Erectile dysfunction

Erectile dysfunction occurs when you can't get and maintain an erect penis. In some cases, your penis may become partly erect but not hard enough for sexual intercourse, while in other cases, it may not become erect, full or swollen at all. In either case, your sex life can be affected.

Erectile dysfunction is a very common condition and is not usually serious. It can affect men at any age. However, you’re more likely to have erectile dysfunction if you’re older. Erectile dysfunction is estimated to affect one in two men aged 40 to 70, although it often only happens occasionally. If it keeps occurring, you should see your GP as it may be a sign of a more serious underlying condition. 

It can usually be treated by taking an erectile dysfunction tablet before sex. Your GP may also recommend lifestyle changes. As heart disease can cause erectile dysfunction, your GP may also recommend medication to treat your heart disease. 

Most men will occasionally be unable to get or maintain an erection — often the cause is anxiety, tiredness or drinking too much alcohol. This is a temporary effect and most men can get an erection in most cases when sexually aroused. 

However, some men have persistent problems getting and maintaining an erection, with one in two men aged 40 to 70 having erectile dysfunction and seven in 10 men aged 70 or over. Regular or ongoing erectile dysfunction can take its toll on your confidence, sex life and relationships. 

In eight out of 10 cases of erectile dysfunction, the cause is physical. Erectile dysfunction causes include:

• Damage to your nerves or spinal cord — this can affect the nerves in your penis; long-distance cycling can put pressure on nerves in your penis and reduce their function; other conditions that can damage these nerves include: 
• A fractured pelvis
• A spinal injury 
• A stroke
• Multiple sclerosis 
• Parkinson’s disease
• Surgery or radiotherapy in your genital area
• Diabetes — this is a common cause of erectile dysfunction as it can affect both the nerves and blood vessels of your penis
• Hormone imbalances such as reduced levels of the male sex hormone testosterone — low testosterone levels may also cause reduced sex drive and mood changes; it can occur after a head injury that affects a part of the brain called the pituitary gland, which regulates testosterone production
• Lifestyle factors, including lack of exercise, smoking, higher than recommended alcohol consumption and drug abuse
• Narrowing of the blood vessels that supply your penis, which reduces blood flow and therefore prevents an erection — this is the most common cause of erectile dysfunction in men aged over 40 as blood vessels can narrow with age; other risk factors for narrowing of the blood vessels include coronary heart disease, high blood pressure, high cholesterol and smoking
• Side effects of certain medications — common medications that can cause erectile dysfunction include certain antidepressants, diuretics, high blood pressure medications (eg beta-blockers such as atenolol and propranolol) and cimetidine which reduces stomach acid production

In rare cases, erectile dysfunction is caused by a venous leak. This occurs when too much blood flows out of your penis through its veins. 

Physical causes of erectile dysfunction tend to result in the condition developing slowly eg starting with intermittent erectile dysfunction and/or partial erections, which then worsen. In these cases, your sex drive will likely be normal and erectile dysfunction can therefore cause anxiety, depression and low self-esteem — this can then worsen your erectile dysfunction. 

In some cases, erectile dysfunction causes are psychological, such as:

• Depression
• Performance anxiety — most men will occasionally be unable to get or maintain an erection, which prevents them from having sexual intercourse; however, failing to get an erection can cause anxiety, which then makes it harder to get an erection next time; this can trigger a vicious cycle of anxiety and erectile dysfunction
• Previous sexual abuse
• Relationship problems
• Stress and anxiety

Psychological causes of erectile dysfunction tend to result in the condition developing suddenly. Once the psychological cause has been addressed, erectile dysfunction often improves. However, if anxiety or depression worsens, erectile dysfunction can worsen too. 

If you can get a normal erection sometimes, it is more likely that the cause of your erectile dysfunction is psychological rather than physical. 

Erectile dysfunction can usually be treated, often by treating any underlying physical or psychological conditions. In some cases, medication may be recommended, such as erectile dysfunction tablets.

