Problems getting or keeping an erection – known as erectile dysfunction (ED) – can have a big impact on your relationships and quality of life, whether it’s you or your partner who’s affected. After all, a good sex life can play a large role in your emotional and physical wellbeing. As well as being important if you’re hoping to have children, it helps you and your partner feel close to each other.
Research shows that ED (sometimes called impotence) can affect your mood and confidence, and may lead to worries about rejection by your partner. Or, if you’re not in a relationship, you might feel worried about what will happen when you meet someone, and avoid getting intimate because of your erection problems. Whatever your situation, ED can feel very isolating and make you despair about how to revive your sex life. And while there’s a lot more openness about sexual problems these days, it can still be a difficult thing to talk about.
Experts used to think that ED was mainly psychological – so-called ‘performance anxiety’. But nowadays, doctors understand that physical causes, usually involving problems with the blood supply to the penis, often contribute. Knowing this can change the way you think about it. ED doesn’t say anything about your masculinity: it’s normally a symptom of a medical problem, along with some very understandable emotional causes. And it can usually be treated successfully.
“As ED can sometimes be associated with another condition or risk factor, it’s important that you don’t ignore it – and instead get checked out for any underlying conditions that could be causing it or contributing,” says
, doctor and Healthily expert. “A lot of men feel embarrassed about seeking help. But the good news is that there’s a lot that you can do to address ED, look after your overall wellbeing and get back to enjoying the sex life you deserve.” So read on to learn more.
What is erectile dysfunction?
Most men have erection problems from time to time – they’re often caused by things such as stress, tiredness or drinking too much alcohol. An occasional problem doesn’t mean you have ED, and it’s usually nothing to worry about.
But some people have issues more often. ED means you’re regularly unable to get an erection that’s hard enough for any kind of penetrative sex. Or you might get hard at first, but lose your erection before you and your partner are satisfied. It may not happen every single time you have sex but if it happens a lot of th time and seems to be a persistent issue - or it’s affecting your relationship - it’s probably time to take it seriously.
ED can start to happen suddenly or gradually. It might only be a problem at certain times – for example, you may get an erection when you touch yourself (
), but not when you’re with a partner.
How common are erection problems?
The short answer? Very - although it’s difficult for doctors to be sure of exact numbers. ED’s strongly linked to age - it rises from between 1 and 10 in 100 in men under 40 to at least 50% by the age of 70.
But it can still be an issue if you’re younger. In an Italian study, 1 in 4 men with new-onset ED were under 40.
How an erection happens
To understand what might be stopping you from getting an erection, it can be helpful to look at what should happen.
Basically, your penis gets filled with blood, which makes it stiff and hard. Here’s what happens step by step:
- When you’re turned on, signals from your brain and nerves in your penis make the muscles inside 2 chambers in your penis relax.
- Blood flows into these chambers, causing pressure, which makes your penis get bigger and hard.
- The membrane around the chambers helps to trap the blood there, to keep your penis hard.
- When the muscles contract – after you’ve had an orgasm, for example – the flow of blood into your penis stops, and the blood flows back out again.
What causes erectile dysfunction?
ED often has an underlying physical cause. But your mind plays a big part in sex and feeling turned on, so your emotions are also likely to be involved.
For most men, ED has a combination of physical and psychological causes, and one can affect the other.
