Wellness · Sexual health
Erectile dysfunction, beyond the pill.
Common, treatable, and often a first signal of cardiovascular health you should know about. Here is what to do.
Why trust this guide
- 01
Clinically reviewed
Written by our editorial team and reviewed by a registered UK clinician before publication.
- 02
Sourced from evidence
Every claim is checked against BSSM and EAU guidelines and other peer-reviewed sources you can see at the end.
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Non-judgmental
Straight-talking, respectful and practical — no stigma, no upsells, no shame.
Key facts
Erectile dysfunction at a glance.
The essentials, in plain English — how common it is, what causes it, first-line treatments, and when to escalate.
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How common
ED affects around 50% of men over 40 at some point — you are not alone and it is very treatable.
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A cardiovascular signal
Often the first signal of cardiovascular disease — endothelial function fails in the small penile arteries before the coronaries.
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What causes it
Physical, psychological and combined causes — usually more than one factor at once.
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First-line treatment
PDE5 inhibitors (sildenafil, tadalafil) are first-line and safe for the great majority of men.
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If pills fail
Vacuum devices, injections and, ultimately, implants are effective options when tablets do not work.
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When to escalate
Sudden onset, chest pain with sex, or ED after cancer treatment — see a clinician promptly.
Why this guide matters
More than a prescription.
Most ED advice online begins and ends with a pill order. The three points below shape everything else on this page.
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Often a cardiovascular signal
ED is frequently the first warning of vascular disease — worth investigating even if the pills work.
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Rarely “just psychological”
Most cases are mixed — physical, psychological and medication factors together. Treat them together.
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Treatments work — pills, therapy and more
From PDE5 inhibitors to devices, injections, therapy and implants — there is almost always an effective option.
The evidence
A sensible order to work through ED.
The BSSM- and EAU-aligned pathway most clinicians follow — history and cardiovascular work-up first, treatment second.
Phase 1 · History and work-up
Pattern, cardiovascular risk, testosterone
Phase 2 · Contributors
Medications and psychological factors
Phase 3 · Treatment
PDE5 trial, then specialist escalation
- 01
History
Assess the pattern
Constant or situational? Are morning erections present? A situational pattern with morning erections points toward psychogenic causes.
- 02
History
Rule out cardiovascular disease
Check blood pressure, cholesterol and HbA1c — ED is often the first warning of vascular disease.
- 03
History
Testosterone check
A morning total testosterone, ideally repeated, screens for symptomatic hypogonadism.
- 04
Contributors
Medication review
SSRIs, antihypertensives (especially beta-blockers and thiazides) and opioids are common contributors.
- 05
Contributors
Psychological factors
Relationship stress, performance anxiety, depression and heavy porn use can all play a part.
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Treatment
Trial a PDE5 inhibitor
Sildenafil or tadalafil at an adequate dose, with sexual stimulation, on several separate occasions before judging it.
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Treatment
Escalate if pills fail
A urologist or andrologist can offer vacuum devices, injections, or — as a last-line — an implant.
Typical timeline: 2–8 weeks from first GP visit to a treatment that works for you.
Signs it affects you
Signs and drivers to look out for.
A quick self-check for what might be driving the ED — and one clear red flag that means you should not wait.
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Erectile difficulty
Trouble getting or keeping an erection firm enough for sex, most of the time.
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Cardiovascular disease signal
Small penile arteries fail before the coronaries — worth investigating properly.
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Testosterone deficiency
Low libido, fatigue and mood changes alongside ED — check the bloods.
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Medication side effect
New antidepressant, blood-pressure or pain medication timed with the onset.
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Psychological factors
Anxiety, low mood, relationship strain — often present with a situational pattern.
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Post-prostate treatment
Surgery, radiotherapy or hormone therapy for prostate cancer commonly cause ED.
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Diabetes-related ED
Both microvascular and neuropathic damage — good glycaemic control matters.
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Red flag
Chest pain with sex, or ED after any cancer treatment — see a specialist.
How to do it
The treatments that work.
Eight options, in rough order of use — start with the least invasive, escalate as needed with specialist guidance.
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PDE5 inhibitors
Sildenafil, tadalafil, vardenafil, avanafil — taken on demand, with sexual stimulation, at an adequate dose.
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Daily low-dose tadalafil
2.5–5 mg once daily allows spontaneity and can also help lower urinary tract symptoms.
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Vacuum erection device
A drug-free option that draws blood into the penis, held with a constriction ring; safe and effective.
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Alprostadil
Intraurethral pellet or intracavernosal injection — reliable when tablets are not enough.
