Erectile Dysfunction

What is erectile dysfunction (ED)?

Erectile dysfunction (ED) is a common issue affecting many men. The term covers a range of erection problems, from not being able to get an erection at all, to not being able to maintain a firm enough erection to have sex. This may happen all the time or just occasionally. Studies suggest that up to 50% of men of reproductive age report some erectile problems.

What causes erectile dysfunction?

When a man is sexually aroused, signals from the nervous system cause blood to flow to the penis, resulting in an erection. In men with erectile dysfunction, something stops that from happening effectively. This can be for a number of different reasons:

• Vascular causes (affecting the blood vessels) e.g. high blood pressure, atherosclerosis (blockage of the arteries due to cholesterol deposits), artery disease e.g. coronary artery disease (heart disease), peripheral vascular disease
• Diabetes – both type 1 and type 2
• Chronic illness such as chronic obstructive pulmonary disease (COPD), ischaemic heart disease, liver disease, kidney disease, arthritis
• Certain medications e.g. antihypertensives, antidepressants, oestrogens, anti-androgens, digoxin
• Surgery or radiation to the pelvis
• Trauma to the penis
• Problems with the nerves to the penis e.g. following surgery or injury, or due to conditions such as stroke, multiple sclerosis, Alzheimer's disease, and Parkinson's disease
• Hormone imbalance such as hypogonadism, hypothyroidism, hyperthyroidism, pituitary tumours, and hyperprolactinaemia
• Anatomical abnormalities e.g. Peyronie’s disease, hypospadias (abnormal location of the urethra)
• Psychogenic causes such as depression, anxiety, stress, and relationship problems and sexual disorders such as arousal disorders and ejaculation disorders 
• Lifestyle factors such as smoking, being overweight, living a sedentary lifestyle, excess alcohol consumption, drug use e.g. cannabis
• Ageing 

Often the cause is multifactorial.

Psychological erectile dysfunction

A number of psychological therapies can help men to get to the root of any psychological issues that are contributing to erectile dysfunction.

• Sensate focus is a strategy that a man can try with their partner. It involves agreeing not to have sex for a certain period of time, usually several weeks. During this time you can explore different types of closeness and focus on your relationship without any pressure to have sex.
• Psychosexual counselling is a talking therapy that can help a man to explore any issues around relationships and sex. It can be done with or without a partner.
• Cognitive behavioural therapy (CBT) helps you change your mindset and behaviours to improve your wellbeing.

How is erectile dysfunction diagnosed?

It’s very common for men to experience erection problems from time to time. If this happens to you for more than a few weeks, it’s a good idea to visit your GP to explore any underlying issues. You’ll be asked some questions about your general health, mental wellbeing and sexual history before doing some physical checks and tests. These may include:

• Measuring your vital signs, such as your heart rate and blood pressure
• Measuring your height and weight
• Taking blood tests, including testing for diabetes and high cholesterol

A health professional may also want to examine your penis if they suspect an injury or other anatomical issue may be causing your erection problems. If there are signs of prostate issues, they may need to do a rectal examination.

These questions and checks will help to determine the cause of erectile dysfunction, so that action can be taken to treat it.

How to cope with erectile dysfunction?

Erectile dysfunction isn’t easy to live with. You may find it affects your confidence or leaves you feeling frustrated. If you have a partner, you may worry about how it will affect them.
Although it isn’t always easy, the best way to cope is to be honest about the problem and to seek help to find treatment. Talk to your GP or sexual health practitioner about your symptoms and possible solutions. Rather than avoiding sex, be open with your partner about what you are going through.

If your erectile dysfunction is partly or wholly caused by psychological issues – or if the condition itself is affecting your mental wellbeing – psychosexual counselling may help. You may choose to go to “couples therapy” to talk about any problems in your relationship or speak to someone by yourself to better understand the issues you are experiencing.

Some causes of erectile dysfunction can be effectively treated with medication to promote erection. 

How to talk to your partner about erectile dysfunction?

Your partner may have already noticed a problem, or you may have avoided the issue with them. Either way, being honest is the best approach. Let them know that it’s not something you can control or be blamed for, and it’s nothing personal – it doesn’t mean that you don’t find them attractive. Let them know that it’s a common issue and tell them the steps you are taking to fix it. By talking honestly about erectile dysfunction, you may find that you become more relaxed with your partner, which may help your erection problems.

How to support your partner with erectile dysfunction?

Erectile dysfunction doesn’t just affect the person with erection problems – it has a big impact on their partner, too. If your partner is affected by erectile dysfunction, you might understandably feel rejected or insulted, but erection problems are not the same as a lack of desire. Erectile dysfunction does not have to harm your relationship, but in order to cope as a couple, it’s important to be open and honest with each other about your respective feelings.

