Erectile dysfunction (ED) is incredibly common — and incredibly under-discussed. For many men, it’s uncomfortable to talk about, even with a healthcare professional. But an erection (or the lack of one) is often a reliable barometer of overall health.
And while ED can certainly affect confidence and intimacy, the bigger story is that it’s often a symptom, not a standalone condition. Understanding the cause is the first step — not just toward better erections, but better long-term health.
What Is Erectile Dysfunction?
ED is the persistent or recurrent inability to achieve or maintain an erection that is firm enough for sexual activity.
Occasional difficulty is normal — particularly with fatigue, stress, or after alcohol or drugs. But if the problem becomes frequent or consistent, it’s time to look a little closer.
How Erections Work — and Why They Stop
A healthy erection depends on a finely tuned system of:
– Blood flow to the penis
– Nerve signals from the brain and spine
– Hormonal support (especially testosterone)
– Pelvic floor muscles that help maintain rigidity
– Mental arousal and emotional state
A good way to assess what’s going on is to monitor your morning or nocturnal erections. These are physiological (rather than caused by arousal) and are a way of assessing whether your ED may have a psychological or a physical component. If stress and anxiety affect your erectile function, this is less likely to cause changes in your nocturnal and early-morning erections. If your ED has a physical cause, you would often expect to see a reduction in these physiological erections. Believe it or not there are gadgets for monitoring this – the very well-designed Techring (www.myfirmtech.com) which monitors erectile function overnight.
Categories of Erectile Dysfunction: What Might Be Going On
1. Vascular Causes
By far the most common, especially over the age of 40. Erections require good arterial inflow and venous outflow control. If the arteries are narrowed (atherosclerosis), blood supply to the penis is reduced. The body also produced nitric oxide (NO) which widens the blood vessels and improves penile blood supply. If you have new symptoms of ED and especially if you have a family history of heart disease, are overweight, have high blood pressure and/or are a smoker, consider this your cue to arrange a check up with GP.
Red flag: ED is now considered an early warning sign for cardiovascular disease. Research shows men with ED are at higher risk of heart attack, stroke, and peripheral artery disease.
[1] In fact, ED often shows up 3–5 years before heart symptoms.
2. Neurological and Medication-related Causes
Nerve damage or disruption can prevent the brain from communicating properly with the penis. This is seen in:
– Diabetes (due to peripheral neuropathy)
– Multiple sclerosis
– Parkinson’s disease
– Spinal cord injuries or disc issues
– Prolonged cycling or trauma to the pelvic area can irritate and compress the nerves and cause symptoms
– Many common medications such as anti-depressants and medication for hair loss can also have ED as a side effect.
3. Hormonal Causes
Testosterone is important — not just for libido, but also for erectile function. Low levels can reduce both the desire for sex and the physical ability to maintain an erection. Other hormonal imbalances (thyroid, prolactin, cortisol) can also play a role.
4. Psychological Causes
Performance anxiety, stress, low mood, or relationship strain can all affect arousal. The mind plays a powerful role in sexual function — and it works both ways. Worrying about an erection not happening often makes it not happen. Having an unhealthy relationship with pornography can also affect erectile function.
This is particularly common in younger men and those who are otherwise physically healthy.
5. Pelvic Floor Dysfunction
Often overlooked, the pelvic floor plays a key role in erectile function. These deep muscles at the base of the pelvis help trap blood in the penis during erection. If they’re weak, the erection can be lost. If they’re overactive or tense, they can create discomfort or interfere with the normal blood flow and nerve supply. Men experiencing pelvic pain or Peyronie’s disease often have associated issues with ED.
What Medical Tests Might Be Recommended?
1. Blood Tests
To rule out common contributors such as:
– Testosterone levels – Low testosterone can affect libido and erectile function.
– HbA1c or fasting glucose – To check for diabetes or pre-diabetes, which can affect both blood vessels and nerves.
– Lipid profile – High cholesterol can contribute to vascular narrowing.
– Thyroid function & PSA – Both underactive and overactive thyroid can impact sexual function and you may be tested for diseases affecting the prostate.
– Prolactin – Elevated prolactin can reduce testosterone levels and affect erections.
2. Blood Pressure Check
To rule out blood pressure problems.
3. Cardiovascular Risk Assessment
Because ED is often an early sign of vascular disease, your doctor may assess your overall risk of heart disease and stroke. This could include:
– ECG (electrocardiogram)
– QRISK score calculation (used in the UK to predict heart disease risk)
– Referral for cardiac review if red flags are identified
5. Neurological Tests
To rule out neurological problems.
6. Psychological Screening
This might include questionnaires or a conversation about stress, anxiety, low mood, or relationship factors. These are sometimes overlooked but can have a significant impact — either as the main cause or in combination with physical factors.
