Erectile dysfunction (ED), also known as impotence, is the inability to get and maintain an erection that is sufficient for satisfactory sexual intercourse.
Read more about the symptoms of erectile dysfunction.
ED 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.
Why does erectile dysfunction happen
ED can have a range of causes that can be both physical and mental (psychological). Physical causes include:
Psychological causes of ED include:
Read more about the causes of erectile dysfunction.
Although you may be embarrassed, it is important that a healthcare professional diagnoses ED so that the cause can be identified.
ED can usually be diagnosed after a consultation with your GP. This will involve answering questions about your symptoms, as well as a physical examination and some simple tests.
Read more about diagnosing erectile dysfunction.
How is erectile dysfunction treated
ED 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.
There are several treatment options that have proved very successful for ED. Medication, such as sildenafil (sold as Viagra), can be used to successfully manage it in at least two-thirds of men. 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 ED have improved significantly in recent years. These days most people are eventually able to return to successful intercourse.
Read more about treating erectile dysfunction.
Symptoms of erectile dysfunction
The main symptom of erectile dysfunction (ED) is the inability to get and maintain an erection for satisfactory intercourse.
ED should not be confused with ejaculation problems such as premature ejaculation, which is a condition where the process of arousal, orgasm and ejaculation occurs very rapidly.
Inability to get an erection
Sometimes ED 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.
In these circumstances, it is likely that the underlying cause of ED is primarily psychological (stress related). However, if you are unable to get an erection under any circumstances, it is likely that the underlying cause is primarily physical.
Seek medical advice
See your GP if ED persists 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).
Many websites offer treatments for ED but their use is not recommended. The medications that are offered by these sites could be fake and may be dangerous. Even if the medications are genuine, they may not be suitable for you.
It is important that you only take medication for ED that your GP has prescribed for you.
Read more about treating erectile dysfunction.
Causes of erectile dysfunction
Erectile dysfunction (ED) can have many causes, such as other medical conditions, certain medications and stress related (psychological) issues.
To understand more about the possible causes of erectile dysfunction (ED) it is useful to understand how erections occur.
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. Therefore, anything that interferes with the nervous system or the blood circulation could lead to ED.
Anything that affects libido (level of sexual desire) can also cause ED 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 that are produced by the body).
There are four main types of health conditions that can cause physical problems resulting in ED. These are:
Examples of vasculogenic conditions that can cause ED include:
ED is strongly associated with cardiovascular disease. For this reason, it may be one of the first causes that your GP considers when making your diagnosis and planning your treatment.
Examples of neurogenic conditions that can cause ED include:
Examples of hormonal conditions that can cause ED include:
Peyronie's disease, which affects the tissue of the penis, is an example of an anatomical condition that can cause ED.
In some men, certain medicines can cause ED, including:
Speak to your GP if you are concerned that a prescribed medicine is causing ED. Alternative medication may be available. However, it is important never to stop taking a prescribed medicine unless you are advised to do so by your GP or another qualified healthcare professional who is responsible for your care.
Possible psychological causes of ED include:
ED 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 ED.
There are many emotional issues that may also affect your physical ability to get or maintain an erection. These include:
Other possible causes of ED include:
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.
Some things your GP may ask you about include:
If you do not want to talk to your GP about ED, 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.
Your GP will also need to ask you detailed questions about your sexual history. Try not to be embarrassed because ED is a common problem. You can request a male GP at your surgery if you prefer.
Your GP may ask about:
ED that occurs all the time may suggest an underlying physical cause. If ED only occurs when you are attempting to have sex with your partner it may suggest that there is an underlying psychological (mental) cause.
Assessing your cardiovascular health
An important cause of ED is narrowed blood vessels. These are also linked with cardiovascular disease (conditions that affect the heart and blood flow). Your GP may therefore assess your cardiovascular health by seeing if you have any of the symptoms of cardiovascular disease. If you do, it is likely to be causing your ED.
Your GP may:
Physical examinations and tests
Your GP may carry out a physical examination of your penis to rule out anatomical causes (conditions that affect the physical structure of your penis).
If you are over the age of 50, your GP may suggest that you have a digital rectal examination (DRE). This involves your GP wearing gloves and inserting a finger into your anus (back passage). A DRE can be useful for diagnosing problems with the prostate (the small gland between the penis and the bladder), such as prostate cancer.
Blood tests may also be used to check for possible 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).
In some cases you may be referred to a specialist for further testing, although this is usually only required if you are unusually young to be experiencing ED. This is because ED is relatively rare in men who are under 40.
If it is thought that your ED is related to cardiovascular disease, these tests are rarely necessary.
Intracavernous injection test
An intracavernous injection test involves injecting a man-made (synthetic) hormone into your penis to increase the blood flow. This may be used to assess any abnormalities in your penis to help plan surgery.
If the injection fails to produce an erection it may indicate that there is a problem with the blood supply to your penis. If you do get an erection during an intracavernous injection test, it is still possible that there is a problem with your blood vessels. You may, therefore, need an ultrasound scan as well.
Arteriography and dynamic infusion cavernosometry or cavernosography
These are specialised tests that involve injecting dye into the blood vessels of your penis and studying the dye on a scanner. These are only likely to be used if you are being considered for surgery or if a problem has been detected with your blood vessels.
If there may be an underlying psychological cause for your ED, your GP may refer you for a psychological assessment. This could be with:
Treating erectile dysfunction
If you have erectile dysfunction (ED) the treatment that you will receive will depend on the underlying cause of the condition.
The treatment options for ED are explained below.
Treating underlying conditions
If your ED is caused by an underlying health condition, such as heart disease or diabetes, that condition may need to be treated first before treatment for ED can begin. In some cases, treating the underlying cause may also resolve the problem of ED.
