Introduction 

Erectile dysfunction (ED), also known as impotence, is the inability to get and maintain an erection.

Erectile dysfunction is a very common condition, particularly in older men. It is estimated that half of all men between the ages of 40 and 70 will have it to some degree.

When to see your GP

See your GP if you have erectile dysfunction for more than a few weeks. They will assess your general state of health because the condition can be the first sign of more serious health conditions, such as heart disease (when the heart’s blood supply is blocked or interrupted).

Why does erectile dysfunction happen?

Erectile dysfunction can have a range of causes, both physical and psychological. Physical causes include:



narrowing of the blood vessels going to the penis – commonly associated with high blood pressure (hypertension), high cholesterol or diabetes



hormonal problems



surgery or injury



Psychological causes of ED include:



anxiety



depression



relationship problems



Sometimes erectile dysfunction only occurs in certain situations. For example, you may be able to get an erection during masturbation, or you may find that you sometimes wake up with an erection but you are unable to get an erection with your sexual partner.

If this is the case, it is likely the underlying cause of erectile dysfunction is psychological (stress related). If you are unable to get an erection under any circumstances, it is likely that the underlying cause is physical.

Erectile dysfunction can also be a side-effect of using certain medicines.

 

Diagnosis

Although you may be embarrassed, it's important to get a diagnosis so that the cause can be identified.

Your GP can usually diagnose erectile dysfunction. This will involve answering questions about your symptoms, as well as a physical examination and some simple tests.

 

How is erectile dysfunction treated?

Erectile dysfunction is primarily treated by tackling the cause of the problem, whether this is physical or psychological.

The narrowing of the arteries (called atherosclerosis) is one of the most common causes of ED. In these cases your GP may suggest lifestyle changes, such as losing weight, to try to reduce your risk of cardiovascular disease. This may help to relieve your symptoms as well as improving your general health.

You may also be given medication to treat atherosclerosis, such as cholesterol-lowering statins and drugs to reduce your blood pressure.

A number of treatments have been successful in the treatment of erectile dysfunction. Medication, such as sildenafil (sold as Viagra), can be used to manage it in at least two-thirds of cases. Vacuum pumps that encourage blood to flow to the penis and cause an erection are also successful in 90% of cases.

Psychological treatments include cognitive behavioural therapy (CBT) and sex therapy.

Overall, treatments for erectile dysfunction have improved significantly in recent years. Most men are eventually able to have sex again.

 

 







Male sexual dysfunction

Don't suffer in silence with erection problems or premature ejaculation: find out the causes and treatments

Causes of erectile dysfunction 

 

Erectile dysfunction (ED) can have many causes, such as certain medical conditions, medications and stress.

It's important to identify the cause of erectile dysfunction and treat any underlying conditions.

Erections

When a man becomes sexually excited (aroused), his brain sends signals to the nerves in his penis. The nerves increase the blood flow to the penis, causing the tissue to expand and harden.

Anything that interferes with the nervous system or the blood circulation could lead to erectile dysfunction.

Anything that affects the level of sexual desire (libido) can also cause erectile dysfunction because a reduced libido makes it more difficult for the brain to trigger an erection. Psychological conditions, such as depression, can reduce libido, as can changes in hormone levels (chemicals produced by the body).

Physical causes

There are four main types of health conditions that can cause physical problems resulting in erectile dysfunction. These are:



conditions affecting the flow of blood to your penis – vasculogenic



conditions affecting your nervous system, which is made up of your brain, nerves and spinal cord – neurogenic



conditions affecting your hormone levels – hormonal



conditions affecting the physical structure of your penis – anatomical



 

Injuries and surgery

Penis injuries or surgical treatment of the penis, pelvis or surrounding areas can sometimes lead to erectile dysfunction.

Erectile dysfunction is also thought to occur in up to 15-25% of people who experience a severe head injury.

