Erectile dysfunction

Symptoms of erectile dysfunction

Erectile dysfunction is a symptom. This can mean:

• Being unable to get an erection at all.

• Being able to get an erection sometimes, but not every time you want to have sex.

• Getting an erection, but losing it too quickly (before being able to have sex or masturbate).

• Getting a partial erection, which isn't hard enough to have sex or masturbate.

People with erectile dysfunction might have other symptoms, such as:

• A loss of interest in sex (low libido).

• Feeling upset, stressed, anxious, or depressed about having difficulties getting an erection.

Some of the different causes of erectile dysfunction (see below) can also cause other symptoms.

How do erections happen?

It's useful to understand how erections happen normally, as this helps to explain why the different causes of erectile dysfunction cause problems.

An erection is when the penis becomes enlarged and firm, to allow for sexual penetration or masturbation.

Erections usually happen because someone is sexually aroused, although not always - they can also occur for no obvious reason, especially in boys going through puberty. It's also normal to wake up with an erection ('morning wood') even if not feeling aroused.

Usually, though, getting an erection requires being sexually aroused. Sexual arousal is very complicated, and everyone gets aroused by different things. Feeling anxious, tired, preoccupied, or otherwise not turned-on can stop this happening. Sexual arousal can also be affected by psychological and mental health issues, such as depression.

When sexually aroused, the brain sends messages down through the spinal cord, and through nerves in the pelvis, to the penis. These messages cause changes in the blood vessels of the penis. Arteries supplying the penis dilate (get wider), allowing more blood flow into the penis. Muscles in the penis and pelvis squeeze the veins which drain blood from the penis, reducing the blood flow out of the penis. This causes blood to build up inside the tissues of the penis, increasing the pressure inside the penis, and making the penis firm and erect.

So, problems with the nerve supply to the penis, and problems with blood flow to the penis, can also cause erectile dysfunction.

What causes erectile dysfunction?

It's normal to have difficulty getting or keeping an erection from time-to-time. This can be due to:

• Being tired.

• Being stressed.

• Being distracted.

• Drinking too much alcohol.

• Using other recreational drugs, such as MDMA (ecstasy).

Once those triggers have disappeared, it should be possible to get an erection again as normal.

It's also normal to be unable to get an erection or have an orgasm for a short time after ejaculating. This is known as the 'refractory period' and usually lasts minutes to hours, although can sometimes last for days in some people.

However, some men have long-standing, or recurring ED problems, and this can cause them lots of distress.

Causes of erectile dysfunction can be divided into 'physical' and 'psychological' problems. Sometimes, there may be more than one cause, and it's possible to have both physical and psychological issues affecting erections at the same time.

What is the main cause of erectile dysfunction?

This differs depending on age. In men over the age of 40, physical problems causing reduced blood flow to the penis are the most common cause of erectile dysfunction. In younger men, psychological problems are more common.

Physical causes of erectile dysfunction

About 8 in 10 cases of erectile dysfunction are due to a physical cause. These include:

• Reduced blood flow to the penis, due to narrowing of blood vessels (atherosclerosis).

  • This is the most common cause of erectile dysfunction. Narrowing of the arteries can be caused by:

    • Smoking.

    • High blood pressure.

    • Having high cholesterol.

    • Diabetes.

    • Getting older.

• Nerve damage (eg, multiple sclerosis, stroke, Parkinson's disease).

• Nerve injury (eg, spinal injury, fractured pelvis, radiotherapy to the genital area).

• Low testosterone levels.

• Side-effects of medications (eg, antidepressants, beta-blockers, diuretics, blood pressure medications).

• Complications of surgery or medical procedures (eg, nerve damage due to prostate surgery).

• Alcohol and drug abuse (eg, heroin, cocaine, marijuana, steroids).

• Cycling. Sitting in the saddle too long, especially for long rides, can put pressure on the nerves that go to the penis.

• Venous leak (meaning that blood leaves the penis too quickly, causing loss of an erection).

Reduced blood flow to the penis is, by far, the most common cause of erectile dysfunction in men over the age of 40. Like in other parts of the body, the arteries which take blood to the penis can become narrowed. The blood flow may then not be enough to cause an erection.

