Overview
- Erectile dysfunction (ED) is the repeated inability to get or keep an erection firm enough for satisfactory sexual intercourse
- Occasional difficulty is common and not usually a cause for concern; ED becomes a health concern when it happens frequently, lasts for more than a few weeks or causes distress to a man or his partner
How does a Normal Erection Happen?
- An erection happens when sexual arousal causes the brain to send signals that relax the blood vessels in the penis. Blood flow increases and fills two spongy chambers, making the penis firm. Healthy nerves, blood vessels, hormones and emotional wellbeing all need to work together for this process to happen smoothly.
- ED occurs when any part of this process is disrupted for example, if blood flow is reduced, nerve signals are damaged, hormone levels are low or the mind is distracted by stress or anxiety.
How Common is Erectile Dysfunction (ED)?
- ED affects an estimated 30 million men in the United States alone
- Report says that ED is experienced by 52% of men aged 40–70 years, with complete (severe) ED affecting about 10% of men in this age group
- The chance of having ED increases with age, but ageing alone does not cause it ; ED is usually linked to an underlying health condition
Who is Commonly Affected?
- Men over the age of 40, with the likelihood rising with each decade of life
- Men with diabetes, heart disease, high blood pressure or high cholesterol
- Men who are overweight or physically inactive
- Men who smoke or who drink alcohol heavily
- Men experiencing stress, anxiety, depression or relationship difficulties
What Causes Erectile Dysfunction (ED)?
ED usually happens because of a mix of physical and psychological factors and often both are present together.
Physical Causes:
- Reduced blood flow to the penis due to narrowed blood vessels (atherosclerosis)
- Diabetes: It can damage the nerves and blood vessels that control an erection
- High blood pressure and high cholesterol
- Low testosterone or other hormonal problems
- Nerve damage from pelvic surgery (e.g. for prostate cancer), spinal injury or multiple sclerosis
- Certain medicines, including some antidepressants, blood pressure tablets and antihistamines
- Obesity
- Peyronie's disease (scar tissue inside the penis causing curved, painful erections)
- Smoking, heavy alcohol use and recreational drug use
Psychological Causes:
- Stress and anxiety, including performance anxiety
- Depression
- Relationship problems or poor communication with a partner
Symptoms of Erectile Dysfunction (ED)
- Trouble getting an erection
- Trouble keeping an erection long enough for sexual activity
- Reduced interest in sex, which may occur alongside ED
Warning Signs that Need Prompt Medical Attention
- ED combined with chest pain, breathlessness or dizziness during sexual activity, it could signal underlying heart disease and needs urgent medical attention
- Sudden ED following pelvic injury, surgery or a new medicine
- ED together with fatigue, reduced muscle mass or low mood, which may point to low testosterone
- An erection lasting more than 4 hours (priapism), this is a medical emergency
Diagnosis and Investigations
- Medical and sexual history: Your doctor will ask about the pattern of ED, medicines, lifestyle and relationship factors
- Physical examination, including checks of the genitals and blood pressure
- Blood tests to check blood sugar, cholesterol and testosterone levels
- Psychological assessment, when stress, anxiety or depression may be contributing
- Specialised tests such as nocturnal erection monitoring or a Doppler ultrasound of penile blood flow, used only in select cases
Understanding the Underlying Cause
ED can be linked to blood vessel, nerve, hormone or psychological factors or a combination of these. Identifying the likely cause helps your doctor recommend the most suitable treatment for you.
Treatment Options
Treatment is tailored to the underlying cause and is usually started with the simplest, safest option first.
Lifestyle Changes
Often recommended as a first step and may improve ED on their own in some men, especially when it is linked to weight, smoking or inactivity.