If you are taking a medication that can cause ED and there is an alternative medicine available, your GP will discuss this with you. 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 who is responsible for your care.
The symptoms of ED can often be improved by making changes to your lifestyle. You can reduce your risk of ED by:
As well as helping to improve your ED, these types of changes can also improve your general health. For example, losing weight may help to reduce your risk of cardiovascular disease (conditions that affect your heart and blood vessels).
Read more about preventing cardiovascular disease.
Phosphodiesterase-5 (PDE-5) inhibitors
Phosphodiesterase-5 (PDE-5) inhibitors are one of the most widely used and effective types of medication for treating ED. They work by temporarily increasing the blood flow to your penis.
In England, three PDE-5 inhibitors are available for treating ED. They are:
Sildenafil, tadalafil and vardenafil
Sildenafil and vardenafil 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 and vardenafil, 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 of the tablet if it is taken with food, so you should take your PDE-5 inhibitor on an empty stomach. You can then eat after an hour without affecting the medicine.
Only take one tablet within a 24-hour period.
You may have the choice of which PDE-5 inhibitor to take as sildenafil, tadalafil and vardenafil are likely to be equally effective. Your GP should explain the benefits of each medication and how it works. The choice may depend on:
There have been many studies to test the effectiveness of sildenafil, tadalafil and vardenafil. 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:
These medications are triggered by sexual stimulation, so you also need to be aroused for the medication to work.
PDE-5 inhibitors should be used with caution in men who have cardiovascular disease, such as coronary heart disease (when your heart's blood supply is blocked or interrupted). However, sexual activity is also likely to be beneficial for your cardiovascular health. Your GP should discuss the risks and benefits with you and will prescribe PDE-5 inhibitors if you are fit enough.
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). However, this will also depend on your individual circumstances and, in some cases, PDE-5 inhibitors will be safe to use.
PDE-5 inhibitors should also be used with caution in men who:
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:
In some cases, PDE-5 inhibitors can still be used even if you are affected by one of these conditions. For example, after they have consulted an expert, your GP may advise that PDE-5 inhibitors are safe three to six months after a heart attack.
PDE-5 inhibitors can cause some side effects, including:
Your GP can prescribe PDE-5 inhibitors to anyone as long as it is safe to do so (see warnings above). However, 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.
Some men are entitled to PDE-5 inhibitors on NHS prescriptions (see below). This means they only need to pay the prescription charge. If you are entitled to free NHS prescriptions, then it will not cost you anything.
Read more about help with prescription costs.
Men with the following medical conditions are entitled to NHS prescriptions for PDE-5 inhibitors:
Men who are receiving or who have received certain medical treatments may also be entitled to NHS prescriptions for PDE-5 inhibitors. These treatments include:
You may also be entitled to an NHS prescription if you were receiving some types of ED medication on September 14 1998 which was paid for by the NHS. This is because the availability of ED medications on the NHS was changed in 1999 but those who had been on ED medication for some time were allowed to continue receiving it on the NHS.
In certain circumstances, some specialist centres may provide an NHS prescription for PDE-5 inhibitors - for example, if ED is causing you severe distress. The healthcare professional who is treating you will consider whether ED is:
A vacuum pump is another treatment method for ED. It 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 in order 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 very effective. After using a vacuum pump, nine out of 10 men are able to have sex, regardless of the cause of their ED.
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.
Men who qualify for NHS prescriptions for ED treatments may be able to get a vacuum pump on the NHS (see above for more details). However, some men will need to buy one.
The Sexual Advice Association produces a number of factsheets, including one on vacuum pumps that provides details of companies that supply them.
If your ED does not 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:
You may be trained in how 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 that is inserted into the urethra is successful for up to two-thirds of men.
Alprostadil should not be used:
Urethral application may also not be used in:
Alprostadil can cause some side effects including:
See the Alprostadil medicines information for more information about this medicine.
As with PDE-5 inhibitors, NHS prescriptions for alprostadil 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.
If a hormonal condition is causing ED, you may be referred to an endocrinologist. An endocrinologist is a healthcare professional 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 for ED is usually only recommended if all other treatment methods have failed. It may also be considered in:
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 is unlikely to be used.
Penile implants are a type of surgery that may be considered. These can be:
Penile implants are not usually available on the NHS and inflatable implants may be very expensive. However, around three-quarters of men report being satisfied with the results of this type of surgery.
As with all types of surgery, having penile implants inserted carries a risk of infection. If you take preventative antibiotics (medicines to treat bacterial infections), 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.
If your ED 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 ED, you may benefit from counselling (a talking therapy).
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).
Set aside a time when it is just the two of you. Massage, touch or stroke each other, with or without clothes on. The idea is to explore your bodies knowing that you will not have sex.
After the agreed period of time has passed, you can begin touching each other's genital areas. You may want to spend several weeks gradually increasing the amount of time spent touching the 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 is a form of relationship therapy where you and your partner can discuss any sexual or emotional issues that may be contributing to your ED. By talking about the issues, you may be able to reduce any anxiety that you have and overcome your ED.
The counsellor can also provide you with some practical advice about sex, such as foreplay techniques and how to make effective use of other treatments for ED in order 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 ED. 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 ED - for example, to do with:
Your CBT therapist will be able to help you to adopt more realistic and helpful thoughts about these issues.
Read more about cognitive behavioural therapy.
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 in order to learn it correctly.
By strengthening and training these muscles, you may be able to reduce the symptoms of ED.
Some complementary therapies, such as acupuncture, have claimed to treat ED. However, there is little evidence that 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.
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