starts working in about 30–60 minutes and lasts about 24–36 hours. Food has little effect. Long-acting, so there’s no need to plan.
• Vardenafil (Levitra®): approved doses 5mg, 10mg and 20mg. Starts working in about 15–30 minutes and lasts about 4–5 hours. A high-fat meal delays absorption. Works relatively quickly.

Source: the package insert for each medicine; Hatzimouratidis K, et al.¹⁰; Tsertsvadze A, et al.¹¹

Each medicine

• Sildenafil (Viagra®): the first PDE5 inhibitor approved in Japan, in 1999. It has the longest track record in the world and the most clinical data on its effects and safety.¹⁰ Generics are available at relatively affordable prices. Take it before a meal or after a light meal.
• Tadalafil (Cialis®): its biggest feature is how long it lasts: up to 36 hours.¹³ Sometimes called “the weekend pill”, so you don’t need to time it closely, and food barely affects it. You can also take 5mg every day (daily tadalafil), which can be expected to give steady improvement whenever you have sex.¹³
• Vardenafil (Levitra®): works relatively quickly (about 15–30 minutes).¹⁰ Clinical trials report that it can be expected to work in men with diabetes too.¹⁴ Food affects it, so take it on an empty stomach.

What applies to all of them

• Main side effects: headache, flushing, a blocked nose and indigestion, usually mild and short-lived.¹⁵
• If you have heart or blood-vessel disease, talk to a doctor first, including about the risk of sex itself.
• They don’t work without sexual stimulation: they aren’t pills that cause an erection on their own.

Which medicine suits you is best decided with a doctor, looking at your lifestyle, any health conditions and possible interactions with medicines you take.

Compare our ED medicines →

5Getting ED treatment through online care

How online care works for ED, from the basics to the actual steps.

What online care is

Online care means seeing a doctor by video call or similar, on your phone or computer. Japan’s Ministry of Health, Labour and Welfare has issued “Guidelines for the Appropriate Implementation of Online Medical Care”¹⁶ to promote safe and appropriate online care.

ED suits online care very well, for these reasons:

• Diagnosis is mostly by questions: ED is diagnosed mainly from your history and symptoms, so an in-person physical exam often isn’t essential.
• The medicines are well established: PDE5 inhibitors have been used for many years, and the criteria for prescribing them are clear.
• Privacy: no worrying about being seen in a waiting room.
• Easy to keep going: no regular trips to a clinic, so it’s easier to stay on treatment.

How it works

1. 1Online questionnaire: enter your symptoms, medical history and the medicines you take.
2. 2Consult with a doctor: by video call, the doctor reviews your answers and decides on a treatment plan.
3. 3Prescription: the right medicine is prescribed.
4. 4Delivery: your medicine arrives at home (some services deliver as soon as the next day).

With Noah, you can see a doctor online and get ED medicine prescribed and delivered to your home, start to finish. The first consult is a video call of about 5 minutes; follow-ups are by video or chat. It’s one option if you’d rather not go in person, or you’re too busy to get to a clinic.

Online or in person

In-person care should come first in these cases:

• If serious heart or blood-vessel disease is suspected
• If you have several underlying conditions
• If a physical exam is needed (such as a genital exam or blood tests)
• If the doctor decides they can’t gather enough information online

Online care is convenient, but the doctor may decide to switch you to in-person care when needed. Under the Ministry’s guidelines,¹⁶ patient safety comes first.

6Costs, and whether insurance covers it

What patients most want to know about the cost of ED treatment and insurance.

Insurance

As a rule, ED treatment is private care (jiyū shinryō). Health insurance doesn’t apply, so you pay the full cost of both the consult and the medicine.

However, since April 2022, some ED medicines (such as tadalafil) may be covered by insurance, but only when they’re used for fertility treatment.¹⁷ If that applies to you, talk to a fertility clinic.

What it costs with Noah

• Consults: free, first and follow-up.
• Medicine: only if a doctor prescribes it. From ¥107 a tablet (the daily tablet, on the 12-month plan).
• Delivery: free anywhere in Japan.

Prices include tax. Private care (jiyū shinryō): not covered by public health insurance.

Ways to keep costs down

• Choose generics: the same active ingredient as the brand, at a more affordable price.
• Use online care: save the time and travel of clinic visits.
• Get more at once: a larger prescription can lower the cost of each dose.

