Erectile dysfunction: causes and what helps

Most men occasionally fail to get or keep an erection, the NHS says, usually because of stress, tiredness or drinking too much alcohol. Erectile dysfunction is when it keeps happening, and the NHS says that might be a sign of a health condition that can be treated.

It's also something many men keep to themselves. The British Association of Urological Surgeons (BAUS) says many men live with erectile dysfunction in silence, without seeking help or advice. The MHRA, which regulates medicines in the UK, cites research suggesting two in five men would avoid seeking medical advice for it.

What is erectile dysfunction (ED)?

Erectile dysfunction, or ED, is when you can't get an erection, or can't keep one long enough to have sex. It's also known as impotence. NICE's guidance for GPs describes it as a persistent problem, and as a symptom with many possible causes rather than a disease in itself.

Depending on the cause, you may still get erections at other times, such as when you wake up, the NHS says. NICE's guidance tells GPs to ask about the quality of morning erections (morning wood) when they assess it. Some men also notice a low sex drive alongside erection problems.

How common is erectile dysfunction?

The NHS calls erectile dysfunction very common, particularly in men over 40, and it becomes more common with age. The exact figure depends on how it's measured: BAUS puts it at one man in ten, and studies of older men find more.

• In Britain, the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) interviewed 15,162 people aged 16 to 74 in 2010 to 2012. Of sexually active men, 12.9% had had difficulty getting or keeping an erection for 3 months or more in the past year, from 7.6% of men aged 16 to 24 to 30.0% of men aged 65 to 74. Mild and occasional problems counted.
• Across Europe, the European Male Ageing Study of 3,369 men aged 40 to 79 from eight European centres, including Manchester, found around 30% reported erectile dysfunction, and only 38% of those men were concerned about it.
• In the United States, the Massachusetts Male Aging Study of men aged 40 to 70 near Boston, in 1987 to 1989, found minimal, moderate or complete erectile dysfunction in 52%. Complete erectile dysfunction tripled from 5% to 15% between 40 and 70.

NICE notes that estimates vary with the definitions and methods used, and that erectile dysfunction is probably under-reported to doctors.

What causes erectile dysfunction?

The most common cause is a problem with blood flow to the penis, linked to conditions such as high blood pressure, high cholesterol and diabetes, and to smoking and obesity, according to NICE's guidance for GPs. Hormones, nerves, medicines, alcohol and psychological pressures can play a part too, and most cases have more than one cause.

An erection needs enough hormones, a good blood supply to the penis, healthy nerves and sexual desire, BAUS explains. Nerve signals from the brain relax smooth muscle in the penis, blood flows in, and the veins that would drain it are squeezed shut. If one of these fails, the erection may fail too.

Physical causes

When erection problems happen often, the NHS says the cause may be high blood pressure or high cholesterol, diabetes, depression or anxiety, or hormone problems. NICE's list adds:

• heart and circulation disease, smoking and obesity
• nerve conditions such as multiple sclerosis, Parkinson's disease, a stroke or a spinal cord injury
• surgery or radiotherapy to the pelvis, such as an operation to remove the prostate
• hormone problems such as low testosterone or an overactive or underactive thyroid
• changes in the penis itself, such as Peyronie's disease (which bends the erect penis) or a tight foreskin

BAUS says erectile dysfunction is seen in almost a third of men with diabetes, mostly because of damage to blood vessels and nerves.

Psychological causes

Stress, depression, anxiety, relationship problems, embarrassment and guilt can all cause erectile dysfunction, BAUS says. NICE's list of psychological causes also includes worries about performance and post-traumatic stress disorder.

Worry can keep a problem going. BAUS says a man who has had difficulty getting an erection, whatever the cause, often feels pressure to perform, which can lead to performance anxiety. NICE notes this can develop on top of a physical cause and keep the symptoms going. See our guide to sexual performance anxiety in men.

Medicines, alcohol and drugs

Erectile dysfunction can be a side effect of some medicines, the NHS says. NICE's list includes some blood pressure medicines (such as beta-blockers), some water tablets (such as thiazides), several types of antidepressant, some epilepsy medicines and finasteride, as well as alcohol, cannabis, cocaine, heroin and anabolic steroids.

If you think a medicine is to blame, talk to your GP before changing anything. The NHS says your doctor may switch you to a different medicine, and that you shouldn't stop an antidepressant suddenly or without talking to your doctor first. NICE adds that for most men, treating the underlying condition properly is more likely to help than changing a medicine that might be contributing.

