Erectile dysfunction might feel embarrassing, but it’s more common than you think. We look at the causes, prevention and treatment tips.
Medically reviewed by Dr Roger Henderson and words by Annie Hayes
Erectile dysfunction is more common than you might think and this debilitating condition – characterised by the repeated inability to get or keep an erection firm enough for sexual intercourse – is also on the rise. Studies estimate that 322 million men across the globe will be affected by 2025, causing a significant impact on their quality of life. Although it can occur at any age (including in teenagers) it becomes more common with increasing age, with around half of men between the ages of 40 and 70 experiencing some degree of ED, and around 70% of men over the age of 70 having it.
Though occasional erection problems can be embarrassing in the heat of the moment, they’re often harmless. However if you find yourself frequently flying at half mast, it could be a symptom of something more serious. The good news is, erectile dysfunction is easily assessed, and it really can treated at any age.
We asked Professor David Ralph, consultant in Urology at King Edward VII’s Hospital; Giulio Garaffa, consultant uro-andrologist at International Andrology; and Dr Luke Pratsides, lead GP at Numan; to detail the common causes of erectile dysfunction, advise treatment options, and share preventative lifestyle measures:
Why can’t I get an erection?
When a man is sexually excited, brain signals prompt muscles in the penis to relax, boosting blood flow. The chambers inside the penis become engorged with blood, resulting in a rigid erection.
This process requires different systems in the body to work in sync, including your nerves, hormones, muscles, veins, and arteries. When a stage of this sequence is interrupted, it can interfere with your erection.
Erectile dysfunction can often be attributed to lifestyle factors: stress, tiredness, or too many glasses of red.
Erectile dysfunction can often be attributed to lifestyle factors: a stressful day at work, tiredness, or one too many glasses of red. Emotional or relationship difficulties can also come into play. And sometimes there’s a physical cause, such as underlying disease, injury, or the side effects of medication.
It may come on gradually or more suddenly, and can be caused by one factor, or several biological and psychological factors combined. If you experience erectile dysfunction frequently – more than half of the times you have sex – or it becomes a source of distress for you and your partner, it’s worth speaking to a healthcare professional.
‘While erectile dyfunction is a common condition, the underlying causes behind it can be complex,’ says Dr Pratsides. ‘Some of these can be serious and most commonly are related to physical diseases like diabetes, high cholesterol and low testosterone, as well as mental health related causes like anxiety and depression.’
What causes erectile dysfunction?
Every man’s experience of erectile dysfunction is different. Some men are totally unable to achieve an erection, while others may do so inconsistently, or only sustain very brief erections. The most common causes of erectile dysfunction are psychogenic and vascular, says Professor Ralph.
Psychogenic erectile dysfunction is caused by emotional or mental stressors and is ‘most likely to occur in younger individuals,’ he says, while vascular relates to the circulatory system, and is ‘more likely to occur in older patients, in particular those who smoke, are overweight, or have high blood pressure’.
Physical causes of erectile dysfunction
While the most common physical causes of erectile dysfunction are related to circulation, they’re not the only physical conditions your doctor may explore. The wider list includes:
- Heart disease
- Clogged blood vessels (known as atherosclerosis)
- High cholesterol
- High blood pressure
- Metabolic syndrome
- Kidney disease
- Chronic alcoholism
- Parkinson’s disease
- Multiple sclerosis
- Vascular disease
- Neurologic disease
- Peyronie’s disease
- Substance abuse
- Sleep disorders
- Treatments for prostate cancer or enlarged prostate
- Surgeries or injuries that affect the pelvis or spine
- Low testosterone or hormone imbalances
- Bladder surgery
Certain prescription medications, including blood pressure drugs, antihistamines, antidepressants and tranquilisers can also lead to erectile dysfunction.
Psychological causes of erectile dysfunction
Your brain triggers the cascade of physical reactions that lead to an erection, and as your emotional centre, it plays an important role in the process. The following psychological factors can cause or worsen erectile dysfunction:
- Low self-esteem
- Fear of sexual failure
- Relationship problems
Certain lifestyle factors such as stress, smoking, drinking too much alcohol, poor diet, taking recreational drugs and not exercising frequently can also contribute to the likelihood of erectile dysfunction.
