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Erectile Dysfunction: A Specialist Pelvic Physiotherapist’s Guide to Causes, Tests and Treatments (UK)

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Illustration of an aubergine on a grey background, used as the featured image for a Pelvix guide to erectile dysfunction

Written by Megan Jackson, specialist pelvic health physiotherapist (HCPC registered, MCSP, POGP). Clinically reviewed and updated May 2026.

Erectile dysfunction (ED) is common, treatable, and almost never just about sex. For many men it is the first measurable sign that something else in the body — usually the cardiovascular system — needs attention. This guide explains what ED is, how to tell whether what you are experiencing counts, what tests are worth asking your GP for, and which treatments actually have the evidence behind them, including focused shockwave therapy and pelvic floor physiotherapy.

It is written for two audiences. If you are the man experiencing the symptoms, the sections below will give you what you need to take the next step. If you are a partner, the dedicated section will help you understand what’s going on and how to support without making it worse.

Quick answer. Erectile dysfunction is the persistent inability to get or keep an erection firm enough for sex. It affects roughly half of men aged 40 to 70 in the UK. In 9 out of 10 cases there is at least one underlying physical cause, most commonly affecting blood flow. ED is often an early warning sign of cardiovascular disease and is worth investigating, not ignoring. Most cases respond well to a combination of lifestyle change, medication, pelvic floor physiotherapy and — where appropriate — focused shockwave therapy.

For partners. If you are reading this on behalf of someone you love: ED is almost never about you, and it is almost never “just psychological”. The single most helpful thing you can do is treat it as a health issue that deserves the same care as any other — because it usually is one. Scroll to the section “Supporting a partner with ED” for practical guidance.

What is erectile dysfunction?

ED is the persistent or recurrent inability to achieve or maintain an erection firm enough for sexual activity. Occasional difficulty is normal — fatigue, stress, alcohol, a poor night’s sleep, or a new sexual situation can all interfere. The clinical threshold most urologists use is: symptoms present more than half the time, for at least six months.

The British Association of Urological Surgeons estimates that around 50% of UK men aged 40 to 70 experience ED to some degree.1 So if you are reading this, you are not unusual. You are unusual for actually doing something about it.

How do I know if I have erectile dysfunction?

Ask yourself three questions:

  1. Over the last six months, has it been difficult to get an erection firm enough for sex more often than not?
  2. When you do get one, is it lasting less time than it used to, or going soft before you’d expect?
  3. Have you noticed a change in your morning or overnight erections — fewer of them, less firm, or none?

If the answer to one or more is yes, and it has been going on for several months, what you are experiencing meets the working definition of ED. That doesn’t mean anything is permanently wrong. It means it is worth investigating.

Why morning and overnight erections matter

Healthy men typically have three to five erections overnight, including the one most are aware of in the morning. These are physiological — driven by sleep cycles rather than arousal — and they are useful diagnostic information. Loss or reduction of these strongly suggests a physical (often vascular) cause. Preserved morning erections in the presence of daytime difficulty point more towards a psychological component.

Devices like the Techring (myfirmtech.com) can measure this objectively at home if you want clearer information before you see a clinician. They are not essential, but they are a sensible option if the picture is genuinely unclear.

How an erection works — and why it sometimes doesn’t

An erection is the end product of five systems working together:

  • Vascular: arteries deliver blood in; veins are temporarily restricted to trap it. The endothelium (artery lining) releases nitric oxide, which widens the vessels.
  • Neurological: signals from the brain and spinal cord trigger and sustain the response.
  • Hormonal: testosterone, thyroid hormones, prolactin and cortisol all contribute.
  • Muscular: the pelvic floor muscles — specifically the ischiocavernosus and bulbospongiosus — help trap blood in the penis and maintain rigidity.
  • Psychological: arousal, attention, mood and the absence of acute stress are all required.

ED occurs when any one of these systems is compromised. Most often, more than one is involved at the same time.

The causes of erectile dysfunction

Around 90% of ED cases have at least one identifiable physical contributor.1 The categories below overlap — that is the rule, not the exception.

1. Vascular causes

By far the most common, particularly after 40. Narrowed arteries (atherosclerosis) reduce inflow; endothelial dysfunction reduces the body’s ability to produce nitric oxide. Risk factors include high blood pressure, raised cholesterol, smoking, type 2 diabetes, obesity, and a family history of heart disease.