Physical causes of erection problems
90% of men with ED have at least 1 underlying physical cause. Starting with the most common, these include:
- – about 40% of men with ED have a condition that affects the heart or blood vessels. To get hard, lots of blood has to flow into your penis. So anything that affects blood flowing well – such as or clogged arteries () – can cause erection problems. In fact, some research suggests ED should be treated as an early warning sign of cardiovascular disease, or a sign that it’s getting worse in men who’ve already been diagnosed
- – having this blood sugar condition means you’re 3 times more likely to get ED. This can be due to limited blood flow to your penis, damage to the nerves and blood vessels, or a side effect of medication
- - ED is common in men with kidney disease, and there are a few reasons for this. CKD may have an effect on hormone and sperm production, plus it often goes hand-in-hand with cardiovascular disease. It can trigger higher prolactin, and it’s linked with low mood. Men with CKD tend to develop problems with their erection at a younger than average age
- low testosterone – levels of this ‘male’ hormone can affect your sex drive and function. It gradually drops by 1% to 2% a year from when you’re in your 40s. But low levels can also be caused by other things, including , alcoholism, chronic illness and cancer treatments
- high prolactin – high levels of this hormone can happen as a side effect of some medications or if you have a non-cancerous (benign) tumour called a microadenoma on your pituitary gland. It’s not usually dangerous, but can affect your sex drive and erection
- taking certain medications – some medicines are linked to low sex drive and erection problems, including some , and those used for high blood pressure
- taking recreational drugs – such as cocaine and heroin
- neurological problems – things that damage the nerves involved in erections can cause ED, including conditions such as , spinal cord damage, or pelvic surgery or trauma
- problems with your penis – anatomical problems that can cause ED include a tight foreskin and Peyronie’s disease, where scar tissue builds up under the skin of your penis and causes it to bend. It’s more common with age and if you have other conditions, such as diabetes or an autoimmune condition
Psychological causes of erection problems
ED is more likely to have an emotional cause if you only have erection problems in certain situations. For example, you get an erection at night or when you masturbate, but not when you’re with a partner.
It’s worth thinking about whether anything that’s happened in your life might have left you with emotional problems around sex. This might include:
- getting negative messages about sex when you were a child
- having a traumatic sexual experience
- being in an unhappy relationship
- pressure from a partner to perform
- using too much porn - this can make it difficult for you to get aroused with a real-life partner
There’s also some evidence that ED can be linked to mental health conditions such as depression or anxiety. Here’s what you need to know:
- can raise your risk of ED by 39%, according to an analysis of studies. The analysis also found that having ED can nearly triple your chances of having depression
- it’s thought that because depression can cause negative thinking and low confidence, it can lead to performance anxiety – when you feel so worried about getting an erection that this actually stops you getting or staying hard
- depression can also stop your body making enough of the substances that relax the smooth muscle in the chambers of your penis, allowing it to fill with blood
- antidepressants can be linked with ED, and low testosterone can play a role in both ED and depression
- disorders can also raise the risk of ED, a review of studies found. But scientists can’t say for sure whether anxiety actually causes ED. There’s a lot of overlap between anxiety and depression, along with other mental health conditions, so it can be hard to work out which condition is causing problems, and more research is needed
If you think there’s an emotional reason behind your erection problems,
, so they can rule out physical causes.
How to revive your sex life when you have ED
Certain lifestyle factors - like smoking, drinking too much, being inactive and being overweight - are linked with erection problems. And whatever the cause of ED, lifestyle changes can sometimes make a big difference. Losing any excess weight and getting active may reduce the risk of ED by as much as 70% – so try to make these things a priority.
- avoiding smoking can help improve the health of your arteries so blood flows to your penis properly – get tips on how to
- keeping to a healthy weight – this can help blood flow to your penis by reducing blood pressure and lowering cholesterol. Read about
- getting active helps to lower blood pressure and cholesterol, plus it can help indirectly by easing stress and boosting mood – check out
- avoiding too much alcohol. Alcohol interferes with the messages in your brain that tell your penis to get hard. It can also temporarily lower testosterone production. Read our
- eating a helps keep cholesterol and blood pressure to healthy levels, and can also improve energy and mood
- reducing , which can affect your hormones and the way blood flows to your penis, and have an impact on your mood and sex drive
As well as being good for your overall wellbeing, these steps can also help with underlying cardiovascular problems such as high blood pressure and
Natural treatments for erection problems
Interested in trying nutritional or herbal supplements to help? “You may have heard about certain supplements that claim to help you get hard - some may even be described as ‘herbal Viagra’,” says
, doctor and Healthily expert. “Unfortunately, though, we don’t have enough evidence to show they help, or whether they actually do harm.” Here are some of the supplements people try for erection problems.
