Erectile dysfunction (ED) is the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity. It affects a substantial proportion of men, particularly over 40, and can arise from physical causes such as cardiovascular disease or diabetes, psychological factors including anxiety or depression, or a combination of both. Whether ED can be cured depends on its underlying cause—reversible factors like lifestyle issues or medication side effects may resolve completely, whilst chronic conditions often require ongoing management. Importantly, ED may signal underlying cardiovascular disease, making medical evaluation essential for both sexual health and overall wellbeing.

What Is Erectile Dysfunction and Can It Be Cured?

Erectile dysfunction (ED) is the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity. It is a common condition, becoming more prevalent with age—affecting a substantial proportion of men over 40. ED can arise from physical causes (such as cardiovascular disease, diabetes, or hormonal imbalances), psychological factors (including anxiety, depression, or relationship difficulties), or a combination of both.

Whether ED can be "cured" depends largely on its underlying cause. In cases where ED results from reversible factors—such as medication side effects, lifestyle factors like smoking or obesity, or psychological stress—addressing these root causes may lead to complete resolution. For instance, a man whose ED is primarily caused by performance anxiety may find that psychological therapy resolves the issue entirely. Similarly, improving cardiovascular health through weight loss and exercise can restore erectile function in some individuals.

However, when ED arises from irreversible structural damage (such as nerve injury following prostate surgery) or progressive chronic conditions (like advanced diabetes with vascular complications), a complete cure may not be achievable. In these situations, the focus shifts to effective management rather than cure. Modern treatments can enable most men to achieve erections adequate for sexual activity, even if the underlying pathology persists.

It is important to understand that ED may be an early warning sign of cardiovascular disease. The penile arteries are smaller than coronary arteries and may show dysfunction earlier—sometimes 2–5 years before coronary symptoms appear. Therefore, seeking medical evaluation is crucial not only for sexual health but also for overall wellbeing, cardiovascular risk assessment (such as QRISK scoring), and early detection of potentially serious conditions including diabetes and heart disease. Your GP can arrange appropriate blood tests (HbA1c, lipid profile) and blood pressure checks as part of this assessment.

ED may be psychogenic (related to psychological factors, often situational, with preserved morning or spontaneous erections) or organic (due to physical causes, typically persistent across all situations). Understanding this distinction helps guide appropriate investigation and treatment. Referral to a specialist may be needed if there are features such as Peyronie's disease (penile curvature), suspected hormonal problems, or ED that does not respond to initial treatment.

Evidence-Based Treatment Options for Erectile Dysfunction

Phosphodiesterase type 5 (PDE5) inhibitors represent the first-line pharmacological treatment for ED and include sildenafil (Viagra), tadalafil (Cialis), vardenafil, and avanafil. These medicines work by enhancing the effects of nitric oxide, a natural chemical that relaxes smooth muscle in the penis, thereby increasing blood flow during sexual stimulation. Efficacy rates range from 60–70% across various patient populations. Sildenafil and vardenafil typically last 4–6 hours, whilst tadalafil offers a longer duration of action (up to 36 hours), providing greater spontaneity. Tadalafil is also available as a lower-dose daily option (2.5–5 mg). Common side effects include headache, facial flushing, nasal congestion, and indigestion.

Important safety information and contraindications include:

• Absolute contraindication with nitrate medicines (used for angina, including glyceryl trinitrate, isosorbide mononitrate, and nicorandil) and with riociguat (used for pulmonary hypertension), as these combinations can cause dangerous hypotension.

• Caution is required in men taking alpha-blockers (for prostate symptoms or hypertension), as concurrent use may increase the risk of low blood pressure; dose adjustment and timing may be needed.

• Men with unstable cardiovascular disease (recent heart attack or stroke, unstable angina, severe heart failure) should not use PDE5 inhibitors until their condition is stable and they have been assessed as fit to resume sexual activity.

• Rare but serious adverse effects include sudden loss of vision (non-arteritic anterior ischaemic optic neuropathy, NAION) or sudden hearing loss. If these occur, stop the medicine immediately and seek urgent medical attention.

Optimising PDE5 inhibitor use: Sexual stimulation is required for these medicines to work—they do not produce spontaneous erections. Sildenafil is best taken on an empty stomach, as high-fat meals may delay its effect. Allow 4–8 attempts with correct timing and technique before concluding that a particular PDE5 inhibitor has failed. Avoid excessive alcohol, which can impair erectile function.

For men who do not respond to oral medicines or cannot tolerate them, intracavernosal injections of alprostadil (a prostaglandin E1 analogue) offer an alternative. This treatment involves self-injecting medicine directly into the corpus cavernosum, producing an erection within 5–20 minutes with success rates of approximately 70–80%. Initial dose titration and training are provided in a clinic setting. Contraindications include sickle cell disease, leukaemia, and anatomical penile deformity. Whilst effective, some men find the injection process psychologically challenging, and there is a small risk of priapism (prolonged erection) or penile fibrosis with repeated use.

Vacuum erection devices (VEDs) provide a non-pharmacological option, using negative pressure to draw blood into the penis, with a constriction ring then applied to maintain the erection. The ring should not be left in place for more than 30 minutes. Caution is needed in men with bleeding disorders or those taking anticoagulants. These devices are particularly suitable for men with contraindications to medication and have success rates of around 60–80%.

