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Health condition · Clinically reviewed

Erectile dysfunction, a treatable condition and an early cardiovascular signal.

ED is common, often the first sign of vascular disease, and highly treatable. Modern UK care combines lifestyle change, oral tablets and, when needed, injections, devices or prosthesis surgery.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against BSSM, EAU and NICE guidance you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK andrology practice, including PDE5 inhibitors, LI-ESWT and penile prosthesis pathways.

Key facts

Erectile dysfunction at a glance.

The essentials, in plain English. What it is, why it matters beyond the bedroom, and how it is treated in the UK today.

  • What it is

    Persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance.

  • How common

    Around 40 to 50 per cent of men aged 40 to 70 are affected. Prevalence rises steeply with age.

  • Cardiovascular link

    An early marker of endothelial dysfunction and cardiovascular disease. Roughly 70 per cent of cases are vascular.

  • Common triggers

    Diabetes, hypertension, dyslipidaemia, smoking, obesity, sleep apnoea, low testosterone and pelvic surgery.

  • First-line drugs

    PDE5 inhibitors: sildenafil, tadalafil, vardenafil and avanafil. Nitrates are contraindicated with all four.

  • Refractory options

    Intracavernosal alprostadil, vacuum devices, LI-ESWT and, for refractory cases, penile prosthesis surgery.

Why this guide matters

More than a bedroom issue.

ED is common, treatable and often revealing. The three ideas below shape everything else on this page.

  • An early cardiovascular signal

    Around 70 per cent of ED is vascular. New symptoms can precede a heart attack by three to five years and deserve a full cardiovascular workup. See our guide to coronary artery disease.

  • Causes are usually mixed

    Vascular, hormonal, neurological, medication-related and psychological factors often coexist. A good assessment addresses all of them rather than defaulting to a tablet.

  • Treatment success is the norm

    With a stepped approach from lifestyle and oral therapy through injections, devices and prosthesis surgery, satisfactory function is achievable for the vast majority of men.

How the diagnosis is made

From first conversation to a clear plan.

The steps a UK GP or andrologist will normally follow, in order. Most of the work happens in the history and a small panel of bloods.

  1. 01

    Assessing

    Focused sexual history

    Onset, situational vs global symptoms, morning erections, libido, partner factors and psychological context. The IIEF-5 questionnaire gives a validated severity score.

  2. 02

    Assessing

    Medical and medication review

    Diabetes, hypertension, cardiovascular disease, previous pelvic surgery or radiotherapy, and drugs known to impair erections (thiazides, beta-blockers, SSRIs, finasteride, opioids).

  3. 03

    Assessing

    Examination

    Genital and secondary sexual characteristics, peripheral pulses, focused neurological exam and resting blood pressure.

  4. 04

    Confirming

    Baseline bloods

    Fasting glucose or HbA1c, lipid profile, morning total testosterone, LH, FSH, prolactin, thyroid function and PSA where appropriate.

  5. 05

    Confirming

    Cardiovascular risk assessment

    QRISK3, resting ECG and, if indicated, referral for structural imaging such as a coronary CT angiogram.

  6. 06

    Specialist

    Specialist andrology referral

    For complex, refractory, post-surgical or Peyronie-associated cases, or where hormonal replacement is being considered.

  7. 07

    Specialist

    Selective erectile function tests

    Nocturnal penile tumescence testing and penile colour Doppler ultrasound are used selectively in specialist andrology.

Typical timeline: a first assessment to a working treatment plan in two to four weeks.

Symptoms

What ED actually looks like.

The mix and pattern of symptoms often points straight to the underlying cause. A situational, sudden loss with preserved morning erections looks very different from a gradual, global decline with reduced libido.

  • Difficulty achieving an erection

    Struggling to get an erection firm enough for penetration, despite sexual desire and appropriate stimulation.

  • Difficulty maintaining an erection

    Losing rigidity during intercourse or before ejaculation. A common early feature of vascular ED.

