Erectile difficulty at 60 is common, affecting roughly four in ten men in their sixties, but it is far from inevitable or untreatable.1The American Journal of Medicine. Prevalence and Risk Factors for Erectile Dysfunction in the US The causes at this age are overwhelmingly physical rather than psychological, which is actually good news: physical problems tend to respond to specific, well-studied interventions. What works ranges from oral medications and exercise to dietary changes and devices, and the evidence behind most of these options is stronger than you might expect.
Why Erections Change After 60
The core issue is vascular. As you age, the smooth muscle cells lining the erectile chambers of the penis gradually degrade. Once roughly 15 percent of those cells are affected, the tissue can no longer trap blood effectively, and blood leaks back into surrounding veins before an erection can become fully rigid.2PubMed Central. Aging related erectile dysfunction-potential mechanism to halt or delay its onset This is sometimes called venous leakage, and it is distinct from the kind of artery-clogging disease that causes heart attacks, though the two can overlap.
The body does try to fight back. Those same smooth muscle cells ramp up production of nitric oxide, the molecule that relaxes blood vessels and enables erections, in an attempt to counteract the cellular damage caused by oxidative stress.2PubMed Central. Aging related erectile dysfunction-potential mechanism to halt or delay its onset This natural defense mechanism is exactly what modern ED medications exploit and amplify.
On top of this age-related process, conditions that tend to cluster in your sixties pile on additional risk. Metabolic syndrome, which bundles high blood sugar, high blood pressure, excess abdominal fat, and abnormal cholesterol, is associated with more than a twofold increase in the odds of ED.3The Journal of Sexual Medicine. Diabetes Severity, Metabolic Syndrome, and the Risk of Erectile Dysfunction Poorly controlled blood sugar is particularly damaging: men with an HbA1c at or above the diabetic threshold had roughly three and a half times the odds of erectile dysfunction compared to men with normal levels.3The Journal of Sexual Medicine. Diabetes Severity, Metabolic Syndrome, and the Risk of Erectile Dysfunction The upshot is that treating the underlying metabolic problems can meaningfully improve erectile function, not just prevent further decline.
Oral Medications Still Work Well at This Age
PDE5 inhibitors, the class that includes sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra), remain the first-line treatment for a reason. They work by boosting the nitric oxide pathway that your body is already using to maintain erections. In pooled data from clinical trials, sildenafil improved erections across all age groups, including men 75 and older. The percentage of men reporting improvement was about 80 percent for those under 65, around 69 percent for those 65 to 74, and still about 59 percent for men 75 and up.4The Journal of Sexual Medicine. Efficacy and Safety of Sildenafil by Age in Men with Erectile Dysfunction The response does drop with age, but even in the oldest group, more than half of men saw a meaningful benefit.
Tadalafil shows a similar pattern. In a large study focused specifically on men over 65, about 40 percent of those who started with clinically significant ED achieved normal erectile function scores on treatment. Over 80 percent said their erections had improved.5PubMed. Tadalafil is efficacious and well tolerated in the treatment of erectile dysfunction (ED) in men over 65 years of age Tadalafil’s longer duration of action, lasting up to 36 hours versus four to six for sildenafil, makes it popular among older men who prefer not to time a pill precisely before sex.
The main safety concern with PDE5 inhibitors is their interaction with nitrate medications, which are commonly prescribed for angina and other heart conditions. Taking both together can cause a dangerous drop in blood pressure. If you take any form of nitroglycerin, you should not use these drugs without explicit guidance from your cardiologist. Beyond nitrates, these medications are generally well tolerated in men with stable cardiovascular disease.