Vasculogenic conditions

Examples of vasculogenic conditions that cause erectile dysfunction include:



cardiovascular disease – a disease of the heart or blood vessels, such as atherosclerosis (hardening of the arteries) 



high blood pressure (hypertension)



diabetes – a condition caused by high blood sugar levels. This can affect both the blood supply and the nerve endings in your penis, so it is also a neurogenic condition



Erectile dysfunction is strongly associated with cardiovascular disease. For this reason, it may be one of the first causes your GP considers when making a diagnosis and planning your treatment.

Neurogenic conditions

Examples of neurogenic conditions that cause erectile dysfunction include:



multiple sclerosis – a condition that affects the body's actions, such as movement and balance 



Parkinson’s disease – a condition that affects the way that the brain coordinates body movements, including walking, talking and writing



a spinal injury or disorder



a stroke – a serious condition that occurs when the blood supply to the brain is interrupted



 

Hormonal conditions

Examples of hormonal conditions that cause erectile dysfunction include:



hypogonadism – a condition that affects the production of the male sex hormone, testosterone, causing abnormally low levels 



an overactive thyroid gland (hyperthyroidism) – where too much thyroid hormone is produced



an underactive thyroid gland (hypothyroidism) – where not enough thyroid hormone is produced 



Cushing's syndrome – a condition that affects the production of a hormone called cortisol



Anatomical conditions

Peyronie's disease, which affects the tissue of the penis, is an example of an anatomical condition that can cause erectile dysfunction.

Medicine 

In some men, certain medicines can cause erectile dysfunction, including:



diuretics – these increase the production of urine and are often used to treat high blood pressure (hypertension), heart failure and kidney disease 



antihypertensives – such as beta-blockers, that are used to treat high blood pressure



fibrates – medicines used to lower cholesterol levels



antipsychotics – used to treat some mental health conditions, such as schizophrenia



antidepressants –  used to treat depression and some types of pain



corticosteroids – medication that contains steroids, which are a type of hormone



H2-antagonists – medicines used to treat stomach ulcers



anticonvulsants – used to treat epilepsy



antihistamines – used to treat allergic health conditions, such as hay fever



anti-androgens – medication that suppresses androgens (male sex hormones) 



cytotoxics – medication used in chemotherapy to prevent cancer cells from dividing and growing



Speak to your GP if you are concerned that a prescribed medicine is causing erectile dysfunction. Alternative medication may be available. However, it is important never to stop taking a prescribed medicine unless you are advised to do so by a qualified healthcare professional who is responsible for your care.

Psychological causes

Possible psychological causes of erectile dysfunction include:



depression – feelings of extreme sadness that last for a long time



anxiety – a feeling of unease, such as worry or fear



Erectile dysfunction can often have both physical and psychological causes. For example, if you have diabetes, it may be difficult for you to get an erection, which may cause you to become anxious about the situation. The combination of diabetes and anxiety may lead to an episode of erectile dysfunction.

There are many emotional issues that may also affect your physical ability to get or maintain an erection. These include:



relationship problems



lack of sexual knowledge



past sexual problems



past sexual abuse



being in a new relationship



 

Other causes

Other possible causes of erectile dysfunction include:



excessive alcohol intake 



tiredness



using illegal drugs, such as cannabis, heroin or cocaine



 

Cycling

Men who cycle for more than three hours per week may be recommended to try a period without cycling to see if this helps improve erectile dysfunction.

Riding in the correct position with a properly fitted seat may also help to prevent regular cycling from leading to erectile dysfunction.

 


Increased risk

There are some things that can make erectile dysfunction more likely. These are very similar to the risks of cardiovascular disease and include:



lack of exercise or physical activity 



obesity



smoking



high cholesterol



Erectile dysfunction itself can also be a sign of cardiovascular disease.

 

Diagnosing erectile dysfunction 

 

Erectile dysfunction (ED) can often be diagnosed by your GP. They will talk to you about your situation and may carry out a physical examination.

