Erectile dysfunction (impotence)

Erectile dysfunction (ED), also known as impotence, means a man can't get an erection or can't keep one going. It's a very common condition, especially in older men. Half of all men between the ages of 40 and 70 are estimated to have erectile dysfunction to some degree.

If you have erectile dysfunction for more than a few weeks, see a doctor. The doctor will check your general health, because erectile dysfunction can be the first sign of more serious health conditions, such as heart disease (when the heart's blood supply is blocked or interrupted).

Erectile dysfunction (ED) can have many causes, and they may be physical or psychological. The physical causes include:

• narrowing of the blood vessels going to the penis, which is commonly linked with high blood pressure (hypertension), high cholesterol or diabetes
• hormonal problems
• surgery or injury

The psychological causes of ED include:

• anxiety
• depression
• relationship problems

Sometimes erectile dysfunction only happens in certain situations. You may be able to get an erection during masturbation, for example, or you may sometimes wake up with an erection but find you can't get one with your sexual partner.

If that's the case, the underlying cause is likely to be psychological (related to stress). If you can't get an erection under any circumstances, the underlying cause is likely to be physical.

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

You may feel embarrassed, but it's worth getting a diagnosis so the cause of erectile dysfunction can be found. A doctor can usually diagnose it. They'll ask you about your symptoms, examine you physically and do some simple tests.

Erectile dysfunction (ED) is mainly treated by dealing with its cause, whether that cause is physical or psychological.

One of the most common causes is narrowing of the arteries, called atherosclerosis. If that's the problem, your doctor may suggest lifestyle changes, such as losing weight, to lower your risk of cardiovascular disease. This may ease your symptoms and improve your general health too.

You may also be given medicine for atherosclerosis, such as cholesterol-lowering statins and drugs to bring down your blood pressure.

A number of treatments have worked well for erectile dysfunction. Medicine such as sildenafil (sold as Viagra) can manage it in at least two-thirds of cases. Vacuum pumps, which 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.

Treatments for ED have improved significantly in recent years, and most men are eventually able to have sex again.

The main symptom of erectile dysfunction (ED) is not being able to get and keep an erection that is firm enough for satisfactory intercourse.

ED shouldn't be confused with ejaculation problems such as premature ejaculation. In premature ejaculation, arousal, orgasm and ejaculation all happen very quickly.

Sometimes erectile dysfunction (ED) only happens in certain situations. You may get an erection during masturbation, for example, or you may wake up with an erection now and then, but find you can't get one with your sexual partner.

If this is how it is for you, the underlying cause of ED is likely to be mainly psychological (related to stress). But if you can't get an erection under any circumstances, the underlying cause is likely to be mainly physical.

If erectile dysfunction (ED) lasts for more than a few weeks, see your doctor. The doctor will check your general health, because ED can be the first sign of a more serious condition, such as heart disease (when the heart's blood supply is blocked or interrupted).

Many websites offer treatments for ED, but it's not recommended that you use them. The medicines sold on these sites could be fake and may be dangerous. Even if they are genuine, they may not be suitable for you.

Only take medicine for ED that your doctor has prescribed for you.

Erectile dysfunction (ED) can come from many causes, including certain medical conditions, some medicines and stress. So it matters to find out what is behind it, and to treat any underlying condition that turns up.

When a man becomes sexually excited (aroused), his brain sends signals to the nerves in his penis. These nerves increase the blood flow to the penis, and the tissue expands and hardens.

So 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 cause erectile dysfunction too, because a reduced libido makes it harder for the brain to trigger an erection. Psychological conditions such as depression can reduce libido, and so can changes in hormone levels (chemicals produced by the body).

Four main types of health condition can cause the physical problems behind erectile dysfunction (impotence). They are:

• conditions affecting the flow of blood to your penis, which are called vasculogenic
• conditions affecting your nervous system, which is made up of your brain, nerves and spinal cord, and are called neurogenic
• conditions affecting your hormone levels, which are called hormonal
• conditions affecting the physical structure of your penis, which are called anatomical

An injury to the penis can sometimes lead to erectile dysfunction. So can surgery on the penis, the pelvis or the areas around them.