Is it physical or psychological?

Often there's a bit of both, but the pattern gives clues. NICE's guidance for GPs says a sudden start, with good erections that happen on their own or when masturbating, points towards a psychological cause. A gradual start with little or no swelling of the penis points towards a physical one.

BAUS says a purely psychological cause is found in fewer than 1 in 10 men with erectile dysfunction, though a mix of the two is common. Our guide to morning wood explains what erections on waking can and can't tell you.

Is erectile dysfunction an early sign of heart disease?

It can be. NICE's guidance for GPs says erectile dysfunction increases the risk of cardiovascular disease by a factor of 1.46 and may be a marker for future heart and circulation problems. In a man with no other symptoms, it may be a marker of underlying coronary artery disease. GPs are asked to check your heart health when you mention it.

The two share the same risk factors and some of the same changes in the blood vessels, NICE notes, and the British Society for Sexual Medicine's 2017 guidelines call the evidence of a strong link overwhelming. Three studies show its size:

• A US study followed 9,457 men aged 55 or over in the comparison group of a prostate cancer prevention trial from 1994 to 2003 (Thompson and colleagues, JAMA, 2005). Men with erectile dysfunction had a 45% higher risk of later cardiovascular events, similar to the extra risk from current smoking or a family history of heart attack, the authors said.
• A 2013 review pooled 14 studies of 92,757 men, followed for 6.1 years on average (Vlachopoulos and colleagues, Circulation: Cardiovascular Quality and Outcomes). Men with erectile dysfunction had a 44% higher risk of cardiovascular events and, in the 5 studies that measured it, a 25% higher risk of dying from any cause. The link was stronger at younger ages.
• Of 300 men with chest pain and coronary artery disease confirmed by angiography, 49% had erectile dysfunction. Of those, 67% said it began before their heart symptoms, and the average gap between the two was 38.8 months (Montorsi and colleagues, European Urology, 2003). The authors said studies with a comparison group were needed to confirm it as a real predictor.

These are observational studies, so they show a link rather than cause and effect. Even so, NICE asks GPs to check blood pressure, blood sugar and cholesterol and to work out the 10-year heart risk of every man with erectile dysfunction. The NHS advises anyone who buys sildenafil without a prescription to have a check-up with a doctor within 6 months of starting it, because erection problems can be a sign of other serious health conditions, such as diabetes or heart problems.

Can you get and keep an erection without medication?

Healthy lifestyle changes can sometimes help, the NHS says. It suggests losing weight if you're overweight, stopping smoking, eating a healthy diet, exercising daily and trying to reduce stress and anxiety. It also advises drinking no more than 14 units of alcohol a week, and taking a break from cycling if you cycle more than 3 hours a week.

Improving erections naturally like this has some evidence behind it: NICE cites the British Society for Sexual Medicine's view that these changes may bring moderate improvements in erections and in markers of heart risk, and adds that they can help treatments work better. NHS inform, Scotland's NHS website, adds not taking illegal drugs and trying breathing and relaxation exercises for stress. If you can't give up long rides, NICE suggests a properly fitted bicycle seat, set in a suitable position.

Pelvic floor exercises

In a trial of 55 men who had had erectile dysfunction for 6 months or more, pelvic floor exercises taught by a physiotherapist, with biofeedback and lifestyle advice, worked better than lifestyle advice alone after 3 months (Dorey and colleagues, BJU International, 2005). Men who had not responded to lifestyle advice alone were then offered the exercises too. After 6 months, 40% of the men had regained normal erections, 35.5% had improved and 24.5% had not. It was a single small trial. Our guide to pelvic floor exercises for men shows how to do them.

What about herbal and "natural" remedies?

NICE advises GPs not to recommend unlicensed herbal or complementary remedies for erectile dysfunction, because they may contain active drug ingredients that are unsafe for some men or interact with prescribed medicines. The MHRA warns that illegal erection pills may look genuine but contain no active ingredient, the wrong dose, hidden drugs or toxic ingredients.

What treatments are there for erectile dysfunction?

Treatment can usually help, the NHS says. The main treatment is tablets called PDE-5 inhibitors, such as sildenafil, which increase blood flow to the penis. There are also vacuum pumps, talking therapies, treatments for an underlying cause such as low testosterone, and specialist options such as injections and implants.

