Erectile Dysfunction: Everything You Need to Know

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In an ideal world, sex would be a perfect experience every time. Things, however, often aren’t as wonderful as they could be. For men, erectile dysfunction (ED) is often a frustrating condition that can put strain on relationships and your self-esteem. And although ED is a common condition affecting millions of men in the UK, the stigma attached to it means many sufferers delay treatment in fear of embarrassment.

In this guide, we set out to dispel the myths and negativity associated with erectile dysfunction by telling you all you need to know about ED and the numerous ways to treat it. If you’re suffering from this common condition or just want to know more about it, read on.

What is erectile dysfunction?

Erectile dysfunction - also known as impotence - is a condition in which a man struggles to achieve or maintain an erection long enough for sexual intercourse. Despite being the most common sexual disorder in men, ED can cause significant harm to the mental health of those that suffer it because of its associations with self-image and relationship difficulties. Many men and couples do not seek treatment due to feelings of embarrassment. As a result, an estimated 75% of ED cases go untreated.

To diagnose ED, your GP will usually ask you a series of questions related to your sexual health. If your GP decides further investigation is needed, there are a number of tests that can clarify the cause of your ED, including injection tests, ultrasounds and attempts to identify any venous leakages that could be a contributing factor. If you struggle to get an erection during sex, but are not sure if you can achieve an erection at all, you can conduct your own at-home erectile dysfunction test. The Nocturnal Penile Tumescence (NPT) test works by taping a piece of thin paper (or even a ring of postage stamps) around the shaft of your penis before going to bed, and if you get an erection in the night, the paper should tear. This can help indicate whether you had an erection, which helps to determine whether your ED has a physical or psychological cause.

Being diagnosed with ED is often a troubling experience for men. But if you’ve been diagnosed with ED and are feeling some level of hopelessness, it is extremely important to remember a few things:

1. You’re not alone - ED is an extremely common condition and the most common sexual disorder in men
2. The condition is extremely treatable - since Viagra became available as a prescription medication in the late 1990s, a host of highly effective medicinal and non-medicinal treatments for ED have been developed
3. If one treatment doesn’t work for you, it is overwhelmingly likely another one will
4. If the idea of taking ED medication on an ad hoc basis is uncomfortable to you, there are medications that can be taken daily that treat the condition effectively

What causes erectile dysfunction?

Among the first questions you might ask after your difficulties with ED are: why me? What could have caused it? There are a variety of erectile dysfunction causes both physical and psychological, so investigating the cause is a crucial stop on the road to treatment.

One of the things you might hear in everyday conversations about ED is that the condition is “all in your head”. Let us be clear: this is simply not the case. In fact, the cause of ED in men is overwhelmingly physical: 80% of diagnosed cases of ED are caused by an underlying physical condition. Psychological impotence, on the other hand, is far rarer in comparison, accounting for about 10% of cases.

For physical cases of ED, there are a number of underlying causes. Among the most common are cases caused by the side effects of prescription medication: antidepressants (SSRIs), beta blockers, DHT blockers, thiazides, alpha-2 adrenergic receptor agonists and hormone medications can all make it more difficult for men to achieve or maintain an erection. Diabetes and cardiovascular disease can also cause difficulties getting an erection, as well as neurological problems caused by prostatectomies and hypogonadism.

In psychological cases, people with ED usually find they get erections in the mornings, but not during sexual activity. There are a number of factors that can contribute to psychological ED: anxiety, depression, childhood trauma and abuse are among the psychological causes of ED in men.

What are the biggest myths associated with erectile dysfunction?

There are countless myths and negative associations connected with ED - and it’s important to do your best to ignore them and focus on getting better. That said, here’s a short list of the most common ones and their corrections - so you know the facts.

ED only affects older men
This is among the most common myths associated with ED. There’s plenty of talk about ED being a condition that only affects older men, but that simply isn’t the case. While ED is significantly more common in older men, it can affect men of all ages, old and young. In fact, a 2013 study^[1] published in The Journal of Sexual Medicine found 26% of men under the age of 40 suffered some form of ED, and half of those had a severe form of the condition.