To support your partner, let him know that you are there, and reassure him that erectile dysfunction doesn’t change your commitment to him. Don’t be afraid to share your own experiences, but be constructive in finding solutions that you can work on together. Keep your relationship intimate by adjusting your sex life so that there’s no “pressure to perform”, and stay close by carrying on talking and doing things together. Support any lifestyle changes he is advised to make – for example, by joining him in a new exercise regime.

What are the symptoms of erectile dysfunction?

The symptoms of erectile dysfunction are the inability to get an erection or to sustain a firm enough erection to have satisfactory sex. These may occur all the time, or just occasionally. Some men may be able to get an erection while masturbating, but not during sex with another person.

How can I improve my ED?

That depends on what’s causing your erection problems. It’s important to see your GP or visit your GUM clinic so that a health professional can check you over and assess why you might be experiencing erectile dysfunction.

Many contributing causes of ED are lifestyle factors such as smoking, alcohol consumption, being overweight or using drugs. Therefore you can potentially improve erectile problems by quitting smoking and drug use, cutting down alcohol consumption, losing weight if you are overweight, and trying to incorporate more physical activity into your lifestyle.

How can erectile dysfunction tablets help?

Erectile dysfunction tablets help erectile dysfunction by improving blood flow to the penis. Increased blood flow is required to produce and maintain an erection. 

How is erectile dysfunction treated?

The treatment for erectile dysfunction will depend on the cause:

• If your GP suspects that your erection problems are caused by an underlying health condition, they will initiate treatment for that e.g.
  • Lifestyle changes, such as losing weight, cutting down on alcohol or stopping smoking
  • Dietary changes
  • Medication to treat diabetes, lower blood pressure or lower cholesterol levels
• If hormonal changes are behind your erectile dysfunction, you may be prescribed hormone replacement treatment
• If you are taking medication that may be affecting your ability to achieve an erection, your GP may suggest switching to an alternative type of medication
• If your erectile dysfunction has a psychological cause, psychological therapies, psychosexual therapy or counselling may be the most effective treatment. Sometimes you may also be prescribed medication to help you overcome ED in the short term. 

What medications are available for erectile dysfunction?

The first-line medical therapy for erectile dysfunction is a class of medicines known as phosphodiesterase-5 (PDE-5) inhibitors. These work by temporarily increasing the blood flow to the penis.

Four types of PDE-5 inhibitors are available:

• Sildenafil (Viagra)
• Vardenafil (Levitra)
• Tadalafil (Cialis)
• Avanafil (Spedra)

PDE-5 inhibitors are available on prescription and all work in the same way, but they vary in the time it takes for them to take effect, and how long the effects last.

PDE-5 inhibitors are the most common type of medication for erectile dysfunction. 

Other treatments which may be suitable if PDE-5 inhibitors do not work include: 

• Intracavernosal injections, such as alprostadil, which are injected directly into the tissue of the penis
• Intraurethral alprostadil suppositories, which are small pellets that are inserted into the urethra
• Vacuum devices – where the penis is inserted into a pump device which promotes blood flow
• Topical alprostadil – a cream, which is applied directly to the penis
• Surgery e.g. insertion of a malleable or inflatable penile prosthesis which can be used to facilitate erection

These alternative therapies are generally commenced by a specialist urologist.

How effective is ED medication?

The efficacy of different erectile dysfunction treatments varies between different people and you may need to try several different types and doses of medication. Most men (>50%) with ED will find improvement in their erections with treatment with a PDE-5 inhibitor.

It’s important to note that in addition to taking the medication correctly, you must also be sexually aroused in order to achieve an erection.

Which erectile dysfunction medication is right for me?

Your choice of erectile dysfunction medication will depend on how often you would like to be sexually active, how long you would like the effects to last, and whether you have tried any similar medications before without success. 

The first-line medication is usually sildenafil. This is taken up to once a day, around an hour prior to planned sexual activity. It works within 30–60 minutes and its efficacy typically lasts around 4–5 hours. Its effectiveness can be influenced by food, and a heavy or fatty meal can hinder absorption. 

Tadalafil is a long-acting PDE-5 inhibitor, which can be taken either “on-demand”, at least 45 minutes prior to sexual activity, or can be taken once daily as a regular medication. It’s effective within 30–60 minutes, with peak effectiveness occurring around 2 hours after taking it, and it’s effective for up to 36 hours. 

Vardenafil is a short-acting PDE-5 inhibitor that is taken “on-demand” and works within 30–60 minutes of ingestion. Its effects peak after around an hour.

