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Erectile Dysfunction

A standard definition of Erectile dysfunction (ED) is when you are not able to get or maintain an erection that will allow you complete sexual intercourse, or another chosen sexual activity.
Erectile dysfunction is very common in men once they get over the age of 40. In fact, half of men between the ages of 40 and 70 years will have some form of erectile dysfunction.

When ED is due to physical causes, men often experience a more gradual, insidious onset of erectile difficulties.

​Physical causes of ED include: ​

  • Vasculogenic conditions (anything that basically affects the blood flow to the penis) – including disease of the heart or blood vessels (cardiovascular disease (CVD)), high blood pressure, raised cholesterol and diabetes. In fact, symptoms of ED can be an early warning to other health problems particularly cardiovascular problems.
  • Neurogenic conditions (this means any condition which affects the nervous system) – including multiple sclerosis, Parkinson’s disease, stroke, diabetes and spinal injury or disorder
  • Hormonal conditions(which affect the hormones) – including an overactive thyroid gland, an underactive thyroid gland, hypogonadism (low testosterone level), Cushing’s syndrome (high cortisol level), a head or brain injury recently or in the past and subarachnoid haemorrhage or radiation to the head (these may cause hormonal changes, particularly a low testosterone)
  • Anatomical conditions (which affect the structure of the penis) – including Peyronie’s disease where there is a severe bend in the penis
  • Surgery and radiation therapy for bladder, prostate or rectal cancer
  • Injury to the penis
  • Side effect of prescribed drugs
  • Recreational drug use
  • Excessive alcohol consumption
  • Smoking
  • Obesity
  • Sedentary lifestyle

As mentioned earlier if the cause of your ED is atherosclerosis (where fatty plaques build up in your arteries restricting blood flow) then this narrowing is likely to affect other blood vessels in the body as well, including the arteries that supply blood to the heart. ED is usually affected first because the arteries supplying the penis are far smaller than those providing blood to the heart. So, ED is an early warning sign of future heart problems, kind of like the canary in the mineshaft. With the first appearance of ED the time frame is five years before the atherosclerosis causes problems with the circulation of the heart. This is why it is extremely important to see you doctor as soon as the symptoms of ED start. ​

​Hormones have now been found to play an increasingly important role in the development of ED. In particular low levels of the male hormone testosterone has been associated with ED. This deficiency can occur at any age but is more common in the ageing male where it is referred to as Late Onset Hypogonadism. To determine if you are suffering from low testosterone levels or hypogonadism your doctor will ask you fill out a questionnaire, the ADAM questionnaire. The ADAM questionnaire stands for Androgen Deficiency in the Ageing Male. It consists of a series of questions relating to your sexual and physical health. In particular the ADAM questionnaire focuses on your libido and erection strength. An example of the ADAM questionnaire can be seen here. Your doctor will also take an early morning blood sample on two separate occasions to determine your testosterone levels. The ADAM questionnaire together with your blood results will determine whether you should be placed on testosterone replacement therapy (TRT).

Although bicycle riding is a great form of exercise it may not always be good for your penis. The blood vessels or nerves supplying the penis which are situated under the bones of the backside (ischial tuberosities) can become compressed by the narrow bicycle seat. In fact, 1 in 4 competitive cyclists suffer from some form of ED. If you ride a bike for more than three hours a week and suffer from ED, then try some time off the saddle to see if this improves things. A special split seat with extra padding can also take the pressure off the nerves and blood vessels supplying the penis.

It was only as recently as twenty years ago that it was thought that ED was all psychological and all in the head. However, our understanding has improved, and we now know that ED is multifactorial and can be caused by a number of causes including many physical causes. But sometimes the problem really is in your head. This is because your brain chemistry and nerve connections are essential for giving the commands for an erection (although a spinal reflex which is independent of the brain is also present). Sometimes when your mind is focused on other worries ED can develop. When we are stressed the body releases adrenaline. This hormone is the fight or flight hormone and is released when the body senses danger. Danger makes us feel anxious, whether the threat is real or perceived the body releases adrenaline. This hormone works by shunting our blood to heart and lungs and away from the smaller parts of the body like the finger and toes, and yes, the penis. This effect of adrenaline was an essential element that helped humans survive from predators, after all when you are trying to outrun a sabre-toothed tiger your heart and lungs would need more blood than your penis! Hence any form of anxiety or stress could trigger ED. A psychological cause of ED is more likely if:

  • Your erection is fine except with your partner
  • You are suffering stress and anxiety from work
  • You are suffering from stress at home with the family
  • There are marital problems and dissatisfaction (which may also cause premature ejaculation)
  • You are depressed
  • Failing once is followed by fear of subsequent failure
  • Your partner has sexual problems
  • You are bored sexually possibly caused by watching too much pornography
  • You are worried about your sexual orientation
  • You have suffered previous sexual abuse

​If you have been suffering with ED for more than a few weeks, it is important to see a health professional or your doctor since it may be a warning sign of other more serious health problems.

​ED is such a personal topic that many men put off discussing it. This is why we have created the Helpline where you can talk to a trained health professional. The service is private and confidential, and our trained staff can signpost to other healthcare professionals and also offer advice about treatments.

How is ED diagnosed by your doctor? Well to help your doctor come to a diagnosis a questionnaire is used. It comprises of a series of five questions that are scored from 1 to 5. A total of 22 to 25 is considered normal.

​The questions are regarding your experience over the previous 6 months. An example of the questions and the responses are given below:

1. How would you rate your confidence that you could get and maintain an erection?

Answer options are:

1: very low

2: low

3: moderate

4: high

5: very high

2. How often were your erections hard enough for penetration when you were sexually stimulated?

1: almost never

2: a few times (much less than half the time)

3: sometimes (about half the time)

4: most times (much more than half the times)

5: almost always/always

3. How often were you able to maintain your erection during intercourse after you penetrated?

1: almost never

2: a few times (much less than half the time)

3: sometimes (about half the time)

4: most times (more than half the time)

5: almost always/ always

4. How difficult is it to maintain your erections to the completion of intercourse?

1: extremely difficult

2: very difficult

3: difficult

4: slightly difficult

5: not difficult

5. How often was the sexual intercourse satisfactory for you?

1: almost never

2: a few times (much less than half the time)

3: sometimes (about half the time)

4: most times (more than half the time)

5: almost always/ always

A total score of 12 to 21 is considered mild erectile dysfunction. A score of 12 to 16 is considered mild to moderate erectile dysfunction. A score of 8 to 11 is considered moderate erectile dysfunction and a score of 5 to 7 is severe erectile dysfunction.

Your doctor will also ask you about your sexual history, diet and lifestyle. You will have an assessment, which includes measurement of your height, weight and waist. You will also need a medical, which includes:

  • Heart and lungs check
  • Blood pressure check
  • A quick check of your genitals to rule out any obvious physical abnormality
  • Cholesterol check
  • Diabetes test
  • A morning blood test of your testosterone levels (see our factsheet on ‘Testosterone deficiency’)

A prostate examination may be required if you have symptoms of an enlarged prostate gland, such as a weak stream and/or urgent and/or frequent urination.

​If you feel that you are not quite ready to open up to your GP then you can either phone our Helpline or visit a genitourinary medicine (GUM) clinic. Their details can be found on the British Association for Sexual Health and HIV (BASHH) website you can also see a sex therapist.

The cause of the ED should be treated first whether this is physical, psychological or a mixture of both. Only twenty years ago the only options were injections directly into the penis or the herb yohimbine, now however, there have been major advances in the treatment of ED and most sufferers can now be treated effectively.

​Lifestyle changes will be recommended by your doctor if atherosclerosis is causing your ED. This will not only improve your ED but your overall general health and help protect your heart. These include:

  • Stopping smoking
  • Limiting the amount of alcohol, you drink to no more than 14 units a week
  • Losing weight if you are overweight
  • Eating a healthy Mediterranean-style diet
  • Taking moderate daily exercise
  • Trying to reduce stress and anxiety

​Medication such as the statins may also be prescribed to treat atherosclerosis. Drugs may be prescribed to treat hypertension but bear in mind many of this class of drugs actually cause ED as a side effect.