Your GP may ask you about:



your symptoms



your overall physical and mental health



your alcohol consumption



whether you take drugs



whether you are currently taking any medication



If you do not want to talk to your GP about erectile dysfunction, you can visit a genitourinary medicine (GUM) clinic. You can find your nearest GUM clinic on the British Association for Sexual Health and HIV (BASHH) website.

Sexual history

You'll also be asked about your sexual history. Try not to be embarrassed because erectile dysfunction is a common problem. You can request a male GP at your surgery if you prefer.

You may be asked about:



your previous and current sexual relationships 



what your sexual orientation is 



how long you have been experiencing erectile dysfunction



whether you can get any degree of erection with your partner, on your own or when you wake up in the morning 



whether you have been able to ejaculate or orgasm



your libido (your level of sexual desire)



Erectile dysfunction that happens all the time may suggest an underlying physical cause.

Erectile dysfunction that only occurs when you are attempting to have sex may suggest an underlying psychological (mental) cause.

Assessing your cardiovascular health

Your GP may assess your cardiovascular health. Narrowed blood vessels are a common cause of erectile dysfunction and linked with cardiovascular disease (conditions that affect the heart and blood flow).

Your GP may:



measure your blood pressure to see if you have high blood pressure (hypertension)



listen to your heart rate to check for any abnormalities



measure your height, weight and waist circumference to see if you are a healthy weight for your height 



ask you about your diet and lifestyle, for example, how much exercise you do



test a sample of your blood for glucose (sugar) and lipids (fatty substances), as high levels can indicate conditions affecting your heart or blood vessels



Physical examinations and tests

A physical examination of your penis may be carried out to rule out anatomical causes (conditions that affect the physical structure of your penis).

If you have symptoms of an enlarged prostate, such as weak or irregular urination, a digital rectal examination (DRE) may be suggested. 

Blood tests can also check for underlying health conditions. For example, measuring the levels of hormones such as testosterone can rule out hormonal conditions, such as hypogonadism (an abnormally low level of testosterone).

Further testing

In some cases you may be referred to a specialist for further testing. This might be the case if you are unusually young to be experiencing erectile dysfunction as it's rare in men under 40 years of age. 

Intracavernous injection test

An intracavernous injection test involves injecting a man-made (synthetic) hormone into your penis to increase the blood flow. This helps assess any abnormalities in your penis and plan surgery. 

If the injection doesn't result in an erection it may indicate a problem with the blood supply to your penis. In some cases, you may also need an ultrasound scan.

Arteriography and dynamic infusion cavernosometry or cavernosography

These specialised tests involve injecting dye into the blood vessels of your penis and studying the dye on a scanner. These are likely to be used if you are being considered for surgery or if a problem has been detected with your blood vessels.

Psychological assessment

If the cause of your erectile dysfunction is thought to be psychological, you may be reffered for a psychological assessment.

Treating erectile dysfunction 

 

If you have erectile dysfunction (ED), treatment will depend on what's causing it.

Read on to learn about the different treatments you may be offered.

You can also read a summary of the pros and cons of these treatment options, allowing you to compare your treatment options.

Treating underlying conditions

If your erectile dysfunction is caused by an underlying health condition, such as heart disease or diabetes, that condition may need to be treated first. In some cases, treating the underlying cause may also resolve the problem.

If you are taking medication that can cause erectile dysfunction, there may be an alternative. It is important never to stop taking a prescribed medication unless you are advised to do so by your GP or another qualified healthcare professional responsible for your care.

Lifestyle changes

Erectile dysfunction can often be improved by making changes to your lifestyle, such as:



losing weight if you are overweight   



giving up smoking



cutting back your alcohol consumption 



not taking illegal drugs 



exercising regularly



reducing stress



As well as helping to improve your erectile dysfunction, these changes can also improve your general health and may help to reduce your risk of cardiovascular disease (conditions that affect your heart and blood vessels).

