Erectile dysfunction (impotence)

Why does erectile dysfunction happen?

Erectile dysfunction can come from a mix of physical and psychological causes. Physical causes include:

• narrowing of the blood vessels carrying blood to the penis, often linked to high blood pressure, high cholesterol or diabetes
• hormonal problems
• surgery or injury

Psychological causes of ED include:

• anxiety
• depression
• relationship problems

Sometimes erectile dysfunction only shows up in certain situations. For example, you may be able to get an erection during masturbation, or you may notice you sometimes wake up with an erection, yet you cannot get one with your sexual partner.

If this sounds familiar, the underlying cause is likely psychological, often related to stress. If you cannot get an erection under any circumstances, the underlying cause is more likely to be physical.

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

Read more about the causes of erectile dysfunction.

Causes of erectile dysfunction

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

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

Erections

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

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

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

Physical causes

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

• conditions affecting blood flow to the penis, known as vasculogenic causes
• conditions affecting the nervous system, made up of the brain, nerves and spinal cord, known as neurogenic causes
• conditions affecting hormone levels, known as hormonal causes
• conditions affecting the physical structure of the penis, known as anatomical causes

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 often has both physical and psychological causes together. For example, if you have diabetes, you may find it difficult to get an erection, which in turn may make you anxious about the situation. The combination of diabetes and anxiety may then lead to an episode of erectile dysfunction.

Many emotional issues can 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:

• drinking too much alcohol
• tiredness
• using illegal drugs, such as cannabis, heroin or cocaine

Cycling

Men who cycle for more than three hours a week may be advised 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 prevent regular cycling from leading to erectile dysfunction.

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.

Read more about diagnosing 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.

How is erectile dysfunction treated?

Treatment for erectile dysfunction focuses on the root cause, whether that cause is physical or psychological. Once your doctor understands what is behind the problem, a plan can be built around it.

Narrowing of the arteries, known as atherosclerosis, is one of the most common causes. If this applies to you, your doctor may suggest lifestyle changes such as losing weight to lower your risk of heart and blood vessel disease. These changes often ease the erectile problem itself while improving your overall health. You may also be prescribed medicines for atherosclerosis, such as cholesterol lowering statins and drugs that bring down blood pressure.

Several treatments have proven effective for erectile dysfunction. Medicines such as sildenafil, sold as Viagra, help at least two thirds of men who try them. Vacuum pumps, which draw blood into the penis to create an erection, work in about 90 percent of cases. For men whose difficulty is rooted in stress, anxiety, or emotional strain, psychological treatments such as cognitive behavioural therapy and sex therapy can help. Taken together, treatment options have improved a great deal in recent years, and most men are eventually able to resume a satisfying sex life.

Injuries and surgery

An injury to the penis, or surgery involving the penis, pelvis, or nearby areas, can sometimes lead to erectile dysfunction. It is also thought that up to 15 to 25 percent of people who suffer a severe head injury go on to experience this problem.

Vasculogenic conditions

These are conditions related to blood flow, and they include cardiovascular disease (such as atherosclerosis, or hardening of the arteries), high blood pressure, and diabetes. Diabetes can damage both blood supply and nerve endings in the penis, so it is considered a neurogenic condition as well. Because erectile dysfunction is so closely linked with cardiovascular disease, your doctor may check your heart health early on while working out the cause and planning treatment.

Neurogenic conditions

These involve the nervous system and include multiple sclerosis, Parkinson's disease, a spinal injury or disorder, and stroke, a serious event where blood supply to the brain is cut off.

Hormonal conditions

These include hypogonadism, which causes abnormally low testosterone, an overactive thyroid gland (hyperthyroidism), an underactive thyroid gland (hypothyroidism), and Cushing's syndrome, which affects cortisol production.

Anatomical conditions

Peyronie's disease, which affects the tissue of the penis, falls into this category.

Medicine

Certain medicines can also bring on erectile dysfunction in some men. These include diuretics, used for high blood pressure, heart failure, and kidney disease; antihypertensives such as beta blockers; fibrates for lowering cholesterol; antipsychotics; antidepressants; corticosteroids; H2 antagonists for stomach ulcers; anticonvulsants for epilepsy; antihistamines for allergies; anti androgens; and cytotoxic drugs used in chemotherapy. If you suspect a prescribed medicine is causing the problem, talk to your doctor, since an alternative may be available. Never stop a prescribed medicine on your own; only do so on the advice of the qualified healthcare professional overseeing your care.