7Lifestyle changes that help with ED

Alongside medicine, these lifestyle changes may help prevent or improve ED.⁸

• Exercise: at least 150 minutes a week of moderate aerobic exercise (walking, jogging, swimming and so on) has been linked to better blood-vessel function and a lower risk of ED.⁸
• Diet: research links a Mediterranean-style diet (vegetables, fruit, fish and olive oil) with improvement in ED. A balanced diet is the foundation of healthy blood vessels.
• Stopping smoking: smoking directly damages the lining of the blood vessels. After stopping, ED may improve as blood-vessel function recovers.⁷
• Drinking sensibly: some reports say light to moderate drinking doesn’t raise the risk of ED, but chronic heavy drinking is a clear risk factor.
• Managing stress: enough sleep, relaxation, and counselling when you need it.

8Before you start treatment

The key points to know beforehand, so starting treatment goes smoothly.

When to see a doctor

Even if it only “sometimes doesn’t work”, think about seeing a doctor if it keeps happening. ED can be an early sign of an underlying condition such as diabetes or heart disease,⁶ so it’s important to ask early.

What to tell the doctor

• How often it happens, and how bad it is
• When it started
• Every medicine and supplement you take
• Your medical history (diabetes, high blood pressure, heart disease and so on)
• Your smoking and drinking
• Whether you’re under mental stress

Talking with your partner

ED affects your relationship too. If you can, talking openly with your partner often leads to a more positive attitude to treatment and better results.

9Questions

10In summary

ED is a very common condition, experienced by about 1 in 3 men in Japan, and nothing to be ashamed of. Its causes range from physical to psychological, and many cases can be expected to improve with the right treatment.

PDE5 inhibitors (sildenafil, tadalafil, vardenafil) have been used around the world for many years, with a large body of evidence on their effects and safety. Which one suits you varies from person to person, so choose with a doctor.

Now that online care is widespread, you can see a doctor from home and have medicine prescribed and delivered, start to finish. If you can’t quite bring yourself to go to a clinic, why not start with an online consult?

ED is treatable. Don’t carry it alone: take the first step.

11Disclaimer and references

Medical disclaimer

This article is for general information and isn’t individual medical advice. If you have symptoms of ED, always see a doctor. It was written under a doctor’s supervision, but it doesn’t replace diagnosis or treatment for your situation. When you use any medicine, always follow your prescribing doctor’s instructions.

What this article says about the effects and side effects of medicines is based on package inserts and published clinical-trial data. Effects vary with each person’s condition, and the same effect isn’t guaranteed for everyone.

References

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8. 8Esposito K, et al. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial. JAMA. 2004;291(24):2978–2984. PMID: 15213209
9. 9Hatzimouratidis K, et al. Guidelines on Male Sexual Dysfunction: Erectile Dysfunction and Premature Ejaculation. European Association of Urology. 2015.
10. 10Hatzimouratidis K, Hatzichristou DG. Phosphodiesterase type 5 inhibitors: the day after. Eur Urol. 2007;51(1):75–88. PMID: 16949200
11. 11Fink HA, et al. Oral phosphodiesterase-5 inhibitors and hormonal treatments for erectile dysfunction: a systematic review and meta-analysis. Ann Intern Med. 2009;151(9):650–661. PMID: 19884626
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13. 13Porst H, et al. Efficacy and tolerability of tadalafil administered once daily for the treatment of erectile dysfunction. J Sex Med. 2008;5(9):2160–2169. PMID: 18557812
14. 14Goldstein I, et al. Vardenafil, a new phosphodiesterase type 5 inhibitor, in the treatment of erectile dysfunction in men with diabetes. Diabetes Care. 2003;26(3):777–783. PMID: 12610037
15. 15Corona G, et al. The Effect of Phosphodiesterase-type 5 Inhibitors on Erectile Function: An Overview of Systematic Reviews. Front Pharmacol. 2021;12:735708. PMID: 34557099
16. 16Ministry of Health, Labour and Welfare. Guidelines for the Appropriate Implementation of Online Medical Care (partly revised March 2023). https://www.mhlw.go.jp/content/10800000/001233212.pdf
17. 17Ministry of Health, Labour and Welfare. FY2022 revision of medical fees (wider insurance cover for fertility treatment). April 2022.
18. 18Ministry of Health, Labour and Welfare. Warning about unapproved, unlicensed products containing pharmaceutical ingredients. https://www.mhlw.go.jp/

Written by the Noah editorial team · Medically supervised by Noah’s doctors · Last updated 7 Apr 2026