Erectile dysfunction (impotence)

If you have erectile dysfunction (ED), treatment will depend on what’s causing it. The various treatments for erectile dysfunction are outlined below. 

Treating underlying conditions

If your erectile dysfunction is caused by an underlying health condition, such as heart disease or diabetes, that condition may need to be treated first. In some cases, treating the underlying cause may also resolve the problem.

If you are taking medication that can cause erectile dysfunction, there may be an alternative. It is important never to stop taking a prescribed medication unless you are advised to do so by your GP or another qualified healthcare professional responsible for your care.

Lifestyle changes

Erectile dysfunction can often be improved by making changes to your lifestyle, such as:

• losing weight if you are overweight   
• giving up smoking
• cutting back your alcohol consumption 
• not taking illegal drugs 
• exercising regularly 
• reducing stress 

As well as helping to improve your erectile dysfunction, these changes can also improve your general health and may help to reduce your risk of cardiovascular disease (conditions that affect your heart and blood vessels).

Read more about preventing cardiovascular disease  

Phosphodiesterase-5 (PDE-5) inhibitors

Phosphodiesterase-5 (PDE-5) inhibitors are one of the most widely used and effective types of medication for treating erectile dysfunction. They work by temporarily increasing the blood flow to your penis.

In England, four PDE-5 inhibitors are available for treating erectile dysfunction. They are:

• sildenafil – sold under the brand name Viagra 
• tadalafil – sold under the brand name Cialis
• vardenafil – sold under the brand name Levitra
• avanafil – sold under the brand name Spedra

Sildenafil, vardenafil and avanafil work for about eight hours and they are designed to work ‘on demand’. Tadalafil lasts for up to 36 hours and is more suitable if you require treatment for a longer period of time, for example, over a weekend.

Depending on the type of PDE-5 inhibitor you are taking and the dose, it should take about 30-60 minutes before it starts to work. With sildenafil, vardenafil and avanafil, you should be able to have sex from one to 10 hours after taking the medicine. After taking tadalafil, the effects will last for up to 36 hours.

It may take longer to notice the effects if the tablet is taken with food, so it’s best to take it on an empty stomach. You can then eat after an hour without affecting the medicine.

Only take one tablet within a 24-hour period.

Your GP should explain the benefits of each medication and how it works. The choice may depend on:

• how often you are sexually active 
• whether you have tried any of the medications before

There have been many studies to test the effectiveness of these medications. In general, at least two-thirds of men report having improved erections after taking one of these medicines.

If you do not find that PDE-5 inhibitors are effective it may be because:

• you have not waited long enough after taking the dose
• you have waited too long after taking the dose
• the dose is not high enough
• you have not had enough sexual stimulation

These medications are triggered by sexual stimulation, so you also need to be aroused for it to work.

Warnings

PDE-5 inhibitors should be used with caution in men who have cardiovascular disease, such as coronary heart disease. However, sexual activity is also likely to be beneficial for your cardiovascular health. You should discuss the risks and benefits with your GP.

PDE-5 inhibitors should also be used with caution in men who have anatomical problems with their penis, such as Peyronie’s disease (a condition that affects the tissue of the penis).

PDE-5 inhibitors should also be used with caution in men who:

• are at risk of priapism – a painful erection that lasts for several hours
• are also taking long lasting alpha-blockers – a medication used to treat a number of conditions, such as high blood pressure (hypertension)

Do not take PDE-5 inhibitors if you are also taking medicines or recreational drugs that contain nitrates. The combination of the two substances can have a dangerous effect on your heart.

Organic nitrates are often used to treat angina, and butyl nitrate is a recreational drug that is more commonly known as ‘poppers’.

You are also warned not to take PDE-5 inhibitors if you:

• have been advised not to take part in sexual activity or in activities that widen your blood vessels 
• have low blood pressure (hypotension) 
• have recently had a stroke – a medical emergency that occurs when the blood supply to the brain is interrupted
• have unstable angina – an underlying heart condition that causes symptoms such as chest pain
• have had a heart attack – a medical emergency where the blood supply to the heart is suddenly blocked
• have a history of non-arteritic anterior ischaemic optic neuropathy – an eye condition that causes a sudden loss of vision

Side effects

PDE-5 inhibitors can cause some side effects, including:

• headaches and migraines
• flushing (redness) 
• indigestion
• nausea (feeling sick)
• vomiting (being sick)
• a blocked or runny nose
• back pain
• vision disturbances
• muscle pain

Vacuum pumps

A vacuum pump consists of a clear plastic tube that is connected to a pump, which is either hand or battery operated.

You place your penis in the tube and pump out all of the air. This creates a vacuum that causes the blood to fill your penis, making it erect. You then place a rubber ring around the base of your penis to keep the blood in place, allowing you to maintain an erection for around 30 minutes.

It may take several attempts to learn how to use the pump correctly, but they are usually effective. After using a vacuum pump, nine out of 10 men are able to have sex, regardless of the cause of their ED.

Considerations 

You should not use a vacuum pump if you have a bleeding disorder or if you are taking anticoagulant medicines, which reduce the ability of your blood to clot.

Side effects of vacuum pumps include pain or bruising, although these occur in less than a third of men.

Men who qualify for NHS prescriptions for erectile dysfunction treatments may be able to get a vacuum pump on the NHS (see above for more details). However, some men will need to buy one.

The Sexual Advice Association produces a number of factsheets, including one on vacuum pumps that provides details of companies that supply them.