​If these lifestyle changes do not cause an improvement in the symptoms of ED then the first line of treatment are a class of treatments known as the PDE5is or the phosphodiesterase type 5 inhibitors (pronounced phos- pho- di- es- ter- ase) inhibitors (PDE5i) and include tadalafil (Cialis®), vardenafil (Levitra®), sildenafil (Viagra®) and avanafil (Spedra®). PDE5i work for many men but they will not cause an erection unless the man is mentally AND physically stimulated (see our factsheet ‘Oral treatment for erectile dysfunction’).

​A drug called alprostadil (made from prostaglandin E1 or PGE1 is the same as a chemical that the penis produces naturally when it becomes erect) can be injected into the shaft of the penis. This causes vasodilation much like turning on a tap and allows more blood to flow into the penis and get trapped there, which helps you get and keep an erection. Injection therapy is very successful in those men who do not respond to tablets. There are two types of alprostadil injections available, Caverject® and Viridal®.

​Invicorp is another type of injection therapy used to treat ED. It contains two active ingredients (aviptadil and phentolamine mesilate); one increases blood flow to the penis to help you get an erection while the other, phentolamine helps trap the blood there to keep by blocking adrenaline like molecules from squeezing off the blood flow to the penis thus helping to keep the erection working. Invicorp may work well for men who have found little success with other ED treatments and some may find it less painful to use than alprostadil injections.

​Another option is to insert a pellet (MUSE® which stands for Medicated Urethral System for Erection) that contains alprostadil into the urethra (the tube through which you pass water) after urinating. The pellet, about the size of a grain of rice, dissolves and provides you with an erection.

​Alprostadil can also be used topically as a cream (Vitaros®), which is applied to the penis.

​Vacuum devices draw blood into the penis to get an erection, and it is trapped there with a special ring at the base of the penis to keep the erection. These devices suit some people well) and can be used in combination with the PDE5i s such as sildenafil especially in men suffering post prostatectomy ED.

​Testosterone replacement therapy may be required if you are found to have low levels of this hormone. ​

Surgically implanted devices (penile prostheses), which strengthen the penis from inside, are available for the very few men who cannot get an erection in any other way.

​Research has suggested that a small number of men with ED may benefit from exercises to strengthen the pelvic floor muscles, such as Kegel exercise. In fact, some studies have shown that some men have got the same benefits from 3 months of Kegel exercise as Viagra. These lie underneath the bladder and back passage, and at the base of the penis. If your doctor thinks this approach may benefit you, they will refer you to a physiotherapist.

Sex therapy is talking therapy where an individual or couple work with an experienced therapist to assess and treat their sexual and/or relationship problems. By working together, they will identify causal factors that trigger the problems and design a specific treatment programme to resolve or reduce their impact.

​Sex therapy is considered highly effective in addressing the main causes and contributing factors of sexual difficulties. Another result from sex therapy is that it helps people to develop healthier attitudes towards sex, improve sexual intimacy, become more confident sexually, and improve communication within the relationship.

​Sex therapy can also be used in combination with other forms of treatment.

​Your GP or another health professional on the NHS may be able to refer you for sex therapy (depending on area), or alternatively you can opt to pay privately for a sex therapist. However, it is important to make sure that they are qualified and are registered with an appropriate professional body.

​Unfortunately, ageing is one of the causes of ED and you are more likely to suffer with ED, as you get older. It is important to bear in mind that some men have the impression that ED is natural consequence of ageing and that nothing can be done about it. The barrier here is the stoic attitude of acceptance. There are many treatments that can be employed to help older men enjoy healthier sex lives and no one should be denied ED treatments because they are considered too old. Speak to one of our advisors who will be able to recommend the most appropriate treatment to enable you to enjoy a healthy and fulfilling sex life. If you have a partner, it is important to talk to them and also make sure that your doctor is aware of your treatment. Men in their 90’s are now seeking treatment for ED and usually respond to one of the available options.

​You can also visit the NHS Choices website at for information and advice on many different health and lifestyle topics.

ED may be a warning of a future heart problem – like the canary in the mineshaft, it’s an early warning for cardiac health problems so when you have symptoms of ED get your heart checked out.

All consultations are performed by EU registered doctors.
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