The key symptom of erectile dysfunction is the inability to maintain an erection and experience satisfactory sexual intercourse.

You should always mention erectile dysfunction to your GP if you’re experiencing it. It can be a symptom of a serious health condition, such as heart disease, diabetes or depression.

Your GP may ask you about your lifestyle, relationships and any problems you are facing. To check for underlying health conditions, they may also carry out a range of physical tests, including:

• Checking your weight
• Listening to your heart rate
• Measuring your blood pressure
• Testing your blood glucose, cholesterol and hormone levels

Your GP may examine your penis. If you also have the symptom of needing to urinate more often, they may examine your prostate to check for prostate cancer. 

If you have erectile dysfunction and a low sex drive or have had a past head injury, your erectile dysfunction may be caused by a hormone imbalance. Your GP may therefore recommend a blood test to check your hormone levels, specifically testosterone and sometimes prolactin too. 

In some cases, your GP may refer you to a consultant for further tests, diagnosis and/or treatment. If there’s a psychological reason for your erectile dysfunction, your GP may refer you to a psychologist.

Erectile dysfunction treatment is usually effective and the condition goes away. 

Your GP will advise you about lifestyle changes to help relieve your erectile dysfunction. This may involve: 

• Eating a healthy diet and losing excess weight
• Reducing how much alcohol you drink to below 14 units a week
• Reducing stress and anxiety
• Stopping cycling for a while if you normally cycle for more than three hours a week
• Stopping smoking 
• Taking regular exercise

Erectile dysfunction can be an early sign of heart disease or other cardiovascular problems. Your GP may therefore recommend reviewing your lifestyle to determine how you can reduce your risk of these problems developing or worsening. 

There are also several specific erectile dysfunction treatments, which your GP or consultant may suggest depending on the cause of your condition.

Medications 

If your erectile dysfunction is caused by a hormone imbalance, you may receive hormone replacement therapy eg testosterone. If it is caused by narrowing of the blood vessels supplying your penis, which is often linked to high blood pressure and high cholesterol, you may receive medication to lower your blood pressure or lower your cholesterol (eg statins). If it is caused by side effects of medication you are taking for another condition, your GP may discuss alternative treatments with you. 

There are also specific erectile dysfunction medications that work by increasing blood flow to your penis. They target a chemical called cGMP, which is responsible for widening your blood vessels when you are sexually aroused and consequently increasing blood flow. These medications are called phosphodiesterase type 5 (PDE5) inhibitors and should be taken before you have sex — they only work if you are sexually aroused. They include avanafil, sildenafil, tadalafil and vardenafil.

Erectile dysfunction medications are effective in around eight out of 10 cases but are not suitable for everyone. You shouldn’t take erectile dysfunction medications if you are also taking nitrate medications eg glyceryl trinitrate (GTN), which are usually used to treat angina. 

Vacuum pump 

If you can’t take erectile dysfunction medications or they do not work for you, your doctor may recommend a vacuum pump. This is an effective, non-invasive method of getting an erection and involves increasing the blood flow to your penis. 

Creams, injections and pessaries 

A special cream (eg topical alprostadil) can be applied to the tip of your penis and surrounding skin to help you get an erection. It should be applied 5-10 minutes before you have sex. 

Injections are also effective for treating erectile dysfunction and were commonly used before tablets were available. Your doctor or nurse will teach you how to inject a medication into the base of your penis to temporarily increase blood flow. This will produce an erection in about 15 minutes. 

Pessaries (small pellets) contain a similar medication to that found in injections. The pessary is placed into the end of the tube that passes urine out of your penis (urethra). The medication is absorbed into your penis and produces an erection in 10-15 minutes. 

Penile implants 

This is a surgical procedure that is only recommended when other treatments, including erectile dysfunction tablets, have been unsuccessful.

If your erectile dysfunction is caused by an underlying condition, your doctor will arrange the appropriate treatment for this condition.

If your erectile dysfunction is psychological, your doctor may refer you for counselling, sex therapy or cognitive behavioural therapy (CBT) — these may be used in addition to other treatments.