Erectile dysfunction is also thought to happen in up to 15-25% of people who have a severe head injury.

Erectile dysfunction can be caused by vasculogenic conditions, which are problems with the blood vessels. Some examples are:

• cardiovascular disease, which is 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. It 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 doctor considers when making a diagnosis and planning your treatment.

Some neurogenic conditions, which affect the nerves, can cause erectile dysfunction. These 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 the brain coordinates body movements, including walking, talking and writing
• a spinal injury or disorder
• a stroke, a serious condition that happens when the blood supply to the brain is interrupted

Several hormonal conditions can cause erectile dysfunction. These include:

• hypogonadism, a condition that affects the production of the male sex hormone, testosterone, so that levels are abnormally low
• 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

Peyronie's disease is one example of an anatomical condition that can cause erectile dysfunction. It affects the tissue of the penis.

In some men, certain medicines can cause erectile dysfunction. These include:

• diuretics, which 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, medicines that contain 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, medicines that suppress androgens (male sex hormones)
• cytotoxics, medicines used in chemotherapy to prevent cancer cells from dividing and growing

If you are worried that a prescribed medicine is causing erectile dysfunction, speak to your doctor. Another medicine may be available. But never stop taking a prescribed medicine unless a qualified health professional who is responsible for your care tells you to.

Erectile dysfunction can have psychological causes. These include:

• depression, which means feelings of extreme sadness that last for a long time
• anxiety, which is a feeling of unease, such as worry or fear

Often, erectile dysfunction has both physical and psychological causes together. Say you have diabetes and find it hard to get an erection. That difficulty can make you anxious about the situation, and the diabetes and the anxiety combined may 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

Erectile dysfunction can have a few other causes too. These include:

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

If you cycle for more than three hours a week, your doctor may suggest you stop for a while to see whether your erectile dysfunction gets better.

Riding in the correct position, on a properly fitted seat, may also help stop regular cycling from leading to erectile dysfunction in the first place.

Erectile dysfunction (ED) can often be diagnosed by your doctor. They will talk to you about your situation and may carry out a physical examination.

Your doctor 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 medicine

If you don't want to talk to your doctor about erectile dysfunction, you can visit a genitourinary medicine (GUM) clinic instead. The British Association for Sexual Health and HIV (BASHH) website lists these clinics, so you can look for the one nearest to you there.

The doctor will also ask about your sexual history. Try not to feel embarrassed, because erectile dysfunction is a common problem. If you'd feel more comfortable, you can ask to see a male doctor.

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.

Your doctor may check how healthy your heart and blood vessels are. Narrowed blood vessels are a common cause of erectile dysfunction, and they're linked with cardiovascular disease (conditions that affect the heart and blood flow).

Your doctor 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

The doctor may examine your penis to rule out anatomical causes of erectile dysfunction, meaning conditions that affect its physical structure.

If you also have symptoms of an enlarged prostate, such as weak or irregular urination, the doctor may suggest a digital rectal examination (DRE).

Blood tests can check for underlying health conditions too. Measuring hormone levels, such as testosterone, can rule out hormonal conditions like hypogonadism (an abnormally low level of testosterone).

Sometimes your doctor may send you to a specialist for more tests. This can happen if you're unusually young to have erectile dysfunction, because it's rare in men under 40 years of age.

In an intracavernous injection test, a doctor injects a man-made (synthetic) hormone into your penis to increase the blood flow. The test helps show any abnormalities in the penis, and it also helps in planning surgery.

If the injection doesn't bring on an erection, it may point to a problem with the blood supply to your penis. In some cases you may need an ultrasound scan as well.

These are specialised tests for erectile dysfunction (impotence). The doctor injects dye into the blood vessels of your penis and then studies the dye on a scanner. You're likely to have them if surgery is being considered for you, or if a problem has already been found with your blood vessels.

If your doctor thinks the cause of your erectile dysfunction is psychological, you may be referred for a psychological assessment.

If you have erectile dysfunction (ED), the treatment depends on what's causing it. The different options are outlined below.