Avanafil is a highly selective PDE-5 inhibitor, which means it’s associated with fewer side effects. It works within 30–45 minutes of ingestion. 

Why do I need to try different ED medications?

You may need to try different ED medications to find out which one works best for you. Not all ED medications work well for everyone and you may experience unwanted side effects. Therefore, it's worth trying a few different ED medications to decide which is best for you.

Which is the best ED medication?

That depends on your individual needs and preferences and there is no conclusive evidence to suggest one PDE-5 inhibitor is superior to the others. Everyone is different, so what’s best for one person may not work so well for someone else. Speak to your doctor to discuss your needs. 

What are the alternatives to erectile dysfunction medication?

Suitable alternatives to ED medication depend on the cause of the issue. For those with a psychological element, psychosexual therapy or counselling may be a more effective or alternative treatment. 

For those who have not had success with PDE-5 inhibitors, medication alternatives are intracavernosal injections, intraurethral pessaries and creams, which typically contain the drug alprostadil. 

The most common non-pharmacological therapy is a vacuum pump, which is a plastic tube connected to a pump that is placed over the penis. When the pump is operated, a vacuum is created inside the tube, which causes blood to flow to the penis and produce an erection. To maintain the erection, a rubber ring is placed at the base of the penis, which can be worn while you have sex.

In cases where the above therapies have not worked, you may be referred for surgical management.

How to prevent ED?

Most men experience erectile dysfunction at some time in their life, but you can reduce the risk by making changes to your lifestyle. These include getting regular exercise, eating a healthy diet and cutting down or giving up alcohol, tobacco products, steroids and illegal drugs. Maintaining an open relationship with your partner(s) and regularly discussing your sexual needs can help to avoid psychosexual and relationship issues.

Lifestyle changes to improve erectile dysfunction

You may be able to improve erectile dysfunction by making some changes to your lifestyle. 
These could include:

• Giving up smoking, or cutting down on the number of cigarettes you smoke
• Drinking less alcohol
• Stopping taking drugs e.g. cannabis
• Getting more exercise
• Losing weight if you are overweight
• Avoiding stress

Can sex therapy help erectile dysfunction?

Some cases of erectile dysfunction are caused by psychological issues surrounding sex and relationships. In these cases, a qualified sex therapist may be able to help you get to the bottom of the issues that are leading to erection problems. You can see a sex therapist by yourself or with a partner.

Can you have surgery for erectile dysfunction?

Occasionally, some men do have surgery to treat erectile dysfunction. However, this is rare and is usually only considered if all other options have been tried  first, or if there are physical injuries or impairments. During surgery, a penile implant is fitted which can be manipulated or inflated to produce an erection.

What are the side effects of ED medications?

Common side effects of PDE-5 inhibitors include:

• Flushing (redness)
• Indigestion
• A blocked or runny nose
• Headache or migraine
• Nausea or vomiting
• Back pain
• Muscle pain
• Dizziness

Less common but serious side effects of PDE-5 inhibitors include:

• Visual disturbances
• Sudden hearing loss
• Priapism (persistent erection) lasting more than 4 hours

Can cycling cause ED?

Some people worry that riding a bike will cause erectile dysfunction. There is limited evidence to support the notion that frequent cycling (>3 hours per week) can increase the chance of developing erectile dysfunction however there is no significant increased risk for those who cycle <3 hours per week. Cycling is a great form of exercise, and being inactive or overweight can increase the risk of having ED. The cardiovascular benefits of regular exercise and of being within a healthy weight range help to protect against many serious diseases, as well as making ED less likely.

Does diet affect erectile dysfunction?

Yes, your diet can affect your chances of developing ED. Men who are overweight are more likely to experience erection problems, so by eating a healthy diet and consuming the recommended number of calories for your size, you can reduce your risk of ED.

Which diseases can cause erectile dysfunction?

There are several diseases and conditions that can lead to erectile dysfunction.

• Vascular conditions, such as heart disease, high blood pressure and diabetes, can all reduce blood flow to the penis, making it harder to get an erection
• Neurological conditions, such as stroke, multiple sclerosis and spinal injuries, can affect nerve function
• Hormonal conditions, such as overactive or underactive thyroid, hypogonadism and Cushing’s syndrome, can all cause erectile dysfunction
• Peyronie’s disease, which affects the tissue of the penis, can make it difficult to get an erection.

Which medications can cause ED?

There are several types of prescription and over-the-counter medicine that can make changes to the body, causing erectile dysfunction. These include:

• Antidepressants, such as fluoxetine
• Anticonvulsant medicines used to treat epilepsy
• Antihistamines, which are commonly used to treat hay fever
• Antihypertensive drugs such as beta-blockers, which are used to treat high blood pressure
• Antipsychotic drugs
• Corticosteroids
• Diuretics

This is not an exhaustive list, so if you are taking any type of medication and think that it may be affecting your sex life, talk to your GP, who may be able to prescribe an alternative.