Important: ED is an early warning sign for cardiovascular disease. Multiple studies and the Princeton IV consensus recommendations now treat ED as a risk-enhancing marker for silent coronary artery disease.2,3 ED often appears two to five years before a cardiac event. If you are under 50 and developing ED with no obvious cause, this matters more, not less. See your GP and ask for a cardiovascular risk assessment.

2. Neurological and medication-related causes

Anything that disrupts the nerve signals between brain, spinal cord and penis can cause ED:

  • Type 1 or type 2 diabetes (peripheral neuropathy)
  • Multiple sclerosis
  • Parkinson’s disease
  • Spinal cord injury or significant disc pathology
  • Prolonged cycling, where pressure on the perineum compresses the pudendal nerve
  • Common medications — SSRIs and other antidepressants, some blood pressure medications, finasteride (used for hair loss and prostate enlargement), and certain antipsychotics

If your ED started within weeks of starting a new medication, that is rarely a coincidence.

3. Hormonal causes

Testosterone is the most commonly implicated, but thyroid disorders, raised prolactin and high cortisol (chronic stress) all play a role. Testosterone affects both libido and erectile function. A blood test is straightforward and worth doing if you have low desire alongside the erection problem.

4. Psychological causes

Performance anxiety, depression, relationship stress, and an unhealthy relationship with pornography can all cause or maintain ED. The trick of performance anxiety is that worrying about an erection failing makes it more likely to fail, which makes you worry more next time. Younger men with otherwise healthy physiology often fall into this loop.

Purely psychological ED is less common than people assume — around 1 in 10 cases. Mixed cases are the norm.

5. Pelvic floor dysfunction

Routinely overlooked and the area I see most often misunderstood. The pelvic floor muscles directly contribute to rigidity by compressing the deep veins of the penis and trapping blood. Weak pelvic floor muscles cannot maintain that compression. Overactive or tense pelvic floor muscles can compress nerves and small vessels, reducing both signal and supply, and they are strongly associated with chronic pelvic pain and Peyronie’s disease — both of which commonly coexist with ED.4

ED as an early warning sign: why you shouldn’t wait

Repeating this because it is the single most important point in the article. The same blood vessels that supply the penis supply the heart and the brain. The vessels in the penis are smaller, so they show damage earlier.

Men with ED have a roughly 1.4-fold increased risk of cardiovascular events compared with men of the same age without ED.2 For men under 50 the relative risk is higher still. Untreated diabetes is often first detected during ED workup.

If you take one thing from this article: don’t treat ED as embarrassing. Treat it as a free, useful diagnostic signal your body is giving you.

When to see someone — and who

If symptoms have been present for more than a couple of months, it is worth a conversation. The right starting point depends on what else is going on.

  • GP: for almost everyone, the GP is the right first stop. They can rule out the medical causes (diabetes, hormonal, cardiovascular risk) that need to be addressed regardless of which treatment you eventually choose.
  • Specialist pelvic health physiotherapist: particularly relevant if you have pelvic pain, post-prostatectomy ED, suspected pelvic floor involvement, or if you’d prefer to start with a non-pharmacological approach. At Pelvix we offer men’s pelvic health assessment across Bristol, Bath and Keynsham. Book an appointment.
  • Urologist: if oral medication hasn’t worked, if you have suspected Peyronie’s disease, or if you have severe ED with a likely structural cause.
  • Sex therapist or psychosexual counsellor: either alongside the above or as the lead treatment if the picture is primarily psychological or relational.

What to expect at a GP appointment

Knowing what is likely to happen tends to make people more, not less, willing to book. Most GPs will:

  1. Ask about onset, frequency, morning erections, libido, mood and medications
  2. Take blood pressure and calculate cardiovascular risk (QRISK3 in the UK)
  3. Order bloods: HbA1c (diabetes), fasting lipids (cholesterol), testosterone (ideally morning sample), TSH (thyroid), prolactin, and often a PSA for men over 50
  4. Discuss lifestyle factors and offer a first-line PDE5 inhibitor (sildenafil or tadalafil) where appropriate
  5. Refer on if the picture is complex or if first-line treatment doesn’t work

Sildenafil and tadalafil are both available on the NHS for clinically eligible patients — the prescribing restrictions were removed in 2025.5

Treatments that actually work

There is no single answer because there is no single cause. A good clinician will help you stack the right combination.

Lifestyle change — the foundation, not the consolation prize

This is where people roll their eyes, but the data is strong. A 2018 systematic review found that 40 minutes of moderate-to-vigorous aerobic exercise four times a week meaningfully improved erectile function in men with vascular ED.6 A Mediterranean diet, smoking cessation, weight loss in the 5–10% range, and good sleep all move the needle independently. They also amplify the effect of every other treatment on this list.