If your erectile dysfunction is caused by another health condition, such as heart disease or diabetes, that condition may need to be treated first. Sometimes, treating the underlying cause also clears up the problem.

If you take a medicine that can cause erectile dysfunction, there may be an alternative. But never stop a prescribed medicine unless your doctor, or another qualified health professional responsible for your care, tells you to.

Erectile dysfunction can often get better if you change some things in your daily life. These are the changes that help:

• losing weight if you are overweight
• giving up smoking
• cutting back your alcohol consumption
• not taking illegal drugs
• exercising regularly
• reducing stress

Along with easing erectile dysfunction, these changes can improve your general health too. They may also lower your risk of cardiovascular disease (conditions that affect your heart and blood vessels).

Phosphodiesterase-5 (PDE-5) inhibitors are among the most widely used and effective medicines for erectile dysfunction. They work by temporarily increasing the blood flow to your penis.

Four PDE-5 inhibitors are used to treat 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 you take them 'on demand'. Tadalafil lasts for up to 36 hours, so it suits you better if you need treatment for a longer period, for example over a weekend.

Depending on which PDE-5 inhibitor you take and the dose, it should take about 30 to 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 tadalafil, the effects last for up to 36 hours.

The effects may take longer to show if you take the tablet with food, so it's best to take it on an empty stomach. You can eat after an hour without affecting the medicine.

Only take one tablet within a 24-hour period.

Your doctor should explain the benefits of each medicine and how it works. The choice may depend on:

• how often you are sexually active
• whether you have tried any of the medicines before

Many studies have tested how well these medicines work. In general, at least two-thirds of men report better erections after taking one of them.

If a PDE-5 inhibitor doesn't seem to work for you, 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 medicines are triggered by sexual stimulation, so you also need to be aroused for them to work.

Doctors need to be careful about prescribing PDE-5 inhibitors if you have cardiovascular disease, such as coronary heart disease. Sexual activity is also likely to be good for your cardiovascular health, though, so talk through the risks and benefits with your doctor.

Take the same care if you have an anatomical problem with your penis, such as Peyronie's disease (a condition that affects the tissue of the penis).

PDE-5 inhibitors should also be used with caution if you:

• are at risk of priapism, which is a painful erection that lasts for several hours
• are also taking long lasting alpha-blockers, a medicine 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. Put together, the two can have a dangerous effect on your heart.

Organic nitrates are often used to treat angina. Butyl nitrate is a recreational drug, better 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 happens 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

PDE-5 inhibitors, the medicines used for erectile dysfunction, can cause some side effects. These include:

• headaches and migraines
• flushing (redness)
• indigestion
• nausea (feeling sick)
• vomiting (being sick)
• a blocked or runny nose
• back pain
• vision disturbances
• muscle pain

A vacuum pump is a clear plastic tube connected to a pump, which is worked either by hand or by battery.

You put your penis in the tube and pump out all the air. This creates a vacuum, and the vacuum makes blood fill your penis so that it becomes erect. Then you slip a rubber ring around the base of your penis to hold the blood in place. That lets you keep the erection for around 30 minutes.

It may take several attempts to learn how to use the pump properly, but pumps are usually effective. After using one, nine out of 10 men are able to have sex, whatever the cause of their ED.

Don't 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.

Vacuum pumps can cause side effects such as pain or bruising, though these happen in less than a third of men. Even so, some men will need to buy one.

If your erectile dysfunction doesn't respond to treatment, or you can't or don't want to use PDE-5 inhibitors or a vacuum pump, your doctor may give you a medicine called alprostadil. It's a synthetic (man-made) hormone that helps stimulate blood flow to the penis.

Alprostadil comes in two forms:

• an injection directly into your penis, which 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), which is called urethral application

You may be trained to inject or insert alprostadil correctly. If your partner is pregnant, use a condom during sex if you are inserting alprostadil into your urethra.

Alprostadil usually produces an erection after five to 15 minutes. How long the erection lasts depends on the dose.