ED is all in your head
Simply untrue. As we explained previously, psychological causes account for a very small proportion of ED cases. In an overwhelming majority of cases, ED is caused by physical factors.

ED treatments are dangerous
Again, untrue. In fact, PDE5 inhibitors such as Viagra (sildenafil) are generally tolerated extremely well by the vast majority of men who take them. ED treatments are safe as long as they are taken safely - and that means taking them as your GP or pharmacist has directed.

ED is caused by watching too much pornography
One popular explanation for ED in recent years is that it is induced by watching too much pornography. The overstimulation caused by viewing pornographic material, the explanation goes, causes men to become desensitised to arousing situations. But the evidence simply doesn’t stack up: a 2019 study^[2] by Bowling Green State University academics found that there was “no evidence that mere pornography use is associated with changes in erection function”.

ED means you’re low on testosterone
A number of websites claiming ED is caused by low levels of testosterone - or what is often referred to as “low-T” - have emerged in recent years. But the fact is erection troubles can happen in men regardless of their testosterone levels, and simply undergoing testosterone treatment is unlikely to help your ED. If you’re concerned about your testosterone levels, you should see your GP.

How can I cure erectile dysfunction?

If you find yourself wondering “can erectile dysfunction be cured”, it’s perhaps beneficial to reframe the question. Unfortunately, a true erectile dysfunction cure doesn’t yet exist - despite plenty of websites claiming to have one. The better question to ask is whether ED can be treated - and the answer is emphatically yes.

Since Viagra exploded onto the market in 1998, a number of effective treatments for ED have become available for men to use. And the good news doesn’t stop there - for all the popular branded treatments for ED, there are also generic alternatives that are just as effective, and yet usually far cheaper.

The most popular treatment for ED in the UK is sildenafil citrate, which is the active ingredient in Viagra. Sildenafil is a hugely popular treatment for ED: every minute, six NHS prescriptions are written for the generic version of Viagra in the UK. That amounts to more than 3.5 million prescriptions for sildenafil a year.

It’s now easier than ever before to get access to sildenafil for the treatment of ED thanks to Viagra Connect, the first over-the-counter erectile dysfunction pills available without a prescription. It contains the same active ingredient Sildenafil, but is currently only available at the standard dose of 50mg.

The reason sildenafil is prescribed so widely is simple: it works. Studies have shown the drug to be highly effective in treating ED in men, with 75% of cases improving upon taking the drug. In addition, while there are plenty of myths that question the safety of sildenafil, the reality is that it is usually very well-tolerated by men who take it properly. There are, of course, circumstances where you should check with your GP before using sildenafil or any other ED medication. We’ve listed these further below.

How does Viagra (sildenafil) work?

Like most other ED treatments, sildenafil belongs to a class of medications known as phosphodiesterase 5 (PDE5) inhibitors. PDE5 is an enzyme that promotes the breakdown of cGMP, a cyclic nucleotide that regulates blood flow to the penis. By preventing PDE5 from degrading cGMP, the increased amount of cGMP creates a vasodilator effect, widening the blood vessels and relaxing the muscles around the penis. This helps blood better reach the penis, thereby helping men achieve or maintain an erection.

Sildenafil tends to take effect around half an hour after it is taken and lasts up to four hours (although in most cases it lasts around two hours). There are, however, considerations to make before taking it. Smoking and drinking alcohol are both significant contributing factors to sexual dysfunction, and can therefore make the medication less effective. In addition, the drug comes in three different doses - 25mg, 50mg and 100mg - so it’s important to find the right dosage for you. Finally, sildenafil is always taken on an as-needed basis. This is not common across all ED medications - but sildenafil should not be used if you do not plan to have sex.

Alternative ED treatments tend to function in a very similar way to sildenafil, relaxing the muscles to increase blood flow to the penis. Where they differ, however, is in duration, time to take effect, and whether the medication is taken daily or as-needed. One exciting potential benefit of Sildenafil usage is its relationship with Alzheimer’s disease - one recent study found that taking sildenafil was linked to a 69% reduced risk of developing Alzheimer’s. More research is required before more definitive conclusions can be drawn about the relationship between this popular ED treatment and the most common form of dementia, but this study is promising. Here you can read more about whether Sildenafil could help prevent Alzheimer’s disease.