  • Reduced rigidity

    Partial erections that are not firm enough for satisfactory penetration, even when arousal feels normal.

  • Loss of morning erections

    Absent or infrequent nocturnal and morning erections point towards an organic (usually vascular or hormonal) cause.

  • Preserved morning erections

    Normal spontaneous erections with situational difficulty in the bedroom suggest a psychogenic component.

  • Reduced libido

    Low sex drive alongside erectile difficulty raises the question of testosterone deficiency or depression.

  • Sudden vs gradual onset

    Sudden, situational onset points to psychogenic ED. Gradual onset over months to years is typical of vascular disease.

  • Red flag - chest pain on exertion

    ED can precede a cardiac event by three to five years. Chest pain, breathlessness or exertional symptoms need same-day review.

Treatment

How ED is treated in the UK.

Lifestyle and risk factors first, then oral therapy, then a stepped ladder through injections, devices, shockwave and, where appropriate, prosthesis surgery. Psychosexual support sits alongside every step.

  • Lifestyle and risk-factor optimisation

    Weight loss, aerobic exercise, smoking cessation, alcohol reduction, treating sleep apnoea and a Mediterranean-style diet all improve erectile function.

  • Treat the underlying cause

    Optimise diabetes, blood pressure and lipids. Review causative medications and consider substitution where safe to do so.

  • Testosterone replacement

    For confirmed hypogonadism with symptomatic ED. Specialist andrology or endocrinology-led, with baseline PSA and haematocrit monitoring.

  • PDE5 inhibitors

    Sildenafil, tadalafil, vardenafil and avanafil. First-line oral therapy. Nitrates are absolutely contraindicated because of the risk of severe hypotension.

  • Intracavernosal alprostadil

    Second-line injection therapy (Caverject, Viridal) with high efficacy in vascular and post-prostatectomy ED. Delivered through a specialist clinic.

  • Intraurethral and topical alprostadil

    MUSE pellets and Vitaros cream are useful for patients who cannot tolerate injections or oral therapy.

  • Vacuum erection devices

    Non-invasive, evidence-based mechanical option. Particularly useful after prostate surgery as part of penile rehabilitation.

  • Low-intensity shockwave therapy

    LI-ESWT is an emerging option for mild to moderate vasculogenic ED. Delivered by specialist andrology centres.

  • Penile prosthesis surgery

    Inflatable or malleable implants are the gold standard for refractory ED. Patient satisfaction rates exceed 90 per cent in appropriate cases.

  • Psychosexual therapy

    Cognitive behavioural therapy, sensate focus work and couple counselling address performance anxiety, relationship strain and trauma.

  • Combination therapy

    Combining an oral PDE5 inhibitor with a vacuum device or alprostadil rescues many patients who fail single-agent therapy.

  • Emerging regenerative therapies

    Platelet-rich plasma and stem cell injections are being studied. Evidence is limited and use should sit within a specialist research setting.

Specialist services at Pulse

Where to be seen if you need more than a repeat prescription.

What this guide is based on

The sources behind every claim on this page.

UK and European specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or andrologist knows your medical history and can tell you which parts of this guide apply to you. If in doubt, get seen.

  • British Society for Sexual Medicine (BSSM). Guidelines on the management of erectile dysfunction.

  • European Association of Urology (EAU). Guidelines on sexual and reproductive health.

  • NICE Clinical Knowledge Summary. Erectile dysfunction.

  • MHRA. Guidance on PDE5 inhibitors and nitrate co-prescription.

  • International Society for Sexual Medicine (ISSM). Standards of care in sexual medicine.

Red flags

When ED needs urgent attention.

Most ED is safely managed in primary care and specialist clinics. These are the situations where prompt medical review really matters.

  • Chest pain or exertional symptoms

    ED can be the first sign of coronary artery disease. Any chest pain, breathlessness or exertional collapse warrants urgent cardiology review.

  • Priapism

    An erection lasting more than four hours after PDE5 inhibitors or intracavernosal injection is a urological emergency. Attend A&E immediately.