- CBD - a component of the cannabis plant that doesn’t get you high - is showing some promise for helping anxiety but so far studies have been small and only carried out in healthy people. There isn’t research to show CBD could help directly with ED
- DHEA is a substance found naturally in our bodies, which helps produce sex hormones, and it gets lower naturally with age. In the US, you can get supplements in health stores but it’s not available in the UK. The jury’s out on whether DHEA supplements can help with erections, though. Some small studies have suggested it might, but others haven’t backed this up - more research is needed
- ginseng is a herb that’s been used for centuries in traditional Chinese medicine for a range of conditions, including low libido and ED. However, research hasn’t shown it has any benefits for erection problems
- L-arginine is an amino acid that may be low in people with ED - which is why some try taking it as a supplement to help. Research is needed to show whether taking a supplement can actually make a difference, though
- Ginkgo biloba has been said to help with erection problems because it’s used traditionally to improve circulation. But so far, research hasn’t backed up its use for any health condition and has found some side effects and interactions with other medicines
What you need to know about supplements for ED
“There isn’t enough evidence for doctors to recommend supplements for erection problems, and you could end up spending a lot of money on things that don’t work,” says Dr Adiele Hoffman. “It’s also worth remembering that just because something’s natural, it doesn’t mean it’s safe - so you should never take a supplement without checking with your doctor or pharmacist first, especially if you’re taking medicines for other conditions. On top of that, some products advertised as ‘herbal Viagra’ have been found to contain medication that should be prescribed by a doctor so you may not know what you’re taking. And as erection problems can be signs of serious underlying conditions, you should always see your doctor to rule these out, rather than taking supplements.”
When to see a doctor
You should see your doctor if you’ve had ED for more than a few weeks or it’s really affecting you. It may be a sign of an underlying health problem, which could become more serious if it isn’t managed – but will usually be treatable once it’s diagnosed.
The thought of talking to your doctor about erection problems might feel embarrassing. But remember that ED is a very common problem. And putting off seeing a doctor is likely to mean the problem (and any underlying conditions) will get worse.
If you don’t feel comfortable talking to your usual doctor, you might find it easier to make an appointment at a sexual health clinic as a first step. They can direct you to further help. The doctors at these clinics are specialists in sexual health, and the experience can feel more anonymous.
You can also try using our
to help you understand what’s going on, and to help you explain things to your doctor.
Dr Adiele Hoffman shares her tips to help you during your appointment:
- if you have a partner, think about whether you’d like them to go with you. You may find it easier to go on your own, but it can be helpful to have support – it’s up to you
- write down what you want to say in advance, so you don’t get overwhelmed when you’re with your doctor
- you could start by saying you want to talk to them about something you find embarrassing. They’re likely to reassure you that they’ve heard it all before, and may prompt you with a question, which can make things easier
- you can get your report emailed to you, so you could show this to your doctor – or show them this page and say you think this is your problem
How is ED diagnosed?
Your doctor’s assessment will usually involve:
- questions – to get a full picture of what’s been happening, they’ll ask about your symptoms, relationships and sexual history, diet and lifestyle
- an examination – this could include measuring your height, weight and waist, listening to your heart and lungs, and checking your genitals
- tests – they’re likely to do a blood pressure check, along with blood tests for cholesterol, blood glucose (to check for diabetes) and testosterone levels
Erectile dysfunction treatment
The good news is that lots of advances have been made in recent years, and ED can usually be successfully treated.
Lifestyle changes are key, but depending on any underlying cause, your doctor may suggest other treatments. These could include tackling any underlying physical and emotional issue, treating erection problems directly with medication and having sex therapy.
