What is erectile dysfunction?

Erectile dysfunction (ED), also called impotence, means you cannot get or keep an erection firm enough for sex. It is very common: more than 1 in 10 males have it (healthdirect), and more than half of Australian men over 50 have some form of it (Healthy Male). It becomes more likely with age, but the higher rates in older men are usually due to other health conditions or medicines, not to ageing itself.

The symptoms are difficulty getting an erection, difficulty keeping one, or not being able to have sex because the penis is not hard enough; you may also notice erections are not as hard as they used to be. Problems with ejaculation, fertility or sex drive are separate conditions — they are not erectile dysfunction. An erection depends on blood flow and nerve signals, so anything that interferes with the blood vessels or the nerves to the penis can cause ED.

The overlooked cause: medicines you take for something else

Some medicines for high blood pressure, high cholesterol, depression and prostate cancer can cause erectile dysfunction (healthdirect), and Australian clinical guidance names several more groups (Australian Prescriber). The cause is easy to miss because the medicine was prescribed for something else.

Never stop a prescribed medicine on your own. If you think a medicine is behind your erection problems, take the question to the GP who prescribed it: they can check whether the timing fits and what your options are. Bring a list of everything you take.

Medicines for…Groups linked with erectile dysfunctionRead next
High blood pressureDiuretics, alpha blockers and beta blockersCan telmisartan cause ED?
Carvedilol and Viagra together?
Depression, anxiety and other mental health conditionsSSRIs and other antidepressants, antipsychotics, anti-anxiety medicinesCan sertraline (Zoloft) cause permanent ED?
High cholesterolSome cholesterol-lowering medicines—
Prostate cancer and an enlarged prostateHormone treatment (antiandrogens) and other prostate treatmentsAlfuzosin and sildenafil together?
Epilepsy and Parkinson's diseaseAnticonvulsants and anti-Parkinson's medicines—
Inflammation and long-term painCorticosteroids and long-term opioid use—

Your GP looks at the timeline: when the medicine was started and when the erection problems began (Australian Prescriber).

It works the other way too: ED medicines can interact with other medicines, so check with your GP before you use one, and never take one if you use nitrates — medicines for angina and chest pain (healthdirect). If you already take a blood-pressure tablet, read whether Viagra can be taken with amlodipine and other blood-pressure medicines.

What causes erectile dysfunction?

Erectile dysfunction can have physical causes, psychological causes or both, and the cause is not always clear. These are the causes named by healthdirect, Healthy Male and Australian Prescriber:

  • Blood vessels and the heart. Atherosclerosis — clogging of the arteries — reduces blood flow to the penis. High blood pressure, high cholesterol, cardiovascular disease and smoking all contribute.
  • Diabetes. You are more than twice as likely to have ED if you have diabetes, and diabetes can also damage the nerves.
  • Weight, metabolism and sleep. Obesity, metabolic syndrome and sleep disorders.
  • Hormones. Low testosterone (hypogonadism), an underactive thyroid, too much cortisol and growth-hormone conditions.
  • Nerves. Spinal cord injury, Parkinson's disease, Alzheimer's disease, multiple sclerosis and stroke.
  • The prostate and pelvic surgery. Prostate disease, and treatment for prostate cancer or an enlarged prostate, including surgery and radiotherapy. Healthy Male reports that 85% of men who have had prostate cancer have erectile dysfunction.
  • The penis itself. Peyronie's disease — scar tissue inside the penis that makes it curve.
  • Alcohol, smoking and other drugs, including cannabis, cocaine, heroin and methamphetamine.
  • The mind and the relationship. Stress, depression or anxiety, unresolved problems in the relationship, and anxiety about sexual performance — most common at the start of a new relationship, especially after earlier problems.
  • Medicines — see the table above.

Which cause is likely yours?

The pattern of the problem is the clue: whether it happens every time or only in some situations, whether it is recent or long-standing, and whether you still get erections in the morning or on your own. These are the questions a GP asks to work out the cause (Australian Prescriber). Match your answers below, then take them to your GP.

If…Your GP will look at
It started soon after a new medicine or a change of doseThe medicine — the timeline is the clue (see the medicines table)
It happens only in some situations — with a partner but not on your own, or in a new relationshipStress, performance anxiety and the relationship; performance anxiety is most common at the start of a new relationship
You have high blood pressure, diabetes, high cholesterol or heart disease, you smoke, or you carry extra weightBlood flow — and a check of your heart, blood pressure, cholesterol and blood sugar, because ED is often the first sign of these conditions
You have had prostate or pelvic surgery or radiotherapy, a spinal injury, or you have a nerve condition such as Parkinson's disease or multiple sclerosisThe surgery, injury or condition itself — each is a recognised cause of ED
Your erection bends or curvesPeyronie's disease
You ejaculate quickly, then lose the erectionPremature ejaculation — the two are often confused and can happen together. It has its own treatments, compared in our guide to lasting longer in bed
You have also lost interest in sexSex drive is a separate problem from ED; your GP may test your testosterone (a blood sample taken before 11 am) if a hormone problem is suspected

For how ED shows up day to day, symptom by symptom, see our companion page on the symptoms of erectile dysfunction in men.

When to see a GP

See your GP if erection problems keep happening or worry you. Occasional problems are common and may not need medical help (healthdirect).

Do not put it off: ED is often the first sign of cardiovascular disease, diabetes, high blood pressure or high cholesterol (healthdirect). Healthy Male calls it an early warning sign that needs a full investigation — men with ED are at higher than normal risk of coronary heart disease, stroke and death (Healthy Male).

At the appointment, expect (healthdirect, Australian Prescriber):

  • questions about your sexual history, general health, relationships and every medicine you take — your GP may also offer to talk with your partner;
  • a physical examination, including your weight, waist, blood pressure and genitals;
  • blood tests for cholesterol and blood sugar, a testosterone test if a hormone problem is suspected, and sometimes an ultrasound;
  • a referral to a specialist such as a urologist, if needed.

Useful questions to ask: which tests you need, what other conditions could be contributing, and whether seeing a psychologist would help (Healthy Male).

How is erectile dysfunction treated?

Treatment starts with the cause: your doctor will first treat any underlying condition, and more than one treatment may be needed. ED cannot always be cured completely, but treatment usually makes sex possible (healthdirect).

  • Lifestyle. Stopping smoking, exercising more, losing weight and eating well can prevent some causes (healthdirect), and some men get back to normal erections simply by looking after their health (Healthy Male).
  • Counselling or sex therapy, such as cognitive behavioural therapy — with your partner if you wish — when stress, anxiety or the relationship play a part.
  • Tablets. PDE5 inhibitors — sildenafil, tadalafil, vardenafil and avanafil — are the usual medicines, and in Australia all of them need a prescription (healthdirect). They work only with sexual stimulation and must never be taken with nitrates. Which one suits you is a separate question, answered on our home page: which ED tablet suits you.
  • Injections and devices. If tablets do not suit or do not work: alprostadil injected into the penis, or a vacuum erection device (healthdirect, Healthy Male) — see penis cones and vacuum devices. A penile implant is an option when nothing else works (Healthy Male).
  • Not proven. Acoustic shockwave therapy and platelet-rich plasma (PRP) injections are marketed by clinics, but they are not yet proven and are not currently recommended (healthdirect, Healthy Male).

Sources