Impotence (or erectile dysfunction)

What is erectile dysfunction?

Erectile dysfunction, sometimes called impotence, is when you're unable to get an erection, or can't keep one long enough for sex. It's very common, particularly in men over 40, and is usually nothing to worry about.

Symptoms of erectile dysfunction

The main sign is difficulty getting or keeping an erection firm enough for sex, though this can show up differently from man to man. You might notice:

• being unable to get an erection at all
• getting an erection but not being able to keep it long enough for sex
• erections that gradually lose their firmness or don't last as long as they used to
• problems that come on suddenly, or develop gradually over time
• a lower sex drive alongside your erection problems.

Depending on the cause, you may still get erections at other times, such as when you wake up, and orgasm is usually still possible even without a full erection.

Causes of erectile dysfunction and who is at risk

Most men occasionally fail to get or keep an erection, usually because of stress, tiredness or drinking too much alcohol. This is nothing to worry about and can also be a side effect of some medicines.

If it happens often, it's usually caused by a physical condition, a psychological factor, or a mix of both. Common causes include:

• vascular disease, which narrows or hardens the blood vessels and reduces blood flow to the penis – this is the most common medical cause
• nerve damage, from conditions such as diabetes, multiple sclerosis, prostate or pelvic surgery, or spinal cord injury
• high blood pressure or high cholesterol
• diabetes, which can damage both the nerves and blood vessels involved in getting an erection
• hormone problems, such as low testosterone, though this is a less common cause
• psychological factors, such as depression, anxiety, stress, guilt or performance anxiety
• medicines, including some for blood pressure, depression and prostate cancer, as well as some recreational drugs
• lifestyle factors such as smoking, drinking more than recommended, or long-distance cycling.

Erectile dysfunction is common, affecting around half of men aged 40 to 70. It's even more common in men with diabetes.

Are there different types of erectile dysfunction?

Erectile dysfunction isn't classified into distinct medical types, but it can show up in different ways. You might find you're unable to get an erection at all, that you can get one but can't keep it firm enough for sex, or that you have difficulty ejaculating.

The underlying cause is usually physical, psychological, or a mix of both, and this affects which treatments are likely to help you.

How erectile dysfunction is diagnosed

Your doctor will ask about your lifestyle, relationships, medicines you take, and how your symptoms started and developed. They'll usually check your blood pressure, weight and heart rate, and examine your genitals to rule out an obvious physical cause.

You'll likely have blood tests to check your blood sugar, cholesterol and hormone levels. If you have symptoms like needing to pee more often, you may also have a prostate examination.

Occasionally, further tests are used, such as monitoring your erections overnight or an ultrasound scan of the blood flow in your penis.

How erectile dysfunction is treated

Lifestyle changes and non-surgical treatment

Healthy lifestyle changes can sometimes help, such as:

• losing weight if you're overweight
• stopping smoking
• eating a healthy diet and exercising daily
• reducing stress and anxiety
• drinking no more than 14 units of alcohol a week
• cutting back if you cycle for more than 3 hours a week.

Medicines called PDE5 inhibitors, including sildenafil, tadalafil, vardenafil and avanafil, increase blood flow to the penis and are the most popular treatment. They work for most men, though they're less effective if your erectile dysfunction has a nerve-related cause. Sildenafil is available from a pharmacy without a prescription, but the other types need one.

If a specific cause is found, this can sometimes be treated directly, for example by switching a medicine that's causing the problem, treating high blood pressure or hormone problems, or having counselling or therapy if your symptoms are linked to your emotional or mental health.

Other options include:

• self-injection therapy, where you inject a drug into the side of the penis before sex – this can be used up to twice a week
• MUSE, a small pellet of medicine inserted into the urethra, which is effective in around 35 to 40% of men
• a vacuum pump, which draws blood into the penis using suction, then holds it in place with a constriction ring for up to 30 minutes – this works for most men and is safe, though it's not always available on the NHS.

Surgical treatment

If other treatments haven't worked, options include:

• a penile implant, where two rods are surgically placed inside the penis; these are permanent, and can be semi-rigid or inflatable
• vascular surgery, sometimes used in younger, healthy men whose erectile dysfunction follows an injury to the groin.

Penile implants aren't usually available on the NHS, and inflatable versions can be expensive privately, though around three-quarters of men are satisfied with the results.

When to see a doctor

See a GP or a sexual health clinic if erection problems keep happening. There's no need to feel embarrassed, since it's a common condition, and it's important to check for any underlying cause that can be treated.

Sexual health clinics offer the same treatment as a GP, often with a walk-in service and faster test results.