What are the alternatives to Viagra (sildenafil)?

After Viagra hit pharmacies in the late 1990s, pharmaceutical companies got to work researching and developing alternative treatments that had a similar effect. In recent years, the most popular prescribed alternatives have been:

• Cialis (tadalafil)
• Levitra (vardenafil)
• Spedra (avanafil)

All these treatments belong to the same family of medication as sildenafil, and work in similar ways. But the duration and time to effect of each are different, and in the case of tadalafil, how you take it.

How does Cialis (tadalafil) work?

Like sildenafil, tadalafil belongs to the PDE5 family of medications. Tadalafil relaxes the muscles in the penis and prostate, aiding blood flow to the penis. This makes it easier for a man to maintain and achieve an erection. Cialis, the branded version of tadalafil, came to market five years after Viagra did, in 2003. In the UK, generic tadalafil didn’t become available until November 2017, when the exclusive license to produce it owned by pharma giant Lilly ended.

While tadalafil’s mechanism of action is almost identical to sildenafil, its duration is very different. While sildenafil will only be effective up to four hours after it is taken, tadalafil can last up to nine times as long, with a duration of up to 36 hours. This is how tadalafil came to be known as the “weekend pill”.

The greatly extended duration of tadalafil means it does not have to be taken on an ad hoc basis for it to be effective. In fact, the drug comes in four different doses. The first two - 10mg and 20mg - are the higher doses, and are usually taken as needed. The other two, however - 2.5mg and 5mg - are taken daily to ensure a continuous effect. This means you do not have to worry about having your medication with you every time you’re about to have sex. It works in exactly the same way as any normal daily treatment.

In addition to its use as an ED treatment, tadalafil is also an effective treatment for a number of different illnesses. It is commonly prescribed for patients suffering from pulmonary hypertension (heart- and lung-related high blood pressure), as well as men who have benign prostatic hyperplasia (enlarged prostate). Because prostate conditions and ED often go hand-in-hand, tadalafil is an effective way to treat both at the same time.

How does Levitra (vardenafil) work?

Like the previous two medications, vardenafil is another PDE5 inhibitor. It increases blood flow to the penis, thereby making it easier to achieve and maintain an erection. Like tadalafil, vardenafil came to market in 2003 under the brand name Levitra. In October 2018, Levitra’s patent expired, enabling the production of generic versions of the medication.

Vardenafil’s duration and time to effect are much more similar to that of sildenafil than tadalafil. After it is taken, the medication typically takes effect in 25-60 minutes. The treatment will remain in the body around 4-5 hours after use, meaning vardenafil should be used on an as-needed basis, rather than daily.

How does Spedra (avanafil) work?

Another PDE5 inhibitor, avanafil belongs to the same family of medications as the previous three treatments and works by increasing blood flow to the penis. Compared to the other three treatments, avanafil is much newer - the drug came to market in 2012 under the brand names Spedra and Stendra. Unlike the other ED treatments in this guide, avanafil does not currently come in a generic version because its patent has not yet expired.

As ever, avanafil is an effective treatment for ED in much the same way sildenafil, tadalafil and vardenafil are. Its unique characteristic, however, is the time it takes to work. While other PDE5 inhibitors typically take 30-60 minutes to take effect, avanafil works much faster, with an effective time of just 15 minutes. Avanafil’s rapid acting time is said to have been the inspiration behind its trade name.

In addition to its fast-acting effects, avanafil has also been shown to address a number of issues associated with older - or what are otherwise known as ‘first-generation’ - PDE5 inhibitors. The treatment’s unique pharmacological profile, according to a 2015 study^[4] published in Expert Opinion on Drug Safety, should reduce the incidence of side effects associated with older ED treatments. If you’ve suffered side effects when taking other ED treatments, it’s possible avanafil might be the right medication for you.

Which erectile dysfunction treatment is best?