Phosphodiesterase-5 (PDE-5) inhibitors

Phosphodiesterase-5 (PDE-5) inhibitors are one of the most widely used and effective types of medication for treating erectile dysfunction. They work by temporarily increasing the blood flow to your penis.

In England, four PDE-5 inhibitors are available for treating erectile dysfunction. They are:



sildenafil – sold under the brand name Viagra 



tadalafil – sold under the brand name Cialis



vardenafil – sold under the brand name Levitra



avanafil - sold under the brand name Spedra



Sildenafil, vardenafil and avanafil work for about eight hours and they are designed to work 'on demand'. Tadalafil lasts for up to 36 hours and is more suitable if you require treatment for a longer period of time, for example, over a weekend.

Depending on the type of PDE-5 inhibitor you are taking and the dose, it should take about 30-60 minutes before it starts to work. With sildenafil, vardenafil and avanafil, you should be able to have sex from one to 10 hours after taking the medicine. After taking tadalafil, the effects will last for up to 36 hours.

It may take longer to notice the effects if the tablet is taken with food, so it's best to take it on an empty stomach. You can then eat after an hour without affecting the medicine.

Only take one tablet within a 24-hour period.

Your GP should explain the benefits of each medication and how it works. The choice may depend on:



how often you are sexually active 



whether you have tried any of the medications before



There have been many studies to test the effectiveness of these medications. In general, at least two-thirds of men report having improved erections after taking one of these medicines.

If you do not find that PDE-5 inhibitors are effective it may be because:



you have not waited long enough after taking the dose



you have waited too long after taking the dose



the dose is not high enough



you have not had enough sexual stimulation



These medications are triggered by sexual stimulation, so you also need to be aroused for it to work.

 

Warnings

PDE-5 inhibitors should be used with caution in men who have cardiovascular disease, such as coronary heart disease. However, sexual activity is also likely to be beneficial for your cardiovascular health. You should discuss the risks and benefits with your GP.

PDE-5 inhibitors should also be used with caution in men who have anatomical problems with their penis, such as Peyronie's disease (a condition that affects the tissue of the penis).

PDE-5 inhibitors should also be used with caution in men who:



are at risk of priapism – a painful erection that lasts for several hours



are also taking long lasting alpha-blockers – a medication used to treat a number of conditions, such as high blood pressure (hypertension)



 

Do not take PDE-5 inhibitors if you are also taking medicines or recreational drugs that contain nitrates. The combination of the two substances can have a dangerous effect on your heart.

Organic nitrates are often used to treat angina, and butyl nitrate is a recreational drug that is more commonly known as 'poppers'.

You are also warned not to take PDE-5 inhibitors if you:



have been advised not to take part in sexual activity or in activities that widen your blood vessels 



have low blood pressure (hypotension) 



have recently had a stroke – a medical emergency that occurs when the blood supply to the brain is interrupted



have unstable angina – an underlying heart condition that causes symptoms such as chest pain



have had a heart attack – a medical emergency where the blood supply to the heart is suddenly blocked



have a history of non-arteritic anterior ischaemic optic neuropathy – an eye condition that causes a sudden loss of vision



 

Side effects

PDE-5 inhibitors can cause some side effects, including:



headaches and migraines



flushing (redness) 



indigestion



nausea (feeling sick)



vomiting (being sick)



a blocked or runny nose



back pain



vision disturbances



muscle pain



 

See the medicines information for erectile dysfunction.

Your GP can prescribe sildenafil to anyone with erectile dysfunction as long as it is safe to do so (see warnings above). Other PDE-5 inhibitors may only be prescribed based on your individual circumstances.