PDE5 inhibitors (Viagra, Cialis and generics)

First-line medication in the UK. They work by amplifying the body’s own nitric oxide signal — so they will not work if there is no arousal, and they will not work as well if the underlying vasculature is severely compromised. Sildenafil is typically dosed on demand; tadalafil can be used either on demand or daily at a lower dose. Side effects (headache, flushing, nasal congestion, occasional visual changes) are usually mild. Not safe with nitrate medication or in certain cardiac conditions — which is why your GP will check first.

Pelvic floor physiotherapy

A 2019 systematic review found pelvic floor muscle training improved erectile function in men with ED, with the strongest evidence in post-prostatectomy and mixed-cause cases.7 The mechanism is straightforward: stronger and better-coordinated pelvic floor muscles maintain rigidity. Where the muscles are overactive (the more subtle and more often missed pattern), down-training and release work are the priority — not Kegels.

What this looks like in practice at Pelvix: a confidential assessment by a specialist pelvic physiotherapist, an individualised programme of muscle training, manual therapy where needed, biofeedback, and ongoing review. See our men’s pelvic health page for more, or book an initial assessment.

Focused shockwave therapy (fESWT)

Of all the developments in ED treatment over the last decade, this is the one with the most interesting evidence trajectory. Focused extracorporeal shockwave therapy delivers low-intensity acoustic waves to the penile tissue. The mechanism is regenerative: new blood vessel formation (neovascularisation), recruitment of endothelial progenitor cells, and improved nitric oxide signalling.8

What the most recent evidence says:

  • A 2025 meta-analysis of 12 RCTs (882 men with vasculogenic ED) showed significant improvements in IIEF-EF and Erection Hardness Score versus sham.9
  • A 2024 umbrella review of 5 systematic reviews reached the same conclusion.10
  • The European Association of Urology (EAU) recommends shockwave therapy for mild vasculogenic ED, for poor responders to PDE5 inhibitors, and for men who prefer a non-pharmacological option.11
  • Effects appear over several weeks and typically last 6 to 12 months, with strong candidates being men who still have some residual erectile function.

Honest caveats: the American Urological Association still classifies shockwave therapy as investigational (Grade C evidence).12 The European and American positions diverge, and you deserve to know that. Shockwave is not a magic wand for severe ED, and not all machines are equal — the strongest evidence is for focused (not radial) shockwave delivered at standardised parameters.

At Pelvix we use the Storz Medical Duolith SD1 — a focused shockwave system used in the published trials. Treatment is non-invasive, takes around 20–30 minutes per session, with a typical course of 6 sessions over 3–6 weeks. Learn more about our shockwave therapy service or see our prices.

Vacuum devices, rings, injections and implants

Worth knowing about, briefly:

  • Vacuum erection devices (VEDs): drug-free, work regardless of cause, used with a constriction ring to maintain the erection. Some men find them mechanical; others find them reliable.
  • Constriction rings: worn for no more than 30 minutes at a time.
  • Intracavernosal injections, urethral pellets and topical creams (Alprostadil): highly effective even when tablets don’t work.
  • Penile implants: reserved for severe, treatment-resistant ED. High satisfaction in the right candidates, but irreversible.

Counselling and psychosexual therapy

Essential when there is a psychological component, and often useful alongside physical treatment regardless. Performance anxiety responds well to specific CBT-style approaches.

Supporting a partner with ED

The most common mistake partners make is making it about themselves — either by taking the lack of erection personally, or by avoiding the topic entirely to spare feelings. Both create more pressure. The aim is to make the topic boring enough to discuss openly.

Practical points:

  • Bring it up outside the bedroom, not during sex. Calm conversations work better than urgent ones.
  • Frame it as a health issue, not a sex issue. “Have you spoken to your GP?” is easier to hear than “What’s going on with us?”
  • Take performance off the table for a while. Intimacy that isn’t aimed at intercourse often reduces anxiety enough for erections to return.
  • Go with him if he wants company. The Pelvix clinic is set up to be unintimidating; some men prefer to bring their partner.
  • Don’t push particular treatments. Your job is to support investigation; the clinical choices are between him and his clinician.

Frequently asked questions

Is erectile dysfunction reversible?

In most cases, yes — partly or fully. Treatment depends on the cause, and the earlier ED is investigated, the better the outcome. Vascular ED responds best to lifestyle change, pelvic floor work and shockwave therapy combined. Hormonal and medication-related causes are often correctable.

