Erectile dysfunction: causes, warning signs and when to see a GP

The NHS defines erectile dysfunction as being unable to get an erection, or unable to keep one for long enough to have sex. NICE CKS puts it as persistent difficulty attaining and maintaining an erection sufficient for satisfactory sexual performance. Persistent matters: the NHS says most men occasionally fail to get or keep an erection, usually because of stress, tiredness or too much alcohol.

It often comes with other changes. The NHS mentions a lowered sex drive in some men, and CKS asks about desire, arousal, ejaculation and orgasm as separate matters from erections themselves, because the cause differs. Distress, loss of confidence and strain on relationships are recognised complications, and some men avoid seeing anyone for months or years as a result.

An erection depends on healthy blood vessels, working nerves, adequate hormones and a relaxed, aroused mind. Anything that interferes with one of these can contribute, and CKS stresses that many men have more than one cause at once.

Erectile dysfunction is not a medical emergency, but it is sometimes the first symptom of something that is. CKS says complications of erectile dysfunction include an increased risk of cardiovascular disease, stroke and all-cause mortality, which is why the cardiovascular risk of the man is examined as part of the assessment. A man who has chest pain, breathlessness or leg pain on walking alongside erectile problems should mention them together.

Back pain with new erectile or other sexual changes belongs in a different category. The NHS says to call 999 or go to A&E if back pain comes with numbness around the genitals or anus, bladder or bowel changes, weakness or numbness in both legs, or changes in how the penis feels during sex including being unable to get or keep an erection.

The NHS also lists passing urine more often than usual alongside erectile problems as a reason for a prostate examination. A painful erection lasting more than 4 hours is an emergency that, per CKS, is a rare adverse effect of specialist treatments for the condition.

• Erection problems with new back pain, leg weakness or numbness, or loss of bladder or bowel control: 999 or A&E.

• A painful erection lasting more than 4 hours: emergency care.

• Erection problems alongside excess thirst, tiredness or passing more urine, which may suggest diabetes.

• Chest tightness or breathlessness on exertion, which should prompt a heart check.

• Sudden onset in a young man, or after pelvic, perineal or genital injury: CKS recommends urology referral.

The NHS says the doctor or nurse may ask about lifestyle, relationships and problems you are having, do basic checks such as blood pressure, and examine the genitals to rule out an obvious physical cause. If you have symptoms such as needing to pee more often, a rectal examination of the prostate may be offered.

NICE CKS adds more detail: past and current sexual relationships, onset, duration and quality of erections, desire, arousal, ejaculation and orgasm, life events, relationship dynamics, mental health, other conditions, risk factors and previous treatments. Examination looks at cardiovascular risk, signs of testosterone deficiency, the external genitalia and, depending on judgement, the prostate. A sexual health clinic is a route the NHS mentions, and many offer walk-in services.

CKS recommends checking HbA1c (a measure of blood sugar control), a lipid profile for cholesterol and a fasting morning total testosterone in all men with erectile dysfunction, with other blood tests added according to the likely cause. These results can reveal diabetes, high cholesterol or low testosterone before any complication has appeared.

The NHS says the aim of assessment is to find treatable causes. Blood pressure measurement is routine, and an ECG or other heart tests may follow if there is a cardiac concern. Psychological assessment or referral for psychosexual counselling is used when the pattern suggests a psychological cause.

The NHS says treatment can usually help. The main treatments are prescribed medicines that increase blood flow to the penis, called PDE-5 inhibitors: sildenafil, tadalafil, vardenafil and avanafil. They are prescription-only, with the NHS noting that sildenafil can also be bought from a pharmacy. CKS advises counselling on how to use them and a follow-up after 6 to 8 weeks to review dose and consider switching drug.

Other routes the NHS lists are vacuum pumps, which encourage blood flow and may not always be available on the NHS, treating the underlying cause such as blood pressure, cholesterol or hormone problems, switching a medicine that is contributing, and counselling or sex therapy when emotional factors are involved. The NHS warns that medicines bought online may be fake or unregulated, and advises checking that online pharmacies are registered with the General Pharmaceutical Council, online doctor services with the Care Quality Commission and doctors with the General Medical Council.

CKS gives referral criteria: urology if symptoms are lifelong, the man is young, there has been pelvic or genital trauma, there is a penile or testicular abnormality, or two PDE-5 inhibitors at maximum tolerated dose have failed; endocrinology for suspected testosterone deficiency; cardiology when the cardiac risk of sexual activity is intermediate or high; and psychosexual or relationship counselling when appropriate.

The NHS suggests losing weight if overweight, stopping smoking, eating a healthy diet, exercising daily and trying to reduce stress and anxiety. It advises not drinking more than 14 units of alcohol a week. CKS includes the same list: weight loss, smoking cessation, alcohol reduction and increased activity, as clinically needed, plus optimisation of any underlying conditions.

Practical points: take any medicines exactly as advised, mention all medicines and supplements to the prescriber, and consider involving a partner, since the NHS notes relationship factors and counselling can help.