The goal of testing isn’t to medicalise everything — it’s to make sure there’s not an underlying issue being missed. For example, some men first discover they have type 2 diabetes or early heart disease after seeing a doctor for ED.
Treatment Options: What Works?
There’s no one-size-fits-all answer. Treatment depends on what’s causing the problem — and often, several things are involved.
1. Address Lifestyle Factors
– Exercise (especially brisk walking and resistance training) has been shown to improve ED. [2]
– Sleep and stress reduction can make a major difference.
– Stop smoking — it’s a major contributor to vascular ED.
– Eat for heart health (we think Mediterranean diets are effective).
2. Medication
– PDE5 inhibitors (e.g. sildenafil/Viagra, tadalafil/Cialis) improve blood flow but not libido
– Side effects include headache, flushing, or nasal congestion.
– They won’t work well in all circumstances and are not suitable for everyone. However, they are sometimes they are useful in conjunction with other therapies.
3. Pelvic Health Physiotherapy
Pelvic floor muscle assessment & treatment — often used after prostate surgery — can improve erections, bladder and bowel symptoms and pelvic pain. But it’s not just about “squeezing” the muscles. Overactivity, tension, or poor coordination can be part of the problem too.
A pelvic health physio can assess this in a supportive, confidential environment.
4. Focused Shockwave Therapy (fESWT)
Focused extracorporeal shockwave therapy (fESWT) is a non-invasive treatment that uses low-intensity sound waves to stimulate healing in penile tissue. It’s been used for over a decade in Europe and has growing evidence to support its use, particularly in vascular erectile dysfunction. At Pelvix we have a state-of-the-art Storz Medical ESWT machine for this purpose.
How it works:
– Promotes the formation of new blood vessels
– Improves penile blood flow
– May help to regenerate nerve and tissue function
– Can also improve chronic pelvic pain and Peyronie’s symptoms
What the evidence says:
– A 2017 meta-analysis of 14 studies found significant improvement in erectile function scores compared to placebo in men with mild-to-moderate vascular ED. [3]
– The effects may take a few weeks to appear and can last 6–12 months or more.
– Works best in men who still have some natural erectile function — not a replacement for implants or surgery in severe cases.
– This video tells you more about shockwave therapy https://youtu.be/11REIPO8UZc
5. Vacuum-devices, rings, implants & injections
Vacuum Erection Devices (VEDs)
– A non-invasive, drug-free option that creates an erection by drawing blood into the penis using negative pressure.
– The device consists of a plastic cylinder, a hand or battery-powered pump, and a constriction ring to maintain the erection.
– Can be effective regardless of the underlying cause of ED.
– May feel mechanical or unnatural at first; some men report a sensation of coldness or numbness.
Constriction Rings (Penile Rings)
– Often used in combination with VEDs to maintain an erection by preventing blood from flowing out too quickly.
– Can also be used alone in men who can achieve partial erections.
– Should only be worn for no more than 30 minutes to prevent tissue damage.
Penile Injections, Creams & Pellets
– Involves injecting a medication directly into the side of the penis before intercourse.
– The cream/pellet is most commonly Alprostadil and is either rubbed on the penis or inserted into the urethra.
– Causes direct dilation of blood vessels to trigger an erection within 10–60 minutes.
– Highly effective, especially in cases where pills don’t work.
Penile Implants
– A permanent solution for severe or treatment-resistant ED.
– Highly effective, with very high satisfaction rates among men and their partners.
– Irreversible and only considered when other treatments have failed or are unsuitable.
– Involves surgical risks (infection, mechanical failure, anaesthesia) but outcomes are generally very positive when done by experienced urologists.
6. Counselling or Sex Therapy
Very useful, particularly in those experiencing ED with a psychological component
Treatment Options: What Works?
If ED has been going on for more than a few months, speak to a healthcare professional. That could be your GP, a urologist, or a physiotherapist with pelvic health training.
It’s not embarrassing, it’s sensible. And in many cases, treatment is effective — and improves other aspects of life too.
- Vlachopoulos, C. et al. (2013). Erectile dysfunction and cardiovascular disease: Current and emerging risk factors. Current Opinion in Cardiology, 28(6), 615–620.
https://doi.org/10.1097/HCO.0000000000000005 - Gerbild, H. et al. (2018). Physical activity to improve erectile function: A systematic review of intervention studies. Sexual Medicine, 6(2), 75–89.
https://doi.org/10.1016/j.esxm.2018.01.003 - Lu, Z. et al. (2017). Low-intensity extracorporeal shock wave therapy for erectile dysfunction: A systematic review and meta-analysis. Urology, 90, 47–54.
https://doi.org/10.1016/j.urology.2015.12.031