Although each of the PDE5 inhibitors mentioned above have been shown to be effective in treating ED, the fact is no one treatment will work for everyone. Instead of asking which ED treatment is best, it might be better to ask which ED treatment is best for you. Finding the answer to that question might mean simply trying one, and if it doesn’t work, moving on to the next. It’s important to reiterate that treating ED is similar to treating many conditions: there is no one-size-fits-all approach. That said, here’s what the clinical studies say about the efficacy of these ED treatments:

• Viagra (sildenafil) - shown by studies to be effective in up to 75% of cases of ED
• Cialis (tadalafil) - shown by studies to be effective in up to 81% of cases of ED
• Levitra (vardenafil) - shown by studies to be effective in up to 63% of cases of ED
• Spedra (avanafil) - shown by studies to be effective in cases of moderate to severe ED

These are the results the academic research shows. But as a patient, don’t forget: the most important thing is finding a treatment that works for you.

What are the side effects of erectile dysfunction treatments?

Although ED treatments are typically well-tolerated by most people who take it, some will experience side effects. These commonly include:

• Headache
• Flushing
• Nasal congestion
• Common cold symptoms
• Indigestion

Rare but serious side effects of PDE5 inhibitors include erections lasting longer than four hours. This can lead to a condition called priapism, which can cause permanent impotence. If you experience a painful erection, or an erection that lasts longer than four hours, seek help from your local emergency department immediately.

When should I not take erectile dysfunction treatments?

You should consult your doctor before taking ED treatments if you:

• Have a heart problem
• Have a stomach ulcer or bleeding problem like haemophilia
• Have a penis deformity such as Peyronie’s disease (curved penis)
• Have sickle cell anaemia

You should not take PDE5 inhibitors if you:

• Have had an allergic reaction to one in the past
• Are taking nitrates for chest pain
• Have a serious heart or liver condition
• Have recently suffered a stroke or heart attack
• Have low blood pressure
• Have a rare inherited eye disease, such as retinitis pigmentosa

How effective are natural remedies for erectile dysfunction?

There are plenty of herbs available to purchase in store and online that promise to cure or treat ED. But the fact is, these products are often unregulated and have scant scientific evidence to support their efficacy. In addition, herbal remedies for ED could have adverse effects both sexually and elsewhere in the body. The safest and most reliable treatments for ED are ones that are regulated and licensed for use by doctors, walk-in pharmacies and online pharmacies.

How to treat erectile dysfunction naturally

One complementary approach for combating ED, that does have some scientific support, is doing erectile dysfunction exercises such as improving the control of the pelvic floor muscles. This has shown to boost erectile function and can be achieved with simple Kegel exercises. To try this yourself, start by identifying and getting a feel for your pelvic floor muscles - you can do this by stopping and releasing your urine flow mid-wee. Next, isolate your pelvic floor muscles by imagining you’re pulling your genitals inwards, trying not to tense other muscles. Squeeze and hold your pelvic floor muscles for 3-5 seconds, and then repeat this 10 times, doing a few sets each day. You can do this wherever you are, and trying it in different positions (lying down, seated, standing etc.) will help you see the biggest improvement. If you make this a habit, you can expect to improve erectile functioning in 4 to 6 weeks. Be aware that this method does not have the same efficacy rate that erectile dysfunction tablets have, but it can certainly help to complement your medication with this practice.

An area that you may not have considered impacting ED is your diet, and there are certain foods which may help to promote normal erectile functioning. Foods for erectile dysfunction include spinach which is rich in nitrates which have a vasodilating effect, so potentially improves the blood flow to the penis. Oats contain the nonessential amino acid L-arginine that can help relax the muscle lining on the blood vessels which aids with blood flow. Check out our ED Foods infographic to learn about 8 more erection-boosters for your diet!

Do steroids affect you sexually?

If you’re taking steroids medicinally, you should speak to your GP about any sexual concerns you have. If you’re taking steroids recreationally or as part of a fitness regimen, however, it’s very important to know that injections of testosterone and anabolic-androgenic steroids can have serious repercussions on your long-term sexual health. While your sex drive and performance may remain high while taking steroids, studies^[5] show that upon discontinuing them ED and severely reduced libido can occur.