Erectile dysfunction

Erectile dysfunction — what it is and why it matters

Erectile dysfunction (ED) — also called impotence — means being unable to get an erection, or keep one firm enough for satisfactory sex. It is extremely common — surveys suggest at least 1 in 2 men aged 40 to 70 experience it to some degree — yet many never mention it to a doctor.

ED is treatable in most cases. More importantly, it is often an early warning sign of cardiovascular disease — the same atherosclerosis that narrows heart arteries affects penile arteries first because they are smaller.

Always worth a GP conversation — not just for sex life, but for overall health.

How erections work

An erection requires:

1. Nerve signals from brain and spinal cord (arousal)
2. Blood flow — arteries dilate, corpora cavernosa fill and compress veins
3. Hormones — testosterone supports libido and function
4. Psychological state — anxiety disrupts the pathway

Failure at any step causes ED. Morning erections suggest intact physical mechanism — if these disappear suddenly alongside ED, physical cause is more likely.

Causes — physical (organic)

Vascular (most common in older men)

Atherosclerosis — cholesterol plaques narrow arteries. Risk factors:

• high blood pressure
• high cholesterol
• smoking
• obesity
• diabetes
• sedentary lifestyle

Penile arteries (~1 to 2mm) clog before coronary arteries (~3 to 4mm) — ED may precede heart attack or stroke by 3 to 5 years.

Diabetes

Damages endothelium (blood vessel lining) and autonomic nerves. ED affects 50 to 60% of men with diabetes — often develops 10 to 15 years earlier than in non-diabetic men. Good HbA1c control reduces progression.

Neurological

• spinal cord injury
• multiple sclerosis
• Parkinson’s disease
• prostate surgery (radical prostatectomy) — nerve-sparing techniques reduce but do not eliminate risk
• pelvic surgery or radiotherapy

Hormonal

Low testosterone (hypogonadism) — reduced libido, fatigue, ED. Less common as sole cause but contributes. Obesity and diabetes lower testosterone. Thyroid disorders occasionally affect function.

Prolactinoma (pituitary tumour) — rare — high prolactin suppresses testosterone.

Medicines

Common contributors:

• some antidepressants (SSRIs, especially paroxetine)
• blood pressure medicines (thiazide diuretics, beta-blockers — though newer agents less problematic)
• finasteride for hair loss or prostate — small percentage
• antiandrogens for prostate cancer
• opioid painkillers long term
• antipsychotics

Never stop prescribed medicines without GP advice — alternatives often exist.

Other physical

• Peyronie’s disease — scar tissue causing curvature and painful erections
• sleep apnoea — linked to ED independently of obesity
• chronic kidney disease
• liver cirrhosis
• alcohol excess long term

Causes — psychological (psychogenic)

• performance anxiety — often starts after one failed attempt
• depression and anxiety
• relationship conflict
• stress — work, financial, bereavement
• pornography-related ED — debated; performance anxiety more established

Psychogenic features:

• sudden onset
• situational (works with one partner, not another)
• morning/nocturnal erections preserved
• young age with no risk factors

Mixed ED — physical cause plus anxiety about performance — is very common.

When to see a GP urgently

• Priapism — erection lasting more than 4 hours without sexual stimulation — medical emergency (999) — risks permanent damage
• ED after pelvic fracture or spinal injury
• ED with testicular pain, breast enlargement, or severe headaches/visual changes (rare pituitary problems)
• Chest pain or breathlessness on exertion alongside new ED — possible angina

What happens at a GP appointment

Expect a thorough but confidential assessment:

1. History — onset, morning erections, relationship, libido, alcohol, smoking, exercise
2. Medical history — diabetes, heart disease, surgery, medicines
3. Examination — blood pressure, BMI, genital exam, testicular size, peripheral pulses
4. Blood tests — fasting glucose or HbA1c, lipids, testosterone (morning sample if indicated), thyroid, prolactin if suggested
5. Cardiovascular risk assessment — QRISK score — ED counts as a risk factor in some guidelines

Referral to urology or sexual medicine clinic if:

• young man with suspected primary organic cause
• failed first-line treatments
• Peyronie’s disease
• considering injections, vacuum devices, or surgery
• psychosexual therapy needs

First-line treatment — lifestyle

Evidence-based improvements:

Change	Effect on ED
Stop smoking	Improves vessel function within weeks to months
Weight loss (5 to 10%)	Significant improvement in obese men
Exercise (150 min/week)	Improves endothelial function
Reduce alcohol	Excess impairs nerves and hormones
Treat sleep apnoea	CPAP improves ED in studies
Control diabetes/BP/cholesterol	Slows vascular damage

Pelvic floor exercises strengthen bulbocavernosus muscle — helps venous leakage pattern. 6 months daily practice — free and side-effect free.