Treating erectile dysfunction

Your treatment plan will depend entirely on the cause, so it helps to understand the range of options available.

Treating underlying conditions

If an underlying illness such as heart disease or diabetes is behind your erectile dysfunction, treating that condition first may resolve the problem on its own. If a medicine you are taking is the cause, ask your doctor about alternatives, but again, do not stop taking anything without medical guidance.

Lifestyle changes

Making changes in daily life often brings real improvement. Helpful steps include losing weight if you are overweight, giving up smoking, cutting back on alcohol, avoiding illegal drugs, exercising regularly, and reducing stress. Beyond helping your erections, these changes also support your general health and lower your risk of cardiovascular disease.

Phosphodiesterase 5 (PDE 5) inhibitors

PDE 5 inhibitors are among the most widely used and effective medicines for erectile dysfunction. They work by temporarily boosting blood flow to the penis. Four such medicines are available: sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Spedra). Sildenafil, vardenafil, and avanafil act for about eight hours and are meant to be taken as needed. Tadalafil lasts up to 36 hours, which makes it a good choice if you want coverage over a longer stretch, such as a weekend.

Depending on which medicine and dose you take, expect it to start working within about 30 to 60 minutes. With sildenafil, vardenafil, or avanafil, you should be able to have sex anywhere from one to 10 hours after taking it. Tadalafil's effects can last up to 36 hours. Taking the tablet with food may slow down how quickly it works, so it is best taken on an empty stomach; you can eat again after an hour without any problem. Stick to one tablet in any 24 hour period.

Your doctor will walk you through the benefits of each option, and the right choice may come down to how often you are sexually active and whether you have tried any of these medicines before. Across many studies, at least two thirds of men report improved erections after taking one of these medicines. If a PDE 5 inhibitor does not seem to be working for you, consider whether you waited long enough, or perhaps too long, after taking it, whether the dose might need adjusting, or whether you had enough sexual stimulation, since these medicines still need arousal to take effect.

Warnings

Caution is needed if you have cardiovascular disease such as coronary heart disease, though sexual activity itself can actually benefit heart health; it is worth discussing the balance of risks and benefits with your doctor. Caution is also needed with anatomical conditions such as Peyronie's disease, and in men at risk of priapism, a painful erection that lasts for several hours, or those taking long acting alpha blockers for conditions such as high blood pressure.

Do not combine PDE 5 inhibitors with medicines or recreational drugs containing nitrates, since the combination can be dangerous for your heart. Organic nitrates are commonly used for angina, and butyl nitrate is a recreational drug known as poppers. These medicines should also be avoided if you have been told to avoid sexual activity or activities that widen blood vessels, if you have low blood pressure, if you have recently had a stroke, if you have unstable angina, if you have had a heart attack, or if you have a history of non arteritic anterior ischaemic optic neuropathy, an eye condition causing sudden vision loss.

Alprostadil should not be used by men at risk of priapism, including those with sickle cell anaemia, alongside other erectile dysfunction medicines, or if you have a penile implant or have been told to avoid sexual activity. The urethral form is also unsuitable for some men with anatomical problems of the penis, or those with penile infections such as balanitis, an inflammation of the head of the penis.

Side effects

PDE 5 inhibitors can cause headaches or migraines, flushing, indigestion, nausea, vomiting, a blocked or runny nose, back pain, vision disturbances, and muscle pain. Alprostadil may cause changes in blood pressure, dizziness, headache, pain in the penis, urethral burning or bleeding, and reactions at the injection site, such as swelling.

Vacuum pumps

A vacuum pump is a clear plastic tube connected to a hand operated or battery operated pump. You place your penis inside, draw out the air to create a vacuum, and this pulls blood into the penis to produce an erection. A rubber ring placed around the base then holds the blood in place, letting you keep the erection for around 30 minutes. It can take a few tries to get the technique right, but pumps are generally effective, and nine out of 10 men are able to have sex afterward, whatever the underlying cause of their ED.