Medications That Can Cause the Problem
Before adding a new treatment, it is worth checking whether something you already take is contributing. An analysis of the FDA’s adverse-event database found that two classes of drugs accounted for the vast majority of ED reports: 5-alpha reductase inhibitors (finasteride and dutasteride, prescribed for enlarged prostate or hair loss) and neuropsychiatric medications, including certain antidepressants, antipsychotics, and anti-anxiety drugs. Together, these two classes made up about 86 percent of ED reports among the 20 most commonly implicated drugs.6PubMed Central. Medications Most Commonly Associated With Erectile Dysfunction – Section: RESULTS
Other common culprits include certain blood pressure medications (particularly older beta-blockers and thiazide diuretics), opioid pain medications, and some antihistamines. If your erectile difficulties began or worsened around the time you started a new prescription, that timing is worth bringing up with your doctor. In many cases, a swap to a different drug in the same class can solve the problem without adding another medication to the mix. Smoking damages the nitric oxide signaling pathway that erections depend on, and quitting has been shown to improve erectile quality, so stopping tobacco is one of the simplest medication-free changes you can make.7PubMed Central. Effects of cigarette smoking on erectile dysfunction
Exercise as Treatment, Not Just Prevention
Aerobic exercise does not just reduce your risk of ED over time. It can actively improve erections you are already having trouble with. A meta-analysis of randomized controlled trials found that aerobic exercise improved erectile function scores by an average of about 3 points on the standard clinical scale, with larger gains in men who started out with more severe dysfunction: around 5 points for severe ED versus about 2 points for mild ED.8The Journal of Sexual Medicine. Effect of aerobic exercise on erectile function: systematic review and meta-analysis of randomized controlled trials For context, PDE5 inhibitors typically improve scores by about 6 to 9 points, so exercise alone gets you partway there, and the two interventions can be combined.
The most effective protocols in studies involved moderate-to-vigorous aerobic exercise four times per week for about 40 minutes per session, totaling around 160 minutes a week, sustained for at least six months.9PubMed Central. Physical Activity to Improve Erectile Function: A Systematic Review of Intervention Studies Brisk walking, cycling, swimming, or jogging all count. The mechanism is straightforward: aerobic exercise improves endothelial function (the health of your blood vessel linings), reduces inflammation, improves blood pressure and blood sugar control, and can reduce body fat. All of these directly address the vascular roots of ED.
Pelvic Floor Exercises
Kegel exercises are not just for women after childbirth. The muscles of the pelvic floor play a direct role in trapping blood inside the penis during an erection, and strengthening them can make a meaningful difference. In a randomized trial, men who performed pelvic floor exercises with biofeedback guidance saw their erectile function scores improve by nearly 7 points after three months compared to a control group. By six months, 40 percent of participants had regained normal erectile function, another 35 percent had improved, and about a quarter did not respond.10PubMed Central. Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction
A separate study using a program of pelvic floor exercises combined with electromyographic biofeedback and electrical stimulation found that about 47 percent of men regained normal erections and another 24 percent improved. The outcomes were best in men whose ED involved venous leakage, which is precisely the mechanism that drives age-related erectile decline.11Physical Therapy. Treatment of Erectile Dysfunction by Perineal Exercise, Electromyographic Biofeedback, and Electrical Stimulation The exercises are free, have no side effects, and can be done alongside any other treatment. The challenge is doing them consistently and correctly. A few sessions with a pelvic floor physiotherapist to learn the technique is worth the investment.
The Mediterranean Diet Connection
What you eat has a measurable relationship with erectile function, and the evidence points consistently toward a Mediterranean-style diet. A large long-running study of male health professionals found that men over 60 who scored highest on a Mediterranean diet scale had roughly an 18 percent lower risk of developing ED than those who scored lowest.12JAMA Network Open. Association of Diet With Erectile Dysfunction Among Men in the Health Professionals Follow-up Study The effect was even stronger in younger men, but it remained significant in the over-70 group as well.
In a controlled trial of men with metabolic syndrome, two years on a Mediterranean diet led to improved endothelial function and lower inflammation markers, and significantly more men in the diet group achieved normal erectile function scores compared to the control group.13PubMed. Mediterranean diet improves erectile function in subjects with the metabolic syndrome The diet emphasizes vegetables, fruits, whole grains, olive oil, nuts, fish, and moderate wine intake. The mechanism is likely the same as with exercise: reducing inflammation, improving blood vessel health, and better controlling blood sugar and cholesterol.14PubMed Central. Mediterranean diet and erectile dysfunction: a current perspective This is not a quick fix, but over months, dietary changes can meaningfully shift the baseline from which your other treatments operate.