Erectile dysfunction tests
The first step to overcoming erectile dysfunction is to visit your GP for testing and a clinical diagnosis, says Professor Ralph. They will likely conduct a physical exam of your penis and prostate, and ask you specific questions about your symptoms and sexual history. They may refer you to a urologist, or perform additional tests to help determine the underlying cause(s). These may include:
- Ultrasound: used to examine the blood vessels of the penis.
- MRI scan:to look for structural abnormalities.
- Nocturnal penile tumescence (NPT) test:to assess night-time erections.
- Injection test:Where medication is injected into your penis to stimulate an erection.
- Urine test: to check for diabetes or other underlying health conditions.
- Blood test: to check for diabetes, heart disease, thyroid issues, and low testosterone levels.
Erectile dysfunction and asking for help
Talking about erectile dysfunction might feel awkward at first, but starting the conversation is well worth it so don’t be embarrassed about asking for help. It’s important to work with your doctor, so that they can rule out or treat any underlying medical conditions that may be causing your erectile dysfunction. In almost 75 per cent of cases, there’s a physical cause. That means the condition – and the erectile dysfunction – can be treated.
Erectile dysfunction treatment
The treatment for erectile dysfunction depends on the cause. Sometimes it’s as simple as making a few healthy lifestyle changes. Other times, talk therapy, medical treatments, or (on rare occasions) surgery may be more appropriate. Minimally invasive treatments will be recommended initially – such as quitting smoking, losing excess weight, cutting out alcohol, and increasing physical activity.
Your doctor will also recommend ‘a balanced diet, which always includes fruit and vegetables and limits the intake of sugar and refined products,’ says Garaffa. And if you’re taking any medications with side effects, they may look to change the type of medication or the dose. You should never stop taking medications without first talking to your doctor.
Erectile dysfunction medical treatments
Your doctor may prescribe medications or medical treatments to help you manage the symptoms of erectile dysfunction. There are a number of different options: some are taken orally, while others are injected directly into the penis or inserted into the urethra:
- Oral medications
Medication for erectile dysfunction include Viagra, Cialis, Levitra, Spedra and their generic counterparts, says Garaffa. ‘These medications act as vasodilators and therefore promote blood flow to the penis,’ he explains. These work by increasing blood flow to your penis by affecting the chemical involved in widening the blood vessels when you are sexually aroused. They are known as phosphodiesterase type 5 (PDE5) inhibitors and work well in about 80% of men.
You should not take a PDE5 inhibitor if you take nitrate medicines, usually prescribed for angina or heart disease. In England, Scotland and Wales sildenafil is available for all men with ED from GPs and specialists on a NHS prescription from GPs as well as specialists but in Northern Ireland, a specialist has to assume the responsibility for prescribing it.
- Penile injections
This involves injecting medication into the penis to widen the blood vessels. These were the most common treatment before tablets became available but are now used less often, causing an erection to usually develop within 15 minutes whether or not you are sexually aroused.
- Topical vasoactive drugs
Creams and gels that are applied to the penis to promote blood flow such as topical alprostadil, used up to 30 minutes before you have sex.
- Vacuum pump
A vacuum pump is essentially a tube that ‘mechanically pumps the blood to the penis, causing an erection,’ says Garaffa. Several different devices are available but in all of them the penis is placed into a plastic container and a pump then sucks the air out of the container to create a vacuum. This causes blood to be drawn into the penis and so causes an erection.
- Shockwave therapy
Shockwave therapy is administered using a wand-like device that effectively pulsates different areas of the penis in order to ‘rejuvenate the tissue of the penis and improve the quality of erections,’ says Garaffa.
- Penile suppositories
Suppositories involve a pre-filled applicator used to deliver a pellet into the urethra. This is painless, and contains medicine similar to that used for injection treatment. It is quickly absorbed into the penis and so can cause an erection within 10-15 minutes.