PDE5 inhibitors — sildenafil, tadalafil, vardenafil

See our dedicated sildenafil and tadalafil guide for dosing and safety detail.

How they work: Block phosphodiesterase-5 (PDE5), prolonging cGMP — the chemical that relaxes smooth muscle and increases blood flow when sexually aroused. Require arousal — they do not create spontaneous erections.

Sildenafil (Viagra, generic)

• Dose: 25 to 100mg — typical 50mg
• Onset: 30 to 60 minutes
• Duration: 4 to 6 hours
• Food: High-fat meal delays absorption — take on empty stomach for fastest effect
• Side effects: Headache, flushing, indigestion, nasal congestion, visual colour tinge (rare)

Tadalafil (Cialis, generic)

• Dose: 10 to 20mg as needed, or 2.5 to 5mg daily for continuous effect
• Onset: 30 minutes (daily dosing removes timing pressure)
• Duration: Up to 36 hours
• Food: Less affected by meals
• Side effects: Back pain, muscle ache, headache, flushing

Vardenafil (Levitra)

Similar to sildenafil — alternative if others poorly tolerated.

Effectiveness: 70 to 80% of men achieve improved erections with PDE5 inhibitors when ED has physical cause. Less effective with severe diabetes, post-prostate surgery, or low testosterone untreated.

NHS availability: Generic sildenafil on NHS prescription — quantity limits vary. Tadalafil increasingly available. Pharmacist-supplied without prescription possible for some brands after consultation.

Critical safety — nitrates

Never combine PDE5 inhibitors with:

• GTN spray or tablets (angina treatment)
• Isosorbide mononitrate/dinitrate
• Recreational poppers (amyl nitrite)

Combination causes severe hypotension — potentially fatal. If you have angina, discuss with cardiologist before ED treatment.

Caution with: alpha-blockers (tamsulosin for prostate — separate timing), recent stroke or heart attack (usually wait 6 months), unstable angina, severe heart failure.

Second-line treatments

If PDE5 inhibitors fail or contraindicated:

Vacuum erection devices (VED)

Plastic cylinder over penis — manual or battery pump creates vacuum, drawing blood in; constriction ring at base maintains erection. 70 to 80% success — bruising, coldness, ejaculation trapped by ring. NHS prescription possible.

Alprostadil — injections or urethral pellets

Intracavernosal injection (ICI) — alprostadil (Caverject) into side of penis — produces erection in 5 to 15 minutes. 80 to 90% effective — training required; risks priapism, scarring with overuse.

Urethral pellet (MUSE) — less popular — less effective.

Testosterone replacement

Only if confirmed low testosterone with symptoms — gel or injections. Does not help if testosterone is normal. Monitored for prostate effects.

Psychosexual therapy

CBT and couples counselling — especially for primary psychogenic or mixed ED. Available through GP referral or Relate.

Surgical options

Penile implants — inflatable or malleable rods — for severe ED unresponsive to other treatment. Last resort — high satisfaction in selected patients. NHS funding for specific criteria.

Vascular surgery — rarely performed now — limited evidence except in young men with pelvic trauma.

ED after prostate treatment

Radical prostatectomy — ED rates depend on nerve-sparing and age — 25 to 80% at 12 months. Recovery can take 18 to 24 months — early PDE5 inhibitor use may aid recovery (“penile rehabilitation”).

Radiotherapy — ED develops more slowly over years.

Discuss preservation strategies before surgery with urologist.

ED and mental health

ED causes anxiety, depression, and relationship strain — which worsen ED in a vicious cycle. Breaking the cycle often needs:

• open communication with partner
• realistic expectations — treatment improves function, not necessarily teenage performance
• professional support when needed

SSRIs for depression can cause ED — mirtazapine or bupropion may have lower risk — discuss with GP if antidepressant-related.

Myths — the facts

Myth: “ED means low testosterone.” Fact: Most ED is vascular — testosterone is normal in majority. Test only if clinical suspicion.

Myth: “Young men can’t have physical ED.” Fact: Diabetes, obesity, and congenital vascular issues affect young men. Psychogenic is more common under 40 but not exclusive.