How long does shockwave therapy take to work?

Initial improvements typically appear within 4–8 weeks of starting treatment, with the full effect at 3–6 months. A standard course at Pelvix is 6 sessions over 3–6 weeks.

Is shockwave therapy painful?

No. Most men describe it as a tapping or buzzing sensation. There is no anaesthetic needed and no recovery time afterwards.

How is shockwave therapy different from Viagra?

PDE5 inhibitors like Viagra are a temporary fix — they amplify the body’s natural signal each time you take one. Focused shockwave therapy aims to improve the underlying tissue, with effects that persist for 6–12 months or more. Many men use both: shockwave to improve the foundation, PDE5 inhibitors when needed for confidence on a particular occasion.

Can pelvic floor exercises help all types of ED?

Not all, but more than you’d think. Pelvic floor physiotherapy is particularly effective for post-prostatectomy ED, ED with pelvic pain, and mixed-cause ED. It is also useful as a complement to other treatments. If the muscles are overactive rather than weak, Kegels alone can make things worse — assessment matters.

Can stress alone cause ED?

Yes, but stress on its own is a less common single cause than people assume. About 1 in 10 cases are purely psychological. Far more often, stress is one of several contributors and tipping points.

Will my GP take this seriously?

Yes. UK GPs are well-trained to recognise ED as both a treatable problem and a clinical opportunity to spot cardiovascular and metabolic disease earlier. NICE-aligned NHS guidance treats ED as a routine reason to consult.

Take the next step

If your ED has been going on for more than a couple of months, the most useful thing you can do this week is one of the following:

  • Book a GP appointment — ask specifically about cardiovascular risk assessment and bloods.
  • Book an initial assessment at Pelvix — confidential, evidence-based, with a specialist pelvic physiotherapist. We’re based in Keynsham and see men across Bristol and Bath. Book online here.
  • Ask us about focused shockwave therapy — read more about our shockwave service or get in touch to discuss whether it’s right for you.

About the author. Megan Jackson is a specialist pelvic health physiotherapist and the founder of Pelvix Specialist Pelvic Physiotherapy in Keynsham, serving Bristol and Bath. HCPC registered, Chartered Society of Physiotherapy member, POGP member. Pelvix offers focused shockwave therapy, men’s pelvic health assessment, and a full range of pelvic physiotherapy services. Read more about Megan.

References

  1. British Association of Urological Surgeons. Erectile dysfunction (impotence): patient information leaflet. baus.org.uk
  2. Vlachopoulos C, Jackson G, Stefanadis C, Montorsi P. Erectile dysfunction in the cardiovascular patient. European Heart Journal. 2013;34(27):2034–46.
  3. Miner M, Nehra A, Jackson G, et al. All men with vasculogenic erectile dysfunction require a cardiovascular workup. American Journal of Medicine. 2014;127(3):174–82.
  4. Cohen D, Gonzalez J, Goldstein I. The role of pelvic floor muscles in male sexual dysfunction and pelvic pain. Sexual Medicine Reviews. 2016;4(1):53–62.
  5. NHS Business Services Authority. Removal of Selected List Scheme restrictions for sildenafil and tadalafil, 2025.
  6. Gerbild H, Larsen CM, Graugaard C, et al. Physical activity to improve erectile function: a systematic review of intervention studies. Sexual Medicine. 2018;6(2):75–89.
  7. Myers C, Smith M. Pelvic floor muscle training improves erectile dysfunction and premature ejaculation: a systematic review. Physiotherapy. 2019;105(2):235–43.
  8. Capogrosso P, Frey A, Jensen CFS, et al. Low-intensity shock wave therapy in sexual medicine — clinical recommendations from the European Society for Sexual Medicine (ESSM). Journal of Sexual Medicine. 2019;16(10):1490–1505.
  9. Updated meta-analysis of randomized controlled trials of low-intensity extracorporeal shockwave therapy for erectile dysfunction. Future Science OA. 2025.
  10. Effectiveness of low-intensity extracorporeal shock wave therapy in erectile dysfunction: an umbrella review. 2024.
  11. Salonia A, Bettocchi C, Carvalho J, et al. EAU Guidelines on Sexual and Reproductive Health. European Association of Urology, 2024.
  12. Burnett AL, Nehra A, Breau RH, et al. Erectile dysfunction: AUA Guideline. Journal of Urology. 2018 (current as of 2024 amendment).