If blood vessel narrowing (atherosclerosis) is causing erectile dysfunction, you are more likely to develop narrowing of other blood vessels - such as the blood vessels supplying the heart. So, it's a good idea to speak to a doctor to find out what you can do to keep your heart healthy, such as stopping smoking, managing diabetes (if you have it), and making sure your blood pressure and cholesterol levels under control.

In most cases of ED due to physical causes (apart from injury or after surgery), the erectile dysfunction tends to develop slowly. So, you may have intermittent or partial ED for a while, which may gradually become worse. You are likely still to have a normal sex drive (libido) unless the cause is due to a hormonal problem.

Physical causes of erectile dysfunction usually cause erectile problems that are present all of the time, meaning that it's difficult to get an erection when masturbating or at any other times, such as first thing in the morning.

For more information on how alcohol and drug abuse can cause ED, see the leaflets on Alcoholism and problem drinking and Drug dependence treatment.

Psychological causes of erectile dysfunction

Erectile dysfunction can also be caused by psychological issues. These can be specific psychological issues around sex and intimacy, or a part of a wider mental health problem, such as depression.

Potential psychological causes include:

• Stress - for example, due to a difficult work or home situation.

• Performance anxiety (feeling anxious about not being able to get an erection, to satisfy your partner, or otherwise to 'perform' during sex).

• Issues with sexual intimacy; for example, people who have had embarrassing or traumatic experiences can find sex difficult or distressing.

• Anxiety.

• Relationship problems.

• Depression.

There might be a link between erectile dysfunction and heavy or problematic use of pornography. Some studies have found that erectile dysfunction is more common in men who have symptoms of pornography addiction. Some people use the term 'porn-induced erectile dysfunction' to describe this. This link is controversial, though, and there is not much research yet in this area; other people dispute the connection. For example, it's not clear if excessive porn use causes erectile dysfunction, or if there are other explanations, such as the excessive porn use being caused by other things, like depression or relationship problems, which are also causing erectile dysfunction.

Usually - although not always - the erectile dysfunction develops quite suddenly if it is a symptom of a mental health problem. The erectile dysfunction may resolve when your mental state improves - for example, if your anxiety or depression eases.

However, some people become even more anxious or depressed when they develop erectile dysfunction, which creates a vicious cycle of worsening anxiety and persisting erectile dysfunction. This is typically the case with performance anxiety as well.

A psychological cause of erectile dysfunction is more likely if you are able to get an erection at some times, but not at others: for example, if you still get morning erections, and can get an erection when masturbating, but can't get an erection for sex.

Patient picks for Men's sexual health

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Are erection problems getting more common in young men?

Erectile dysfunction (ED) is often typified as an issue for older men. With many potential causes, ranging from high blood pressure to type 2 diabetes, it is very common in middle age and beyond. What is less often discussed is the fact younger men can be susceptible too. While it's hard to know the precise proportion, not least because so many men are too embarrassed to see a doctor, what we do know is that many 20- and 30-somethings are suffering in silence.

by Abi Millar

Sexual health

Premature ejaculation

Premature ejaculation (PE) is the term used when a man comes (ejaculates) more quickly than he and/or his partner would like. It means you ejaculate very soon after putting your penis inside (penetrating) your partner, or even before penetration. It is not really known what causes premature ejaculation. Men with premature ejaculation should not be embarrassed about discussing it with their doctor, as it can be helped by a variety of means. Many men do not seek help from their doctor for this problem so it is not known how common it is. Some studies suggest it can be as common as thirty in a hundred men. There are tablets which may be helpful, either taken regularly or as needed. Creams or sprays that numb the penis may also be used. Other treatments include certain techniques used during sex, and psychological treatments.

by Dr Hayley Willacy, FRCGP

How common is erectile dysfunction?

ED is more common as you get older. About 50% of men between the ages of 40 and 70 have erectile dysfunction and about 70% of men aged 70 and above have erectile dysfunction. However, because many men don't seek medical help for ED, it is impossible to know exactly how common it is.

In recent years, erectile dysfunction seems to be becoming more common amongst younger men. We don't know why this is the case. It might be that younger men are becoming more likely to come forward to seek help, rather than suffering in silence. Other possible explanations include mental health problems becoming more common, and internet pornography becoming much more available, possibly leading to problematic porn use.

How is erectile dysfunction diagnosed?