Considerations

Avoid using a vacuum pump if you have a bleeding disorder or take anticoagulant medicines that reduce your blood's ability to clot. Pain or bruising can occur, though this affects fewer than a third of men. Some men choose to purchase their own pump for continued use at home.

Alprostadil

If other treatments have not worked, or PDE 5 inhibitors and vacuum pumps are not suitable for you, alprostadil may be offered. This is a synthetic hormone that stimulates blood flow to the penis. It comes either as an injection directly into the penis, called an intracavernosal injection, or as a small pellet placed inside the urethra, called urethral application. You may be trained to give the injection or insert the pellet yourself. If your partner is pregnant, use a condom during sex when using the urethral form.

Alprostadil usually produces an erection within five to 15 minutes, with the duration depending on the dose. Among men who did not respond to PDE 5 inhibitors, injections worked for 85 out of 100 men, while the urethral form helped up to two thirds of men. If you pay the full cost yourself, a single injection runs roughly 8 to 22 pounds depending on the dose, and a single dose for urethral use costs around 10 pounds.

Hormone therapy

If a hormonal condition is the cause, you may be referred to an endocrinologist, a specialist in hormonal conditions. Many such conditions can be corrected with injections of synthetic hormones that restore normal hormone levels.

Surgery

Surgery is generally considered only after other treatments have not worked. It may also be an option for younger men who have had a serious pelvic injury, for example from a car accident, or for men with a significant anatomical problem of the penis. In the past, surgery was used when there was clear evidence of a blockage in the blood supply to the penis, with the surgeon working to restore normal flow. However, long term results from this approach have proven poor, so it is now rarely used.

Penile implants

Penile implants are a surgical option that may be considered. Semi rigid implants may suit older men who are not sexually active on a regular basis, while inflatable implants, made of two or three parts, can be inflated to produce a more natural feeling erection. Around three quarters of men report being satisfied with the results.

Psychological treatments

If your erectile dysfunction stems from a psychological cause, a therapy called sensate focus may help. If anxiety or depression is contributing to the problem, counselling, a form of talking therapy, may also be beneficial.

Sensate focus

Sensate focus is a form of sex therapy that you and your partner work through together. It begins with an agreement to avoid sex for a set period of weeks or months, during which you can still touch each other but avoid the genital area or a woman's breasts. The goal is to explore each other's bodies without the pressure of sex. Once that period ends, you gradually reintroduce touching of the genital areas, and later the use of the mouth, such as kissing, building up over time to penetrative sex. You can learn more about sensate focus from the College of Sexual and Relationship Therapists, known as COSRT.

Psychosexual counselling

This is a form of relationship therapy in which you and your partner discuss any sexual or emotional issues that may be contributing to the problem. Talking things through can ease anxiety and help resolve erectile dysfunction over time. The counsellor can also offer practical advice, including how to get the most out of other treatments to improve your sex life. Results from this approach vary and it may take time to show benefit.

Cognitive behavioural therapy (CBT)

CBT is another form of counselling that can help. It rests on the idea that how you feel is shaped by how you think about things, and that difficulties often stem more from mindset than from the situation itself. A CBT therapist can help you identify unhelpful or unrealistic thoughts, whether about self esteem, sexuality, or personal relationships, and guide you toward more realistic and helpful ways of thinking about them.

Pelvic floor muscle exercises

Some studies suggest that exercising the pelvic floor muscles, the group of muscles beneath the bladder and rectum and at the base of the penis, may help in certain cases. This involves strengthening the muscles used to control urination and bowel movements. If your doctor thinks this could help you, a physiotherapist can teach you the correct technique, and with practice these exercises may ease your symptoms.

Complementary therapies

Therapies such as acupuncture are sometimes claimed to treat erectile dysfunction, but there is little evidence to support this. Some may even contain ingredients that interact with other medicines and cause side effects. Always check with your doctor before trying any complementary therapy.

Penile implant surgery carries the same infection risk as any operation, though taking preventive antibiotics keeps this fairly low, around two or three cases in every 100. There is also a chance of mechanical problems developing with the implant, which happens in about five per cent of cases within five years.