In some cases you may need to pay the full cost of the medication. The exact price will depend on the dosage and your local pharmacy but four PDE-5 tablets usually cost between £17 and £30.



diabetes



multiple sclerosis



Parkinson’s disease



polio



prostate cancer



spina bifida



certain genetic conditions, such as Huntington's disease





pelvic surgery – which is often used to remove tumours (growths) or to treat conditions such as incontinence



surgical removal of the prostate gland (prostatectomy) – which is often used to treat prostate cancer



dialysis for kidney failure 



kidney transplant



 

 

Vacuum pumps

A vacuum pump consists of a clear plastic tube that is connected to a pump, which is either hand or battery operated.

You place your penis in the tube and pump out all of the air. This creates a vacuum that causes the blood to fill your penis, making it erect. You then place a rubber ring around the base of your penis to keep the blood in place, allowing you to maintain an erection for around 30 minutes.

It may take several attempts to learn how to use the pump correctly, but they are usually effective. After using a vacuum pump, nine out of 10 men are able to have sex, regardless of the cause of their ED.

 

Considerations 

You should not use a vacuum pump if you have a bleeding disorder or if you are taking anticoagulant medicines, which reduce the ability of your blood to clot.

Side effects of vacuum pumps include pain or bruising, although these occur in less than a third of men.

The Sexual Advice Association produces a number of factsheets, including one on vacuum pumps that provides details of companies that supply them.

 

Alprostadil

If your erectile dysfunction doesn't respond to treatment, or you are unable or unwilling to use PDE-5 inhibitors or a vacuum pump, you may be given a medicine called alprostadil. This is a synthetic (man-made) hormone that helps to stimulate blood flow to the penis.

Alprostadil is available as:



an injection directly into your penis – this is called an intracavernosal injection



a small pellet placed inside your urethra (the tube that carries urine from your bladder to the tip of your penis) – this is called urethral application



You may be trained to correctly inject or insert alprostadil. If your partner is pregnant, use a condom during sex if you are inserting alprostadil into your urethra.

Alprostadil will usually produce an erection after five to 15 minutes. How long the erection lasts will depend on the dose.

In men who did not respond to PDE-5 inhibitors, alprostadil injections were successful in 85 out of 100 men. Alprostadil inserted into the urethra is successful for up to two-thirds of men.

 

Warnings

Alprostadil should not be used:



in men at risk of priapism (a painful erection that lasts for several hours) – for example, those with sickle cell anaemia



alongside other erectile dysfunction medications 



if you have a penile implant or if you have been advised to avoid sexual activity 



Urethral application may also not be used in:



some men who have anatomical problems with their penis (conditions that affect the physical structure of the penis) 



men who have infections of their penis, such as balanitis (inflammation of the head of the penis)



Side effects

Alprostadil can cause some side effects including:



changes in your blood pressure



dizziness



headache



pain in your penis 



urethral burning or bleeding



reactions at the site of the injection, such as swelling



 

See the Alprostadil medicines information for more information about this medicine.

As with PDE-5 inhibitors,

may only be available for men with particular health conditions or those receiving some types of medical treatments. If you need to pay the full prescription cost, a single injection of alprostadil costs around £8 to £22, depending on the dose. A single dose of alprostadil for urethral application is around £10. 

Hormone therapy

If a hormonal condition is causing erectile dysfunction, you may be referred to an endocrinologist (who specialises in the treatment of hormonal conditions).

Hormones are chemicals produced by the body. Many hormonal conditions can be treated using injections of synthetic (man-made) hormones to restore normal hormone levels.

Surgery

Surgery for erectile dysfunction is usually only recommended if all other treatment methods have failed. It may also be considered in:



younger men who have experienced serious injury to their pelvic area – for example, in a car accident



men with a significant anatomical problem with their penis



In the past, surgery was used if there was clear evidence of a blockage to the blood supply of the penis. The surgeon could unblock the blood vessels to restore a normal supply of blood. However, research now suggests that the long-term results of this type of surgery are poor, so it's unlikely to be used.

 

Penile implants

Penile implants are a type of surgery that may be considered. These can be:



semi-rigid implants – which may be suitable for older men who do not have sex regularly



inflatable implants – which consist of two or three parts that can be inflated to give a more natural erection



However, around three-quarters of men report being satisfied with the results of this type of surgery.