Your GP will discuss the problem with you, go over any medication you may be taking, and may do a physical examination. This can help to work out the cause of the erectile dysfunction.

Tests aren't always needed, but may be recommended to look for other causes of erectile dysfunction, and associated problems. These depend on the situation, but might include some or all of the following:

• A blood test to check the level of cholesterol and other fats (lipids).

• Blood sugar level.

• Blood tests to rule out kidney and liver disease.

• A blood test for testosterone levels (this needs to be taken in the morning).

• A urine test.

• A check of your blood pressure.

• A 'heart tracing' (electrocardiogram, or ECG).

• A PSA test, if there are symptoms or signs of prostate cancer.

• Other heart tests which are sometimes done, where appropriate, if heart disease is suspected.

There are some more specialised tests, such as scans to measure blood flow in the penis, which may be recommended by hospital specialists in a few situations - but these are rarely needed.

Measuring the severity of erectile dysfunction

The severity of erectile dysfunction is measured on the basis of several factors:

• How you rate your confidence that you can get and keep an erection.

• How often your erections are hard enough for you to penetrate your partner following sexual stimulation.

• How often you can keep your erection after penetrating your partner.

• How hard it is for you to maintain your erection to complete sex.

• How often sexual activity is satisfactory for you.

The Sexual History Inventory for Men questionnaire (SHIM) questionnaire (see 'Further Reading' below) uses these questions to give an idea of whether your erectile dysfunction would be classed as mild, mild-moderate, moderate or severe.

Erectile dysfunction treatment

There are lots of treatments for erectile dysfunction, and they are often very helpful. The following gives a brief summary of the options:

Treating an underlying cause

For example, treating depression or anxiety, changing medication, or treating certain hormonal conditions may cure the associated erectile dysfunction.

Lifestyle and other advice

Lifestyle changes may help, such as:

• Losing weight if you are overweight.

• Stopping smoking.

• Taking regular exercise.

• Reducing or stopping drug use.

• Keeping alcohol drinking to within recommended limits.

Erectile dysfunction is often a sign that you are at higher risk of developing heart disease or other cardiovascular diseases. It's therefore especially important to think about whether you can make any other lifestyle changes to keep your heart healthy.

Also, your doctor may prescribe a statin medicine to lower your blood cholesterol level if your risk of developing cardiovascular disease is high.

They may also suggest blood pressure-lowering medication, if you have high blood pressure (hypertension).

In some people, problematic porn use - such as porn addiction - might be linked to erectile dysfunction (although this is disputed). This might be the case if you use porn very regularly, and are only able to get an erection when viewing porn, but not when having sex with a partner. If you think this might apply to you, it may be helpful to take a break from viewing porn for a few weeks and see if this helps. If porn use is causing problems in your life, and you are finding it difficult to control, consider seeking therapy or counselling.

Counselling

Sometimes couple counselling, or sex therapy is useful. These are most useful if mental health (psychological) problems are the cause of, or the result of, erectile dysfunction.

Psychosexual therapy, or sex therapy, can also be useful for treating emotional and psychological issues that are linked to erectile dysfunction.

Tablets for erectile dysfunction

In the UK there are now four different ED tablets available:

• Sildenafil (Viagra®).

• Tadalafil (Cialis®).

• Vardenafil (Levitra®).

• Avanafil (Spedra®).

Sildenafil, tadalafil, and vardenafil are also available in generic (non-branded) forms.

Sildenafil and tadalafil are available from pharmacies without prescription, following a consultation with a pharmacist. The others are prescription-only.

You take a dose before you plan to have sex. They work by increasing the blood flow to your penis. They do this by affecting cGMP, the chemical involved in widening (dilating) the blood vessels of the penis when you are sexually aroused. Because of the way they work, these medicines are called phosphodiesterase type 5 (PDE5) inhibitors.

Note: none of these tablets will cause an erection unless you are sexually aroused.

PDE5 medications work in 8 out of 10 cases.

PDE5 inhibitors aren't suitable for everyone. For example, they should not be used by:

• People who take nitrate medications (usually prescribed for angina) - using them together can cause a dangerously low blood pressure.

• People with low blood pressure (as they can make it even lower).

• People who have frequent attacks of angina or angina that happens during sex - because they are likely to need nitrate medications to treat angina attacks, and the combination is dangerous.