Erectile dysfunction treatments at a glance

	What it is.	How you get it in the UK.	What the sources say.
Lifestyle changes	Losing weight if you need to, stopping smoking, exercise, less alcohol, a break from long bike rides	On your own, with advice from a GP	The NHS says they can sometimes help; NICE cites the British Society for Sexual Medicine that they may bring moderate improvements
PDE-5 inhibitor tablets	Sildenafil, tadalafil, vardenafil or avanafil, which increase blood flow to the penis	Sildenafil from a pharmacy after speaking with a pharmacist, or on prescription; the NHS says the others need a prescription, but in March 2023 the MHRA decided to make one tadalafil medicine available from pharmacies, if marketed	The main treatment, says the NHS; NICE cites expert opinion that 60 to 65% of men with erectile dysfunction can then have sex successfully
Vacuum pump	A cylinder and pump that draw blood into the penis, often with a ring at the base to help keep the erection	Ask a doctor where to get one: pumps are not always available on the NHS	The NHS says they work for most men and can be used if medicine is not suitable or does not work
Talking therapy	Counselling, psychosexual therapy or relationship counselling	Through a GP (NHS waits can be long) or privately	Can help when erection problems are linked to emotional or mental health problems, says the NHS
Testosterone treatment	Hormone replacement for men with a confirmed deficiency	A hormone specialist (endocrinologist), after blood tests	BAUS says it will not improve erections in men without a hormone deficiency and may even be harmful
Injections or urethral pellets	A medicine injected into the side of the penis, or a pellet placed in the urethra	A urology specialist	BAUS calls injections very effective; with pellets, 35 to 40% of men get good quality erections
Penile implant	Inflatable or bendable implants placed inside the penis by surgery	A urology specialist	Kept for men who have tried other treatments without success or could not tolerate them (BAUS)
Low-intensity shockwave therapy	Low-intensity sound waves used on the penis to help blood flow	Not among the treatments on the NHS erectile dysfunction page	A 2025 Cochrane review rated the evidence low certainty: a small short-term effect men may not notice, and possible longer-term improvement. The EAU gives it a weak recommendation for some men, including those with mild erectile dysfunction caused by blood vessel problems

Doses are not given here: a GP, pharmacist or specialist will advise on any medicine or device. Sources: NHS, NICE CKS, BAUS, the EAU, the MHRA and the 2025 Cochrane review, all listed below.

Tablets: sildenafil and other PDE-5 inhibitors

The NHS names four: sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanafil (Spedra). They increase blood flow to the penis and need sexual stimulation to work, NICE notes. You can buy sildenafil from a pharmacy after speaking with a pharmacist (it's sold as Viagra Connect). The NHS says you need a prescription for the other three. In March 2023, though, the MHRA decided to make Cialis Together (tadalafil) available from pharmacies without a prescription for adult men with erectile dysfunction. If marketed, it will be sold from pharmacies following a discussion with the pharmacist, and the MHRA says other medicines containing tadalafil will still be available to obtain on prescription. NICE cites expert opinion that 60 to 65% of men with erectile dysfunction can have sex successfully with PDE-5 inhibitor tablets.

NHS prescriptions are limited to certain groups, such as men with diabetes, multiple sclerosis or Parkinson's disease, or men treated for prostate cancer, BAUS explains. It adds that generic sildenafil can now be prescribed by your own GP, so you can start treatment before seeing a specialist, if you need one. NICE tells GPs to offer a private prescription to men who don't qualify.

They aren't for everyone. The NHS says sildenafil isn't usually prescribed with nitrates, such as GTN for chest pain. It may not be suitable if you've recently had a heart attack or stroke, or have low or uncontrolled high blood pressure, and taking it with poppers or illegal drugs such as cocaine can increase the risk of serious side effects. Common side effects include headache, dizziness, a blocked nose, feeling sick and blurred vision. Our guide to Viagra (sildenafil) covers how it works and how to get it safely.

Buying online? The MHRA's advice is to use only UK-registered pharmacies, including online pharmacies that display the official green cross logo. For online pharmacies based in Great Britain, you can check the registration on the General Pharmaceutical Council's website. It warns against buying medicines from social media, messaging apps or unknown websites, and it seized almost 20 million doses of illegal erectile dysfunction medicines between 2021 and 2025.