Testosterone Replacement and Its Limits
Testosterone levels decline gradually with age, and many men wonder whether replacement therapy is the answer. It can be, but only in a narrow set of circumstances. Among men with ED, studies find that a large proportion have low testosterone: in one cross-sectional study, about 54 percent of ED patients were hypogonadal (had testosterone below normal thresholds).15PubMed Central. The role of male hypogonadism, aging, and chronic diseases in characterizing adult and elderly men with erectile dysfunction Lower free testosterone correlated directly with worse erectile function scores in that study.
However, replacing testosterone in men who are genuinely low produces only a modest improvement in erections on its own. A meta-analysis of 14 randomized trials found that testosterone therapy improved erectile function scores by about 2.3 points compared to placebo overall. The improvement was somewhat better in men with very low testosterone (below about 230 ng/dL), where the gain was closer to 3 points, and smaller in men who were only mildly low.16PubMed Central. Testosterone Therapy Improves Erectile Function and Libido in Hypogonadal Men Once testosterone reaches a normal threshold, pushing it higher does not improve erections further. The researchers concluded that testosterone alone could be useful for mild ED in genuinely hypogonadal men, but for moderate or severe ED, it works best in combination with a PDE5 inhibitor.
If your ED came on alongside other symptoms of low testosterone, such as fatigue, loss of muscle mass, depressed mood, and reduced sex drive, getting your levels checked is worthwhile. If your testosterone is normal, supplementation is unlikely to help your erections and carries its own risks.
Treating Sleep Apnea
Obstructive sleep apnea is common in older men and is strongly linked to ED, through both oxygen deprivation and its downstream effects on hormones and blood vessel function. What many men do not realize is that treating the sleep apnea can improve erections. A systematic review found that CPAP therapy, the standard treatment for sleep apnea, produced significant improvement in sexual function measures in most of the studies examined.17PubMed Central. Effects of obstructive sleep apnea and its treatment over the erectile function: a systematic review The benefit was clearest in men with moderate to severe ED and appeared to be linked to how many hours per night the CPAP was actually used.18PubMed. CPAP therapy improves erectile function in patients with severe obstructive sleep apnea
If you snore heavily, wake up tired despite a full night’s sleep, or your partner has noticed you stop breathing during sleep, getting a sleep study is one of the more underappreciated paths to better erections. Many men spend years trying ED medications without realizing that untreated sleep apnea is undermining the results.
Vacuum Erection Devices
Vacuum devices, sometimes called penis pumps, work by drawing blood into the penis mechanically and then holding it there with a constriction ring placed at the base. They are low-tech, drug-free, and surprisingly well-regarded by the men who use them. In a survey of middle-aged and older veterans, over 96 percent were able to maintain an erection with the device, and 100 percent said they would recommend it to others. Female partners rated sex as better with the device about 84 percent of the time.19PubMed. Satisfaction with a Vacuum Constriction Device for Erectile Dysfunction among Middle-Aged and Older Veterans
The drawbacks are practical rather than medical. About 23 percent of users in that study reported some discomfort, usually from the constriction ring. The erection produced feels somewhat different from a natural one because the blood is trapped rather than flowing. And there is a learning curve to using the device smoothly. Difficulty getting a satisfactory erection with the device was more common with increasing age. Still, for men who cannot take PDE5 inhibitors or prefer a non-drug option, vacuum devices are a reliable fallback. Newer models are designed to be quieter and easier to handle.20PubMed. Efficacy of a new vacuum erection device (Vigor 2020) for erectile dysfunction: A retrospective study in Japan
Injections and Second-Line Treatments
When pills do not work or cannot be taken safely, intracavernosal injections are the next step. These involve injecting a small amount of medication directly into the side of the penis before sex, which relaxes the smooth muscle and triggers an erection within minutes. The efficacy rates are high, and the injections work even in men who do not respond to oral medications at all.21PubMed. Erectile dysfunction: a global review of intracavernosal injectables
The obvious downside is that you are injecting yourself. Most men report that the needle is smaller and less painful than expected, but the idea puts many off initially. Discontinuation rates are high, not because the treatment fails but because men eventually stop wanting to do it. Side effects can include mild pain at the injection site and, rarely, a prolonged erection that requires medical attention. The injection technique is usually taught in a urologist’s office during the first visit, and most men become comfortable with it after a few uses.