Oral Medicines (PDE5 Inhibitors)
- Sildenafil, tadalafil, vardenafil and avanafil are commonly prescribed tablets that increase blood flow to the penis
- They only work with sexual stimulation and are not aphrodisiacs
- They must not be taken with nitrate medicines (often used for chest pain) as the combination can cause a dangerous drop in blood pressure
Other Treatments
- Vacuum erection devices: A pump creates an erection by drawing blood into the penis
- Injections directly into the penis (e.g. alprostadil), used when tablets are not suitable or effective
- Intraurethral therapy: A small pellet of medicine inserted into the tip of the penis
- Testosterone replacement, only if blood tests confirm a hormone deficiency
- Penile implant surgery, considered when other treatments have not worked
- Psychological counselling or sex therapy, particularly when stress, anxiety or relationship issues play a role
When is a Specialist or More Advanced Treatment Needed?
- If oral medicines do not work or cannot be used safely
- If ED is linked to a hormone deficiency, a structural problem or severe blood vessel disease
- All treatment decisions are made jointly with you, considering your overall health, other medicines and personal preference
Emotional and Relationship Impact
- ED can lead to embarrassment, reduced self-confidence or worry about intimacy
- It can create tension or distance in a relationship if not openly discussed
- Anxiety about ED can, in turn, make ED worse by creating a difficult cycle
- Speaking honestly with your partner and seeking professional support if needed, can ease this burden considerably
Lifestyle and Prevention
- At least 150 minutes of moderate physical activity per week (e.g. brisk walking, cycling, swimming)
- Maintain a healthy body weight
- Eat a balanced diet with plenty of fruits, vegetables and whole grains and limit processed and fried foods
- Stop smoking and limit alcohol intake
- Keep diabetes, blood pressure and cholesterol well controlled
- Manage stress and get adequate sleep
- Talk openly with your partner as ED can affect both partners and shared understanding helps
Long-Term Care
- Regular follow-up with your doctor to review treatment effectiveness and side effects
- ED can be an early warning sign of heart disease, so cardiovascular health should be monitored
- Take prescribed medicines as directed and report any side effects promptly
- Continue lifestyle changes even after starting medical treatment
When to Contact a Doctor?
- ED that lasts more than a few weeks or is getting worse
- ED accompanied by chest pain, breathlessness or dizziness during sexual activity, seek urgent care
- Sudden ED after an injury, surgery or starting a new medicine
- Side effects from ED medicines or an erection lasting more than 4 hours
Myths and Facts
Myth
ED only affects older men.
Fact
ED becomes more common with age, but it can affect men of any age, including younger men, especially when linked to stress, anxiety or lifestyle factors.
Myth
ED is “all in the mind” and is a sign of weak character.
Fact
ED most often has a physical cause, such as poor blood flow, diabetes or heart disease and is not a reflection of a man's character or masculinity.
Myth
ED medicines work instantly for everyone, so lifestyle changes are not needed.
Fact
Medicines help many men, but they work best alongside a healthy lifestyle and they do not treat the underlying cause of ED.
References
- NHS. Erectile dysfunction [online]. Available from: https://www.nhs.uk/conditions/erectile-dysfunction/. Accessed on 16 July 2026.
- Mayo Clinic. Erectile dysfunction — symptoms and causes [online]. Available from: https://www.mayoclinic.org/diseases-conditions/erectile-dysfunction/symptoms-causes/syc-20355776. Accessed on 16 July 2026.
- Urology Care Foundation (American Urological Association). What is erectile dysfunction? [online]. Available from: https://www.urologyhealth.org/urology-a-z/e/erectile-dysfunction-(ed). Accessed on 16 July 2026.
- Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol. 1994;151(1):54–61.
- Cleveland Clinic. Erectile dysfunction (ED) [online]. Available from: https://my.clevelandclinic.org/health/diseases/10035-erectile-dysfunction. Accessed on 16 July 2026.
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Erectile dysfunction [online]. Available from: https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction. Accessed on 16 July 2026.
- Mayo Clinic. Erectile dysfunction — diagnosis and treatment [online]. Available from: https://www.mayoclinic.org/diseases-conditions/erectile-dysfunction/diagnosis-treatment/drc-20355782. Accessed on 16 July 2026.
- NHS. Erectile dysfunction — treatment [online]. Available from: https://www.nhs.uk/conditions/erectile-dysfunction/treatment/. Accessed on 16 July 2026.
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