Vacuum pumps

A vacuum pump is a cylinder that fits over the penis. Pumping the air out draws blood into the penis to cause an erection, and a ring is often placed around the base to help keep it, BAUS explains. The NHS says pumps work for most men and can be used if medicine isn't suitable or doesn't work, though they're not always available on the NHS.

Talking therapies

If emotional or mental health problems are part of the picture, counselling and therapy can help, the NHS says, though NHS waits can be long. When psychological issues are involved, psychosexual counselling combined with tablets may work better than either alone, NICE notes from the British Society for Sexual Medicine. Privately, the NHS suggests a sex therapist who belongs to the College of Sexual and Relationship Therapists (COSRT) or the Institute of Psychosexual Medicine; Relate also offers sex therapy for a fee.

Testosterone, only if it's low

NICE asks GPs to check a fasting testosterone level, taken between 9 and 11 am, in every man with erectile dysfunction. Low sexual desire, fewer morning erections and erection problems are the three most common symptoms of testosterone deficiency, according to the British Society for Sexual Medicine (see low libido in men). Treatment is only offered to men who are deficient: BAUS says it won't improve erections otherwise and may even be harmful.

Specialist treatments

If tablets don't work, aren't tolerated or aren't safe for you, NICE tells GPs to offer a referral to a urology specialist. The options NICE lists are vacuum devices, injections of a medicine called alprostadil into the penis, a small pellet of medicine placed in the urethra (the tube you pee through), surgery on the blood vessels and penile implants. BAUS calls injections very effective, though some men find the idea difficult to accept.

What is the latest treatment for erectile dysfunction?

One of the newest is low-intensity shockwave therapy, which uses sound waves to help improve blood flow to the penis. A 2025 Cochrane review of 21 trials in 1,357 men aged 39 to 65 found it may have a small effect on erections in the short term, perhaps too small for men to notice. In the longer term, it may improve them. The reviewers had little confidence in the evidence, and 9 of the 21 trials received money from companies that make the devices. The European Association of Urology's guidelines give it a weak recommendation for some men, including those with mild erectile dysfunction caused by blood vessel problems.

Can erectile dysfunction be cured?

Whether erectile dysfunction is curable depends on the cause. NICE's guidance says some cases can be cured and others can be managed successfully with medical or surgical treatment. Erectile dysfunction with a psychological cause, a hormonal cause, or one caused by an injury to the arteries in young men may be cured with specialist treatment.

When a medicine is the cause, stopping it can sometimes cure the problem if the timing clearly links the two, NICE says, which is a decision for your GP. NICE also notes that the tablets can be used long term if there is no medical reason to avoid them and no significant side effects. There is no clear evidence that the body gets used to them, though some men respond less well over time as blood vessel disease progresses.

When should you see a GP about erectile dysfunction?

See a GP or go to a sexual health clinic if erection problems keep happening, the NHS says, because it might be a sign of a health condition that can be treated. NHS inform suggests contacting your GP practice if it has lasted more than a few months, the things you can do yourself haven't helped and it's bothering you.

Sexual health clinics can provide the same treatment as your GP surgery, and many offer a walk-in service. You can find a sexual health clinic near you on the NHS website.

What happens at the appointment

The NHS says the doctor or nurse may:

• ask about your lifestyle and relationships, and any problems you might be having
• do some basic health checks, such as taking your blood pressure
• examine your genitals to rule out any obvious physical cause
• examine your prostate if you also need to pee more often than usual

NICE also asks GPs to arrange blood tests for diabetes, cholesterol and testosterone. BAUS adds that these should be done first thing in the morning, before 10am, without eating from the night before.

When it's urgent

• Call 999 or go to A&E if you have an erection that lasts more than 3 to 4 hours, or if you have sickle cell disease and a painful erection that lasts more than 1 hour. The NHS says an erection that lasts this long needs to be treated in hospital as soon as possible to avoid permanent damage to the penis.
• Call 999 if you're taking sildenafil and think you might be having a heart attack, a serious allergic reaction (anaphylaxis) or a seizure.

Erection problems, sex drive and finishing too soon

In Natsal-3, the problems sexually active men in Britain reported most were lack of interest in sex (14.9%), reaching a climax more quickly than they wanted (14.9%) and difficulty getting or keeping an erection (12.9%). Our guides cover each: low libido in men, how to last longer in bed, sexual performance anxiety, morning wood and Viagra (sildenafil).