Low-Intensity Shockwave Therapy
Low-intensity extracorporeal shockwave therapy (LI-ESWT) is a newer approach that uses sound waves applied to the penis to stimulate blood vessel growth and tissue repair. Early results from randomized trials showed significant improvements in both erectile function scores and penile blood flow measurements.22PubMed Central. Shockwave treatment of erectile dysfunction In one study where the median patient age was 64, scores improved significantly at each follow-up point, and measurable penile blood flow increased from about 13 mm to about 20 mm of circumferential change. Age and number of comorbidities were both predictors of how well it worked, meaning younger and healthier men got more benefit.23PubMed. Impact of aging and comorbidity on the efficacy of low-intensity shock wave therapy for erectile dysfunction
This therapy is appealing because it aims to restore natural function rather than provide a temporary fix. However, the evidence is still maturing. Many urologists now offer it, but protocols vary, long-term durability is not yet well established, and it is typically not covered by insurance. It is best thought of as a promising option that may work for mild to moderate vascular ED, not yet a proven replacement for established treatments.
Penile Implants as a Last Resort
For men who have exhausted other options, an inflatable penile prosthesis is the most definitive solution. It involves a surgical procedure to place a hydraulic device inside the penis that you inflate manually when you want an erection and deflate afterward. The satisfaction rates are remarkably high. In one study of men who received implants, 80 percent rated their satisfaction a four or five out of five, and 91 percent said they would choose to have the surgery again.24PubMed Central. Outcomes of and Satisfaction with the Inflatable Penile Prosthesis in the Elderly Male
Age alone should not disqualify someone. A study specifically examining men over 70 who received penile prostheses found that 83 percent were satisfied and about 73 percent were using the device regularly at follow-up. The researchers concluded that motivation matters more than age when deciding whether to pursue this option.25PubMed. Should being aged over 70 years hinder penile prosthesis implantation? The most common complaint was dissatisfaction with penile length, since the prosthesis does not add size. It is a permanent change, so it is typically reserved for men who have genuinely tried and failed other approaches. But for those men, it offers the most reliable erections of any treatment.
What Does Not Work and What to Avoid
The market for over-the-counter sexual performance supplements is enormous, and the evidence for almost all of them is thin. Worse, many of these products are actively deceptive. An analysis of 91 samples of herbal supplements marketed for sexual enhancement found that 81 percent contained undeclared pharmaceutical ingredients, primarily sildenafil or tadalafil. Some contained more than the maximum approved dose of these drugs. Most did not warn about nitrate interactions, which makes them genuinely dangerous for men on heart medications.26PubMed. Adulteration of purported herbal and natural sexual performance enhancement dietary supplements with synthetic phosphodiesterase type 5 inhibitors
If a gas-station pill “works,” it is almost certainly because it contains an unlabeled prescription drug. You are better off getting the real thing from a doctor, with a known dose, a quality-controlled product, and a screen for drug interactions. Common herbal ingredients like horny goat weed, maca, and tribulus have either no rigorous evidence supporting their use or study results too inconsistent to draw conclusions from.
The Relationship Side of the Equation
ED at 60 does not happen in a vacuum. It affects and is affected by the relationship in which it occurs. Research from a large English study of aging found that disagreements with a partner about initiating sex, or feeling obligated to have sex, were associated with greater dissatisfaction with one’s sex life overall, independent of the physical dysfunction itself.27PubMed. Sexual Health and Well-being Among Older Men and Women in England: Findings from the English Longitudinal Study of Ageing In other words, fixing the erection without addressing the communication around it can still leave both partners unhappy.
A multimodal approach that involves both partners tends to produce the best outcomes.28PubMed Central. Sexual Health in the Elderly Population That might mean having an honest conversation about what satisfying sex looks like at this stage of life, since it often looks different than it did at 30. It might mean involving a partner in the treatment process, whether that is learning to use a vacuum device together or adjusting expectations during the weeks it takes for exercise and dietary changes to show results. Performance anxiety can create a self-reinforcing cycle at any age, and addressing the psychological dimension does not mean the problem is “all in your head.” It means you are treating the whole picture.