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Impotence Content Supplied by NHS Choices
Introduction

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.

Diagnosis

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 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
  • 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.


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:

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).

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 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.

NHS prescriptions

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.

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 have received certain medical treatments may also be entitled to NHS prescriptions for PDE-5 inhibitors. These treatments include:

  • 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 

In certain circumstances, some specialist centres may provide an NHS prescription for PDE-5 inhibitors. For example, if ED is causing you severe distress.

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.

Men who qualify for NHS prescriptions for erectile dysfunction 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.

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.

NHS prescriptions

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. 

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

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.

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.

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 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.


See what the doctor sees with Map of Medicine

The Map of Medicine is used by doctors throughout the NHS to determine the best treatment options for their patients. NHS Choices offers everyone in England exclusive and free access to this cutting-edge internet resource, which lets you see exactly what your doctor sees.

The information in the Map has been approved by the UK's leading clinical experts, is based on the best available clinical evidence, and is continually updated. To take advantage of this unique resource go to:

Map of Medicine: 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.

 
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