Erectile dysfunction surgery
In the rare cases where the previous therapies aren’t effective, your doctor may recommend surgical treatment for erectile dysfunction. There are two key types of procedures that may be used: implants and vascular surgery.
Implant surgery: this involves implanting a penile prosthesis – the most detailed types can be inflated with an inbuilt pump to cause an erection whereas basic types require the penis to be straightened by hand. ‘This is a very effective surgical procedure, as the prosthesis will create a normal-looking erection, preserving sensation and orgasm,’ says Garaffa. ‘Satisfaction rates following surgery are very high.’
Vascular surgery: this repairs blocked arteries to restore blood flow to the penis.
Erectile dysfunction risk factors
Certain men have a greater risk of experiencing erectile dysfunction than others. The biggest risk factor is age: it’s estimated that mild or moderate erectile dysfunction affects an additional 10 per cent of men each passing decade (so, 50 per cent of men in their fifties, for example). While it’s more common in older men, ageing isn’t a cause. Other risk factors include:
- Medical conditions:especially diabetes or heart conditions.
- Psychological conditions:such as anxiety or depression.
- Being overweight:especially if you’re obese.
- Certain medical treatments:such as prostate surgery or radiation treatment for cancer.
- Tobacco, drug and alcohol use:especially if consumption is heavy or long-term.
- Injuries:particularly those in the pelvic area.
- Medications:including antidepressants, antihistamines and medications.
- Drug and alcohol use:especially if you’re a long-term drug user or heavy drinker.
5 erectile dysfunction prevention tips
Erectile dysfunction is a complex condition that can be caused by a number of possible underlying causes, ‘some of which you can control, and some of which you can’t,’ says Dr Pratsides.
However, there are a few simple lifestyle changes you can make to help with erectile dysfunction, including:
1.Eat a healthy, balanced diet
A balanced diet is important to ensure your body is getting all the nutrients it needs to function properly, says Dr Pratsides. ‘Try to avoid refined carbs such as bread, rice and sugar, and ensure you’re getting enough protein and healthy sources of fat,’ he says. ‘It’s also worth increasing your overall intake of fruits and vegetables, which are packed with antioxidants and micronutrients.’ And finally, try to eat more nuts and legumes – such as peas and chickpeas – which are great for cardiovascular health, he adds.
- Quit smoking
Smoking can cause blood vessels to narrow, and healthy blood flow is vital for getting and maintaining healthy erections, says Dr Pratsides. ‘The free radicals generated by smoke inhalation can both damage the lining of the arteries and modify the ‘bad’ LDL cholesterol within them,’ he says. ‘This means more restriction in blood flow and potentially more erectile issues, as the penis is full of blood vessels and relies on healthy circulation.’
Losing weight can increase your testosterone levels, which is vital for optimal sexual performance.
- Get moving
Optimal erectile function begins with good blood flow, says Dr Pratsides. ‘Keep your heart as healthy as you can, and your blood vessels clear and flowing, and you’re off to the best start possible,’ he says. As a rule of thumb, the more muscles your body has to recruit for a particular exercise, ‘the harder your heart works to pump blood, and the stronger and healthier it gets. Swimming is just one example, as it uses multiple muscle groups.’ Kegel exercises, which work your pelvic floor muscles, may also be benficial.
- Maintain a healthy weight
Obesity is associated with high blood pressure, diabetes and high cholesterol levels, all of which can contribute to erectile dysfunction, says Dr Pratsides. ‘As many as 79 per cent of men with erectile dysfunction have a body mass index over 25,’ he says. ‘Research has shown that losing weight can also increase your testosterone levels, which is vital for optimal sexual performance.’
- Manage your mental health
Mental health conditions like stress and anxiety affect the brain signals that stimulate a physical response from your body, resulting in erectile dysfunction. This results in further stress, which perpetuates the instance of the condition. Practicing relaxation techniques such as meditation and yoga may help you break free from this cycle. If you’re experiencing anxiety, depression or post-traumatic stress disorder, seek help from your GP and consider talk therapy.