Treating underlying issues
- cardiovascular disease – this may be treated with prescribed medicines and lifestyle changes to lower cholesterol or blood pressure
- diabetes - your doctor will help you control this with changes to your diet, exercise and medication if needed
- hormonal problems – these can be treated with replacement testosterone or medication to lower your levels of prolactin
- anatomical problems with the penis – treatment may include injections to break up scar tissue for Peyronie’s disease, or for a tight foreskin
- psychological issues – if conditions such as depression and anxiety are contributing, you may be referred for counselling
- medications – your doctor will review any medication you’re taking for other conditions and if possible, will change anything that might be affecting your ability to get an erection
Treating erection problems with medication
medicines called phosphodiesterase inhibitors are often prescribed, if any underlying causes have been treated and lifestyle steps aren't helping. They include sildenafil (Viagra) and work by improving blood flow to your penis. They need to be taken about an hour before sex. (You can also get them from a pharmacy in the UK).
- your doctor may suggest a medicine called alprostadil, which can be applied as a cream on the skin, inserted into the urethra (pee hole) as a pellet or injected into the shaft of your penis, if other treatments don’t work. This is the same as the chemical your erect penis makes naturally – it helps blood to flow into the penis and stay there. Alprostadil can also be inserted into your pee tube (urethra) as a pellet, or applied as a cream
- vacuum pumps that draw blood into the penis can be helpful for some people. A ring is placed at the bottom of the penis to help keep the blood in place
- pelvic floor exercises might be helpful for a small number of people with ED, some research suggests. These strengthen the muscles below your bladder and bottom (anus), and at the base of your penis. Your doctor may refer you to a physiotherapist to learn how to do them
- in rare cases, if other treatments don’t help, you may need a surgically implanted device that strengthens your penis from inside
Solving ED with sex therapy
Sometimes, sex therapy can help with erection problems. It may sound a bit intimidating but lots of people find it can make a big difference to sex issues - so it could be worth exploring.
- sex therapy is a specific type of talking therapy for sexual problems, which may be helpful if emotional or relationship issues are contributing to your ED
- you can have sex therapy on your own or with your partner, and it can be used alongside other treatments
- a therapist will help you identify triggers for sex problems and will create a programme of treatment to help
- that may involve things like learning to communicate better about what you both like, and having more physical intimacy that doesn’t involve sex, so you feel closer without the pressure
- sex therapy can help you develop a healthier attitude to sex and learn to communicate better with your partner
Your health questions answered
By Dr Ann Nainan
Can cycling cause erection problems?
“There may be a connection because spending a lot of time in the saddle can potentially damage nerves and put pressure on arteries in your penis, which can contribute to ED. A study found this was more likely in men who spend over 3 hours a week cycling - cycling less than this didn’t have an impact. If you’re having erection problems and you cycle a lot, it’s certainly something that’s worth thinking about. Any damage is thought to be temporary so you could try avoiding cycling for a short time to see if it makes a difference. If you don’t want to do that, making some adjustments could help - for example, having a broader, gel filled saddle, and having handlebars higher than the saddle. A specialist bike store should be able to advise you. Overall, cycling’s good for weight management and the health of your heart and blood vessels, so it’s important to weigh up the benefits against any potential risks.”
Why can I get an erection when I masturbate but not with a partner?
“There can be pressures and concerns when you’re intimate with a partner that aren’t there when you’re pleasuring yourself. For example, any problems with your relationship can creep into the bedroom. If you don’t feel emotionally safe with a partner, that can have an impact, too. You may feel under pressure to perform or you may like different things sexually. These are just a few examples of many things that can affect your sex drive and erection with a partner, and explain why you don’t have problems with your erection when you’re masturbating. You should still start by having a physical check-up, to rule out underlying problems. Then try to think about what’s affecting you with your partner, and talk about it with them if that feels safe, or consider sex therapy.”
Think your partner might have ED? Read our .