  • Sudden loss of vision or hearing

    A rare but recognised association with PDE5 inhibitors. Stop the drug and seek same-day medical assessment.

  • Nitrate co-prescription

    PDE5 inhibitors are absolutely contraindicated with nitrates because of the risk of profound, life-threatening hypotension.

  • New neurological symptoms

    Leg weakness, saddle anaesthesia, bladder or bowel disturbance with ED can suggest cauda equina or spinal cord pathology.

  • Penile pain, curvature or plaque

    Suggests Peyronie disease. Needs specialist andrology assessment before considering vacuum or injection therapy.

  • Post-prostatectomy or pelvic radiotherapy

    Nerve-sparing surgery and radiotherapy commonly cause ED. Early penile rehabilitation improves long-term outcomes.

  • Severe psychological distress

    Low mood, suicidal thoughts or severe relationship breakdown need urgent psychological or GP support alongside ED treatment.

  • Suspected trauma

    Perineal or pelvic trauma with new ED needs urological review to exclude vascular or neurological injury.

Living with it

A treatable condition, with a clear ladder.

Four ideas that make the biggest difference day to day. Foundations, patience, partnership and a willingness to step up when a treatment falls short.

A quiet reminder

Silence is the biggest barrier to good ED care.

Most men wait years to raise the subject. A twenty-minute consultation opens the door to treatments that reliably work.

  1. 01 Foundations

    Treat it as a whole-body problem

    ED is rarely just about the penis. Optimising weight, blood pressure, glucose and cholesterol restores function for many men.

  2. 02 Timing

    Give each treatment a fair trial

    PDE5 inhibitors need adequate stimulation, correct dosing and up to eight attempts before success or failure is judged.

  3. 03 Partner

    Involve your partner where you can

    ED affects two people. Couple-based approaches, from psychosexual therapy to shared decision-making, consistently improve outcomes.

  4. 04 Escalate

    Don’t settle for oral failure

    If tablets don’t work, injections, vacuum devices, shockwave therapy and prosthesis surgery all have strong evidence. Ask for a specialist review.

Frequently asked

Everything we get asked about ED.

Quick answers on the cardiovascular link, PDE5 inhibitors, second-line therapies and prosthesis surgery.

  • Is erectile dysfunction a normal part of ageing?

    Prevalence increases with age, but ED is not simply a consequence of getting older. It is usually driven by treatable factors such as vascular disease, diabetes, medications, hormones or psychological stress. It should always prompt a proper medical assessment rather than acceptance.

  • Why is ED linked to heart disease?

    The penile arteries are small and often show endothelial dysfunction before the coronary arteries do. New-onset ED can precede a cardiac event by three to five years. Every man presenting with ED deserves a cardiovascular risk assessment, including blood pressure, lipids, glucose and QRISK3 scoring.

  • Are PDE5 inhibitors safe to buy online or over the counter?

    Sildenafil 50 mg has been available as a pharmacy medicine in the UK since 2018 after a consultation with a pharmacist. Buying from unregulated online sources is unsafe and often provides counterfeit tablets. Always use a UK-registered pharmacy and check for nitrate interactions before starting treatment.

  • What if PDE5 inhibitors don’t work for me?

    Up to a third of men do not respond adequately to oral therapy. Options include intracavernosal alprostadil, intraurethral or topical alprostadil, vacuum erection devices, low-intensity shockwave therapy, combination regimens and penile prosthesis surgery. A specialist andrology clinic can guide the right next step.

  • Will a penile prosthesis feel natural?

    Modern inflatable implants sit entirely inside the body and are inflated using a small scrotal pump. Satisfaction rates for both patients and partners are consistently above 90 per cent in men who have exhausted other treatments. It is considered the definitive option for refractory ED.

  • Can psychological therapy really help ED?

    Yes. Performance anxiety, depression, relationship strain and previous trauma all directly affect erectile function, and often overlap with organic causes. Psychosexual therapy, CBT and couple counselling improve outcomes on their own and when combined with medical treatment.

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