Among men who did not respond to PDE-5 inhibitors, alprostadil injections worked in 85 out of 100 men. Alprostadil inserted into the urethra works for up to two-thirds of men.

Alprostadil should not be used in the following situations:

• 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 medicines
• if you have a penile implant, or if you have been advised to avoid sexual activity

Urethral application may also not be used in these situations:

• 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 balantis (inflammation of the head of the penis)

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

If a hormonal condition is behind your erectile dysfunction, your doctor may refer you to an endocrinologist. This is a doctor who specialises in treating hormonal conditions.

Hormones are chemicals that your body makes. Many hormonal conditions can be treated with injections of synthetic (man-made) hormones, which bring your hormone levels back to normal.

Doctors usually recommend surgery for erectile dysfunction only when every other treatment has failed. They may also consider it in these situations:

• younger men who have had a serious injury to the pelvic area, for example in a car accident
• men with a significant anatomical problem with the penis

In the past, surgery was used when there was clear evidence of a blockage in the blood supply to the penis. The surgeon could unblock the blood vessels and bring blood flow back to normal. But research now suggests that the long-term results of this kind of surgery are poor, so it's unlikely to be used.

Penile implants are a type of surgery that may be considered for erectile dysfunction. There are two kinds:

• semi-rigid implants, which may suit older men who don't have sex regularly
• inflatable implants, which have two or three parts that can be inflated to give a more natural erection

However, around three-quarters of men say they are satisfied with the results of this surgery.

Penile implants carry a risk of infection, as any surgery does. If you take antibiotics beforehand to prevent it, the rate of infection is around two or three in 100. Mechanical problems with the implants can also happen, and within five years they occur in five per cent of cases.

If your erectile dysfunction has a psychological cause underneath it, a type of treatment called sensate focus may help you.

And if conditions such as anxiety or depression are behind the erectile dysfunction, counselling (a talking therapy) may help.

Sensate focus is a type of sex therapy that you and your partner do together. You both start by agreeing not to have sex for a number of weeks or months. In that time you can still touch each other, but not in the genital area (or a woman's breasts). The idea is to explore each other's bodies knowing that sex is not going to happen.

Once the agreed time is over, you can slowly begin to touch each other's genital areas. You can also start using your mouth on your partner, for example licking or kissing. From there, this can build up to penetrative sex.

If you want to know more about sensate focus, the College of Sexual and Relationship Therapists (COSRT) has information on it.

Psychosexual counselling is a type of relationship therapy. You and your partner can talk about any sexual or emotional problems that may be adding to your erectile dysfunction. Talking things through may ease any anxiety you have, and that may help you overcome the erectile dysfunction.

The counsellor can also give you practical advice about sex, for example how to get the best use out of other treatments for erectile dysfunction so that your sex life improves.

Psychosexual counselling may take time to work, and the results so far have been mixed.

Cognitive behavioural therapy (CBT) is another form of counselling that may help if you have erectile dysfunction. It rests on a simple idea: the way you feel depends partly on the way you think about things. CBT helps you see that your problems are often created by your mindset. The situation itself isn't what makes you unhappy, but how you think about it and react to it.

Your CBT therapist can help you spot any unhelpful or unrealistic thoughts that may be adding to your erectile dysfunction. These might be to do with:

• your self-esteem (the way you feel about yourself)
• your sexuality
• your personal relationships

From there, the therapist can help you take on more realistic and helpful thoughts about these issues.

Some studies suggest that exercising your pelvic floor muscles may help in a few cases of erectile dysfunction. These muscles sit around the underside of the bladder and rectum, and also at the base of the penis.

Pelvic floor exercise means strengthening and training the muscles you use to control your anus (back passage) and to urinate. If your doctor feels this kind of exercise could help you, you may want to talk to a physiotherapist so you learn it correctly.

By strengthening and training these muscles, you may be able to reduce the symptoms of erectile dysfunction.

Some complementary therapies, acupuncture among them, have claimed to treat erectile dysfunction. There's little evidence that they help, though.

In some cases they may even contain ingredients that could interact with other medicines and cause side effects.

Always speak to your doctor before you use any complementary therapy.