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Testosterone replacement
Only if testosterone is genuinely low on repeated morning tests and there are matching symptoms.
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Psychosexual therapy
CBT-based work for performance anxiety, relationship strain, or a mismatch of expectations.
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Cardiovascular risk-factor care
Blood pressure, cholesterol, HbA1c, smoking, weight and activity — treat the vessels, help the erections.
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Penile implant
A specialist, last-line option with high satisfaction when other treatments have failed.
What this guide is based on
The sources behind every claim on this page.
UK and European specialist society guidance and national 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.
If ED is affecting your life, has come on suddenly, or has followed cancer treatment, please see your GP — some causes need a different approach entirely.
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British Society for Sexual Medicine (BSSM). Guidelines on the management of erectile dysfunction.
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European Association of Urology (EAU). Guidelines on sexual and reproductive health.
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NICE. Erectile dysfunction (Clinical Knowledge Summary).
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NHS. Erectile dysfunction — overview and treatment.
Red flags
When it is not just ED.
These signs suggest something that a pill alone will not fix — do not ignore any of them.
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Sudden-onset ED
Usually psychogenic — ask about mood, stress, a new relationship or bereavement. Still worth a check-up.
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ED after cancer treatment
Common after prostate surgery, radiotherapy or hormones — early rehabilitation improves outcomes.
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Chest pain with sex
Call 999. This is angina until proven otherwise and needs urgent assessment.
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Priapism
A painful erection lasting more than 4 hours is a urological emergency — call 999.
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Peyronie’s disease
A bent, painful or shortened erection — see a urologist for assessment.
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Diabetes with poor control
ED often improves with better glycaemic control — worth reviewing the diabetes plan.
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New severe headache on PDE5
Stop the medication and seek medical advice before taking it again.
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Any thoughts of self-harm
Please talk to someone. Samaritans are on 116 123, free, 24 hours a day.
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ED after a new medication
Timed with a new antidepressant, blood-pressure or pain medication — do not stop it, but ask your GP for a review.
Making it stick
Treat it as a whole-body signal.
Four principles to keep in mind — the ones that separate a real fix from a papered-over problem.
A quiet reminder
The pill is the beginning, not the end.
Even when the tablets work, take the opportunity to check your cardiovascular health properly — it is the more important story.
- 01 Treatable
ED is usually treatable
It is rarely just “in your head” — most men respond to first-line treatment with the right dose and support.
- 02 Signal
It is a cardiovascular signal
Do not ignore it. Even if the pills work, get the blood pressure, cholesterol and HbA1c checked.
- 03 Together
Communication matters
Bringing a partner into the conversation reduces anxiety and improves outcomes for both of you.
- 04 Safety
PDE5 inhibitors are safe for most
The main hard rule is no nitrates. Beyond that, most men can take them safely under GP guidance.
Frequently asked
Everything we get asked about erectile dysfunction.
Quick answers on PDE5 inhibitors, testosterone, safety, psychology and when to see a GP.
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Is ED normal in older men?
More common with age, yes — but it is never “just age”. It is worth investigating and treating at any age.
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PDE5 inhibitors — how do they work?
They enhance the natural erection response by improving blood flow to the penis. You still need sexual arousal for them to work.
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Can I take Viagra with heart medication?
Never with nitrates (GTN spray or tablets, isosorbide) — that combination can cause a life-threatening drop in blood pressure. Most other heart medications are fine, but check with your GP.
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How long do they last?
Sildenafil works for around 4–6 hours; tadalafil for up to 36 hours. Vardenafil and avanafil sit in between.
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Do they cause erections without arousal?
No — they do not create erections out of thin air. You need sexual stimulation for them to work.
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Is testosterone the answer for everyone?
Only if testosterone is genuinely low on repeated morning bloods and you have matching symptoms. It is not a general boost.
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What about psychological ED?
Very common, especially in younger men or with sudden onset. CBT-based psychosexual therapy is highly effective.
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Can watching porn cause ED?
Debated in the literature. If it feels problematic — the ED only happens with a partner, not solo — it is worth discussing with a therapist.
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When should I see a GP?
Any persistent ED; sudden onset; ED after cancer treatment; or chest pain with sex. Do not put it off.
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Is it worth investigating?
Yes — often it uncovers treatable cardiovascular disease early, which matters far more than the ED itself.
Related content
Keep reading.
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High blood pressure
The single most common cardiovascular driver of ED — and one of the most treatable.
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Type 2 diabetes
Diabetes damages the small vessels and nerves that erections rely on.
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Sex in midlife
A broader look at libido, intimacy and change in the 40s, 50s and beyond.
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