Your doctor or pharmacist can tell you more about whether or not PDE5 inhibitors are an option for you.

Switching medications

Some medicines can cause erectile dysfunction. Check the leaflet that comes with any medication that you take to see if ED is a possible side-effect. Do not stop any prescribed medication but see your doctor if you suspect this to be the cause of your ED. A switch to a different medicine may be possible, depending on what the medicine is for.

The treatments above can be prescribed or arranged by a GP. If they aren't working, they may offer you referral to see a urology specialist for further assessment, advice and treatment. Treatment options that may then be offered include:

Cream applied to the penis

Topical alprostadil may be prescribed. The cream comes with a plunger. It is applied to the tip of the penis and the surrounding skin. It should be used 5 to 30 minutes before you have sex.

Injection treatment

This was the most common treatment before ED tablets became available. It usually works very well. You are taught how to inject a medicine into the base of the penis. This causes increased blood flow, following which an erection usually develops within 15 minutes. Unlike with tablets, the erection occurs whether or not you are sexually aroused.

Urethral medication

You can place a small pellet into the end of the tube which passes urine and opens at the end of the penis (the urethra). The pellet contains a similar medicine to that used for the injection treatment. The medicine is quickly absorbed into the penis to cause an erection, usually within 10-15 minutes.

Vacuum devices (pumps)

There are several different devices. Basically, you put your penis into a plastic container. A vacuum pump then sucks out the air from the container to create a vacuum. This pulls blood flow to your penis and cause an erection.

When erect, a rubber band is placed at the base of the penis to maintain the erection. The plastic container is then taken off the penis and the penis remains erect until the rubber band is removed (which must be removed within 30 minutes).

Penile implants

Penile implants can be permanently fit into the penis by a surgeon. The most sophisticated (expensive) type can be inflated with an inbuilt pump to cause an erection. The more basic type has to be straightened by hand.

Other treatments

There are other things that are sold as erectile dysfunction treatments, such as herbal treatments and dietary supplements.

It's best to avoid these. For most of them, there is little evidence that they are effective treatments for erectile dysfunction, and they may be harmful. They also aren't regulated or tested in the same way that pharmacy medications are. For example, there are many cases of 'herbal viagra' pills that have been found to have illegal or dangerous ingredients.

Treatment for erectile dysfunction on the NHS

Generic (non-branded) sildenafil can be prescribed without restriction on the NHS.

Branded sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®), avanafil (Spedra®), and alprostadil (MUSE®, Vitaros®, Viridal Duo®, Caverject®) can only be prescribed on the NHS under the 'Selective List Scheme' (SLS) if you have one of the following specific medical condition(s) or previous treatment(s):

• Diabetes, multiple sclerosis, Parkinson's disease, poliomyelitis, prostate cancer, severe pelvic injury, single-gene neurological disease (eg Huntington's disease), spina bifida, spinal cord injury, or severe pelvic injury.

• Dialysis or kidney transplant for end-stage kidney disease.

• Radical pelvic surgery or prostatectomy.

• Severe distress due to erectile dysfunction (needs to be diagnosed by a specialist who has ongoing responsibility for providing prescriptions).

How can you help a partner experiencing erectile dysfunction?

Having a partner with erectile dysfunction can be difficult and distressing for both of you, but there are lots of things that can help.

It can be a difficult topic to broach, but having an sensitive and supportive discussion about what is happening, how you both feel about it, and how you plan to move forward together, is a really important step.

It's useful to gather information about erectile dysfunction first - such as by reading this leaflet - to help you have the conversation.

Be supportive. Men with erectile dysfunction can feel ashamed or guilty. It can really help to let them know that it's not something to be ashamed of, that it doesn't change how you feel about them, and that it isn't a reflection on their masculinity.

You could explore possible solutions to the problem together. You could encourage your partner to see their doctor, or even offer to go with them, if they think that would be easier.

If talking about it is proving difficult, it might be helpful to see a couples counsellor together.

Erectile dysfunction treatment is often very effective. Sometimes, though, treatment doesn't have the desired effect. Some men might not want treatment. If this is the case, remember that there are other ways to share a physical connection, such as non-sexual touching like hugging, holding hands, and cuddling, as well as ways to have sex without an erection, like oral sex or using sex toys.