Myth: “Herbal Viagra is safer.” Fact: Unregulated supplements may contain hidden sildenafil — dangerous with nitrates or heart conditions. Buy from registered UK pharmacies only.

Myth: “You must take Viagra every day forever.” Fact: Use as needed or daily tadalafil — dose can be adjusted or stopped if underlying cause improves.

Partner and communication

ED affects couples — partner may feel rejected or blame themselves. Medical cause, not lack of attraction, is usually the explanation. Involving partner in GP discussion (if both agree) improves outcomes.

Summary checklist

1. Book GP — do not suffer in silence
2. Check cardiovascular risk — treat blood pressure, cholesterol, diabetes
3. Stop smoking, move more, lose weight if overweight
4. Try PDE5 inhibitor if safe — sildenafil or tadalafil
5. Pelvic floor exercises — daily
6. Referral if no improvement — urology or psychosexual therapy

Erectile dysfunction is common, treatable, and medically important. Effective help exists on the NHS — asking is the first step.

Common questions

What causes erectile dysfunction?

Physical causes — reduced blood flow (atherosclerosis), diabetes, high blood pressure, obesity, nerve damage (spinal injury, MS), hormonal problems (low testosterone), and side effects of medicines (some antidepressants, finasteride). Psychological — stress, anxiety, depression, relationship issues. Most long-term ED has a physical component, often mixed with psychological factors.

Is erectile dysfunction normal with age?

ED becomes more common with age but is not an inevitable part of ageing — it often signals treatable conditions like cardiovascular disease, diabetes, or medication effects. Many older men maintain normal function with appropriate treatment.

Can Viagra cure erectile dysfunction permanently?

PDE5 inhibitors (sildenafil/Viagra, tadalafil/Cialis) treat symptoms when taken — they do not cure underlying causes. Addressing root causes — weight loss, blood pressure control, stopping smoking, treating diabetes — may improve ED long term. Some men need ongoing tablet use.

How do I get Viagra on the NHS?

Sildenafil generic is available on NHS prescription from a GP after assessment — some CCGs limit quantity. You can also buy sildenafil and tadalafil from UK pharmacies after pharmacist consultation (without full GP visit for some brands). Assessment checks it is safe — especially heart medicines.

What is the difference between Viagra and Cialis?

Viagra (sildenafil) works within 30 to 60 minutes, lasts 4 to 6 hours, best on empty stomach. Cialis (tadalafil) can work within 30 minutes, lasts up to 36 hours — more flexibility, food has less effect. Both are PDE5 inhibitors with similar effectiveness — choice is preference and side effect profile.

Can diabetes cause erectile dysfunction?

Yes — diabetes damages small blood vessels and nerves. ED affects over half of men with diabetes at some point. Good blood sugar control, blood pressure management, and not smoking reduce risk. PDE5 inhibitors often work but may be less effective — other options exist.

Does masturbation cause erectile dysfunction?

No — masturbation does not cause ED. Excessive pornography use is sometimes linked to psychogenic ED in debate, but evidence is limited. Performance anxiety from any source can contribute psychologically.

When is erectile dysfunction a sign of heart disease?

Arteries supplying the penis are smaller than coronary arteries — they clog first. ED appearing 3 to 5 years before a heart attack is reported in studies. If you have ED plus exertional chest pain, breathlessness, or strong family history of heart disease — GP should assess cardiovascular risk.

Are there natural remedies for ED?

Lifestyle changes with good evidence — weight loss, exercise, stopping smoking, reducing alcohol, treating sleep apnoea. L-arginine shows minimal benefit. Dehydroepiandrosterone (DHEA) and herbal "Viagra" supplements are unregulated with uncertain safety. Pelvic floor exercises (Kegels) help some men post-prostate surgery.

Can you drink alcohol with Viagra or Cialis?

Moderate alcohol is usually acceptable but heavy drinking impairs erections regardless of tablets. Alcohol can worsen sildenafil side effects — dizziness and low blood pressure. Never combine PDE5 inhibitors with recreational poppers (amyl nitrate) — dangerous blood pressure drop.

How often can you take Viagra?

Sildenafil — maximum one dose per 24 hours (typically 50mg, range 25 to 100mg). Tadalafil daily low dose (2.5 to 5mg) allows more spontaneity; on-demand tadalafil — max once per 24 hours (10 to 20mg). Do not exceed prescribed dose — does not improve effect and increases side effects.

Sources

• NHS — Erectile dysfunction
• NICE — Erectile dysfunction
• British Society for Sexual Medicine