Alprostadil

If your erectile dysfunction doesn’t respond to treatment, or you are unable or unwilling to use PDE-5 inhibitors or a vacuum pump, you may be given a medicine called alprostadil. This is a synthetic (man-made) hormone that helps to stimulate blood flow to the penis.

Alprostadil is available as:

• an injection directly into your penis – this is called an intracavernosal injection
• a small pellet placed inside your urethra (the tube that carries urine from your bladder to the tip of your penis) – this is called urethral application

You may be trained to correctly inject or insert alprostadil. If your partner is pregnant, use a condom during sex if you are inserting alprostadil into your urethra.

Alprostadil will usually produce an erection after five to 15 minutes. How long the erection lasts will depend on the dose.

In men who did not respond to PDE-5 inhibitors, alprostadil injections were successful in 85 out of 100 men. Alprostadil inserted into the urethra is successful for up to two-thirds of men.

Warnings

Alprostadil should not be used:

• in men at risk of priapism (a painful erection that lasts for several hours) – for example, those with sickle cell anaemia
• alongside other erectile dysfunction medications 
• if you have a penile implant or if you have been advised to avoid sexual activity 

Urethral application may also not be used in:

• some men who have anatomical problems with their penis (conditions that affect the physical structure of the penis) 
• men who have infections of their penis, such as balantis (inflammation of the head of the penis)

Side effects

Alprostadil can cause some side effects including:

• changes in your blood pressure
• dizziness
• headache
• pain in your penis 
• urethral burning or bleeding
• reactions at the site of the injection, such as swelling

NHS prescriptions

As with PDE-5 inhibitors, NHS prescriptions for alprostadil may only be available for men with particular health conditions or those receiving some types of medical treatments. If you need to pay the full prescription cost, a single injection of alprostadil costs around £8 to £22, depending on the dose. A single dose of alprostadil for urethral application is around £10. 

Hormone therapy

If a hormonal condition is causing erectile dysfunction, you may be referred to an endocrinologist (who specialises in the treatment of hormonal conditions).

Hormones are chemicals produced by the body. Many hormonal conditions can be treated using injections of synthetic (man-made) hormones to restore normal hormone levels.

Surgery

Surgery for erectile dysfunction is usually only recommended if all other treatment methods have failed. It may also be considered in:

• younger men who have experienced serious injury to their pelvic area – for example, in a car accident
• men with a significant anatomical problem with their penis

In the past, surgery was used if there was clear evidence of a blockage to the blood supply of the penis. The surgeon could unblock the blood vessels to restore a normal supply of blood. However, research now suggests that the long-term results of this type of surgery are poor, so it’s unlikely to be used.

Penile implants

Penile implants are a type of surgery that may be considered. These can be:

• semi-rigid implants – which may be suitable for older men who do not have sex regularly
• inflatable implants – which consist of two or three parts that can be inflated to give a more natural erection

Penile implants are not usually available on the NHS and inflatable implants may be very expensive. However, around three-quarters of men report being satisfied with the results of this type of surgery.

Complications

As with all types of surgery, having penile implants inserted carries a risk of infection. If you take preventative antibiotics, the rate of infection is around two or three in 100. Mechanical problems with the implants may occur within five years in five per cent of cases. 

Psychological treatments

If your erectile dysfunction has an underlying psychological cause then you may benefit from a type of treatment called sensate focus.

If conditions such as anxiety or depression are causing your erectile dysfunction, you may benefit from counselling (a talking therapy).

Sensate focus

Sensate focus is a type of sex therapy that you and your partner complete together. It starts with you both agreeing not to have sex for a number of weeks or months. During this time, you can still touch each other, but not in the genital area (or a woman’s breasts). The idea is to explore your bodies knowing that you will not have sex.

After the agreed period of time has passed, you can gradually begin touching each other’s genital areas. You can also begin to use your mouth to touch your partner, for example, licking or kissing, them. This can build up to include penetrative sex.

Psychosexual counselling

Psychosexual counselling is a form of relationship therapy where you and your partner can discuss any sexual or emotional issues that may be contributing to your erectile dysfunction. By talking about the issues, you may be able to reduce any anxiety that you have and overcome your erectile dysfunction.

The counsellor can also provide you with some practical advice about sex, such as how to make effective use of other treatments for erectile dysfunction to improve your sex life.

Psychosexual counselling may take time to work and the results achieved have been mixed.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is another form of counselling that may be useful if you have erectile dysfunction. CBT is based on the principle that the way you feel is partly dependent on the way you think about things. CBT helps you realise that your problems are often created by your mindset. It is not the situation itself that is making you unhappy, but how you think about it and react to it.

Your CBT therapist can help you to identify any unhelpful or unrealistic thoughts that may be contributing to your erectile dysfunction – for example, to do with:

• your self-esteem (the way you feel about yourself) 
• your sexuality 
• your personal relationships

Your CBT therapist will be able to help you to adopt more realistic and helpful thoughts about these issues.

Pelvic floor muscle exercises

Some studies have suggested that, in a few cases, it may be beneficial to exercise your pelvic floor muscles. These are a group of muscles around the underside of the bladder and rectum, as well as at the base of the penis.

Pelvic floor muscle exercise involves strengthening and training the muscles used to control the anus (back passage) and urinate. If your GP feels this type of exercise could be beneficial, then you may want to discuss it with a physiotherapist to learn it correctly.

By strengthening and training these muscles, you may be able to reduce the symptoms of erectile dysfunction.

Complementary therapies

Some complementary therapies, such as acupuncture, have claimed to treat erectile dysfunction. However, there is little evidence they are useful.

In some cases, they may even include ingredients that could interact with other medications and cause side effects.

Always speak to your GP before using any complementary therapies.