 

Complications

As with all types of surgery, having penile implants inserted carries a risk of infection. If you take preventative antibiotics, the rate of infection is around two or three in 100. Mechanical problems with the implants may occur within five years in five per cent of cases. 

Psychological treatments

If your erectile dysfunction has an underlying psychological cause then you may benefit from a type of treatment called sensate focus.

If conditions such as anxiety or depression are causing your erectile dysfunction, you may benefit from counselling (a talking therapy).

Sensate focus

Sensate focus is a type of sex therapy that you and your partner complete together. It starts with you both agreeing not to have sex for a number of weeks or months. During this time, you can still touch each other, but not in the genital area (or a woman’s breasts). The idea is to explore your bodies knowing that you will not have sex.

After the agreed period of time has passed, you can gradually begin touching each other’s genital areas. You can also begin to use your mouth to touch your partner, for example, licking or kissing, them. This can build up to include penetrative sex.

You can find out more about sensate focus from the College of Sexual and Relationship Therapists (COSRT).

Psychosexual counselling

Psychosexual counselling is a form of relationship therapy where you and your partner can discuss any sexual or emotional issues that may be contributing to your erectile dysfunction. By talking about the issues, you may be able to reduce any anxiety that you have and overcome your erectile dysfunction.

The counsellor can also provide you with some practical advice about sex, such as how to make effective use of other treatments for erectile dysfunction to improve your sex life.

For information and advice about sexual arousal, read about good sex.

Psychosexual counselling may take time to work and the results achieved have been mixed.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is another form of counselling that may be useful if you have erectile dysfunction. CBT is based on the principle that the way you feel is partly dependent on the way you think about things. CBT helps you realise that your problems are often created by your mindset. It is not the situation itself that is making you unhappy, but how you think about it and react to it.

Your CBT therapist can help you to identify any unhelpful or unrealistic thoughts that may be contributing to your erectile dysfunction – for example, to do with:



your self-esteem (the way you feel about yourself) 



your sexuality 



your personal relationships



Your CBT therapist will be able to help you to adopt more realistic and helpful thoughts about these issues.

 

Pelvic floor muscle exercises

Some studies have suggested that, in a few cases, it may be beneficial to exercise your pelvic floor muscles. These are a group of muscles around the underside of the bladder and rectum, as well as at the base of the penis.

Pelvic floor muscle exercise involves strengthening and training the muscles used to control the anus (back passage) and urinate. If your GP feels this type of exercise could be beneficial, then you may want to discuss it with a physiotherapist to learn it correctly.

By strengthening and training these muscles, you may be able to reduce the symptoms of erectile dysfunction.

Complementary therapies

Some complementary therapies, such as acupuncture, have claimed to treat erectile dysfunction. However, there is little evidence they are useful.

In some cases, they may even include ingredients that could interact with other medications and cause side effects.

Always speak to your GP before using any complementary therapies.

 



Counselling may be required if the underlying cause of your erectile dysfunction is psychological  


Managing ED on the internet

As erectile dysfunction (ED) can be an embarrassing problem, some men are tempted to look for treatment on their own. It is possible to buy medication over the internet, but you should always exercise caution as there are many sites that offer counterfeit medicines. These medications are not regulated and the amount of active ingredients in them can vary. They could cause unpleasant side effects or they may not be suitable for you.

Always ensure that any online doctor service is registered with the Care Quality Commission (CQC) , that all doctors are registered with the General Medical Council (GMC) and that any prescribed medicines come from a pharmacy which is registered in the UK.

It is also possible that an underlying health condition may be causing your erectile dysfunction and getting this diagnosed and treated may resolve your symptoms. Therefore, always see your GP for a full check-up.






Compare your options

Take a look at a simple guide to the pros and cons of different treatments for erectile dysfunction
Erectile dysfunction