Why Can’t I Stay Hard During Sex?

Erectile dysfunction (ED) is defined as the persistent inability to attain and maintain an erection sufficient for satisfactory sexual performance.¹ If you’re experiencing difficulty staying hard during sex, you’re not alone—ED affects millions of men worldwide and becomes increasingly common with age. The 2025 EAU Guidelines recognize that ED can significantly impact quality of life and may signal underlying health conditions, particularly cardiovascular disease.² ED should be considered a precursor of cardiovascular disease, with more severe and longer-standing ED yielding greater risk.³ Treatment options range from lifestyle modifications to medical interventions. First-line treatments typically include oral medications called phosphodiesterase type 5 inhibitors (PDE5Is).⁴ When these treatments aren’t effective or suitable, second-line options include vacuum erection devices and intracavernous injections.⁵ For men who don’t respond to these treatments, penile implants represent a highly effective third-line solution.⁶ According to the 2025 EAU Guidelines, there are two main types of penile implants available: inflatable devices (two-piece and three-piece) and semi-rigid devices (malleable, mechanical, and soft flexible).⁷ The three-piece inflatable devices are often preferred by patients because they provide more natural erections, while semi-rigid prostheses result in a firm penis that can be manually positioned.⁸ Two-piece inflatable prostheses may be recommended for patients at high risk of complications with reservoir placement, such as those with previous abdominal surgery.⁹ Penile implant surgery has one of the highest satisfaction rates among ED treatments— 92-100% for patients and 91-95% for partners—when accompanied by appropriate counseling.¹⁰ The main complications are mechanical failure and infection, though technological improvements have reduced mechanical failure rates to less than 5% after 5 years.¹¹ It’s important to note that implant surgery is irreversible and should be considered only after thorough discussion with your healthcare provider. While some men worry about penile size in relation to sexual function, the EAU Guidelines emphasize that there is no correlation between penile size and the ability to provide sexual satisfaction.¹² Focused psychosexual counseling may improve sexuality and sexual well-being in both patients and their partners after penile implant surgery.¹³ This counseling can address concerns about performance, expectations, and adjustment to the device. If you’re experiencing ED, it’s essential to consult with a healthcare provider who can evaluate potential underlying causes and discuss appropriate treatment options. The guidelines recommend a shared decision-making approach that considers both medical interventions and psychosexual counseling to address the physical and psychological aspects of erectile dysfunction.¹⁴