What is psychological ED?

Psychological ED is erectile dysfunction that results from psychological problems, such as depression, anxiety or unresolved issues surrounding sex and relationships. In these cases, there is often no issue with the blood flow, vessels, nerves or anatomy of the penis and therefore typical ED treatments such as PDE-5 inhibitors may not work.

What is porn-induced erectile dysfunction and is it real?

Porn-induced erectile dysfunction (PIED) is a recognised issue, particularly among younger men. Studies show that erectile dysfunction and other sexual problems have become more common with the rise of easy-to-access internet pornography. Reducing or stopping exposure to pornography has been shown to help some men combat their erectile dysfunction.

Do alternative therapies help ED?

You may have heard of herbal alternatives to Viagra, which claim to treat erectile dysfunction. However, there is no evidence that these are effective. In fact, the ingredients in some herbal remedies could interfere with the way Viagra and other medicines work, so it is important to consult a doctor before considering them.

What causes erectile dysfunction in young men?

Erectile dysfunction in men under 40 is less likely to be caused by physical problems and more likely to be a psychological issue. Young men may feel under pressure to perform sexually, or anxious about the possibility of an unwanted pregnancy. However, it is still important to see a doctor to rule out underlying physical conditions.

Can stress cause erectile dysfunction?

Yes, stress can be a factor in erectile dysfunction. On its own or in combination with other psychological or physical problems, stress can lead to problems getting an erection or maintaining it. Avoidance of stressful situations and introducing stress-management techniques can often help in the treatment of ED.

What are the physical causes of ED?

Erectile dysfunction can be caused by:

• Problems with your blood vessels, such as high blood pressure, a build-up of cholesterol, coronary artery disease and peripheral arterial disease. 
• Neurological conditions, such as a stroke, multiple sclerosis, Alzheimer’s disease and Parkinson’s disease
• Trauma or injury to the penis or the blood vessels or nerves supplying the penis
• Peyronie’s disease, in which scar tissue causes a curve to develop in the penis.
• Hormone-related problems such as diabetes or thyroid problems
• A combination of several conditions.

Some of these conditions can be serious, so it is always a good idea to speak to your doctor about your erectile dysfunction, so they can investigate the cause of your condition. 

What are PDE-5 inhibitors?

PDE-5 inhibitors e.g. sildenafil/Viagra), tadalafil/Cialis), vardenafil/Levitra and Spedra (avanafil)  are the most common type of medication used to treat erectile dysfunction. They work by dilating the vessels in the penis, thus increasing blood flow to the penis and producing an erection

Are erectile dysfunction and premature ejaculation related?

In some cases, erectile dysfunction and premature ejaculation could be related. If you are experiencing both of these issues, they shouldn’t be treated in isolation: talk to your doctor about possible causes and treatments.

Can ED be reversed?

Yes, in the vast majority of cases, it’s possible to treat the causes behind erectile dysfunction.

Are ED medications safe?

When obtained from a regulated supplier, PDE-5 inhibitors such as Viagra are safe for most people to use. Like any other medication, your ED medicine must be taken according to the directions in the patient information leaflet, and there may be some side effects, including:

• Headaches
• Flushing (redness)
• Indigestion
• A blocked or runny nose
• Nausea or vomiting
• Back pain
• Muscle pain
• Vision disturbances

PDE-5 inhibitors are not safe for those:

• Taking nitrates e.g. for angina. This includes recreational use of “poppers” (butyl nitrate)
• Taking guanylate cyclase stimulators
• With unstable heart disease or unstable angina
• With low blood pressure
• With an eye condition called non-arteritic anterior ischaemic optic neuropathy (NAION)

PDE-5 inhibitors also may not be safe for people:

• With a recent history of stroke
• With a recent history of myocardial infarction
• With liver disease
• With congenital eye conditions e.g. retinitis pigmentosa
• With heart failure
• With arrhythmias
• With hypertension (high blood pressure)
• With kidney disease or on dialysis
• With heart valve conditions such as aortic stenosis
• With anatomical malformations of the penis e.g. Peyronie’s disease or hypospadias
• With sickle-cell disease
• With multiple myeloma or leukaemia
• With bleeding disorders
• With peptic ulcer disease
• Predisposed to long QT syndrome (a heart condition) 

Talk to your GP about the right treatment for you.

At what age is erectile dysfunction most common?

Erectile dysfunction is most common in men aged between 40 and 70. It is thought to affect as many as half of all men in this age group at some time.