Penile prosthesis surgery represents a definitive treatment for refractory cases, involving surgical implantation of inflatable or semi-rigid rods. Whilst patient satisfaction rates exceed 90% among those who proceed with this option, risks include infection, mechanical failure requiring revision surgery, and irreversible changes to penile tissue. Referral to a specialist urology centre is required. NICE Clinical Knowledge Summary guidance emphasises that treatment choice should be individualised, considering patient preference, underlying cause, and contraindications.

Lifestyle Changes That May Improve Erectile Function

Cardiovascular health and erectile function are intimately connected, as both rely on healthy blood vessel function. Evidence demonstrates that lifestyle modifications can significantly improve ED, particularly in men with modifiable risk factors. Weight loss in overweight or obese men has been shown to improve erectile function. Research, including randomised controlled trials, suggests that approximately one-third of obese men with ED who lost 10% of their body weight experienced resolution of their symptoms. This improvement likely results from enhanced endothelial function, reduced inflammation, and improved hormonal balance (particularly increased testosterone levels). Results may vary among individuals.

Regular physical activity is strongly associated with better erectile function. The NHS recommends at least 150 minutes of moderate-intensity aerobic exercise weekly. Studies suggest that aerobic exercise—such as brisk walking, cycling, or swimming—can improve ED by enhancing cardiovascular fitness, reducing blood pressure, and improving endothelial function. Pelvic floor exercises (also known as Kegel exercises) may also benefit some men by strengthening the muscles involved in maintaining erections. The NHS provides resources on pelvic floor exercises for men.

Smoking cessation is crucial, as tobacco use damages blood vessels and impairs blood flow throughout the body, including to the penis. Research indicates that men who stop smoking may experience improvements in erectile function, particularly younger men without established vascular disease. Similarly, reducing alcohol consumption is advisable, as excessive drinking can impair erectile function both acutely and chronically.

Dietary modifications aligned with cardiovascular health—such as adopting a Mediterranean-style diet rich in fruits, vegetables, whole grains, fish, and olive oil—may improve erectile function. Some evidence suggests that this dietary pattern improves endothelial function and reduces inflammation.

Managing stress and improving sleep quality are also important, as both psychological stress and sleep disorders (particularly obstructive sleep apnoea) are associated with ED. If obstructive sleep apnoea is suspected, formal assessment and treatment (such as continuous positive airway pressure, CPAP) may improve erectile function in appropriate patients.

Whilst lifestyle changes alone may not resolve ED in all cases, they form an essential component of comprehensive management and improve overall health outcomes.

When to See a Healthcare Professional About ED

Men should seek medical evaluation for ED rather than attempting to self-manage the condition, as professional assessment serves multiple important purposes. Firstly, ED may be the presenting symptom of serious underlying health conditions, particularly cardiovascular disease, diabetes, or hormonal disorders. ED can precede coronary artery disease by 2–5 years, making it a valuable early warning sign. A thorough medical evaluation can identify these conditions, enabling early intervention that may prevent serious complications such as heart attack or stroke.

Seek urgent medical attention if you experience:

• Priapism (an erection lasting more than 4 hours), which constitutes a medical emergency requiring immediate treatment to prevent permanent penile damage

• Painful erections or penile trauma

• Acute neurological symptoms (such as sudden weakness, numbness, or difficulty speaking)

• Chest pain or severe dizziness during sexual activity or after taking ED medication

Routine consultation with a GP is appropriate when ED persists for more than a few weeks, causes distress, or affects quality of life and relationships. During the consultation, the GP will typically take a comprehensive medical and sexual history, perform a physical examination, and arrange appropriate investigations. These may include:

• Blood tests: HbA1c (diabetes screening), fasting lipid profile (cardiovascular risk assessment), blood pressure measurement and QRISK cardiovascular risk score

• Hormone tests: Morning total testosterone on two separate occasions; if low, further tests including luteinising hormone (LH), sex hormone-binding globulin (SHBG), and possibly prolactin

• Thyroid function tests where clinically indicated

• Review of current medicines, as numerous drugs can contribute to ED

Referral to a specialist may be needed in certain situations:

• Urology: For Peyronie's disease, anatomical abnormalities, or ED that does not respond to first-line treatment

• Endocrinology: For confirmed or suspected hypogonadism (low testosterone) or other hormonal disorders

• Cardiology: For unstable or high-risk cardiovascular disease requiring risk stratification before resuming sexual activity

• Psychosexual therapy: For significant psychological factors contributing to ED

Men should not feel embarrassed about discussing ED, as it is a common medical condition that healthcare professionals routinely address. In the UK, sildenafil 50 mg (Viagra Connect) is available from pharmacies following an appropriate assessment by the pharmacist. However, purchasing medicines from unregulated online sources is strongly discouraged, as this bypasses essential health screening and may be dangerous, particularly for men with undiagnosed cardiovascular disease. Additionally, unregulated online sources may supply counterfeit or substandard medicines. The NHS, MHRA, and General Pharmaceutical Council emphasise that ED medicines should only be obtained through legitimate healthcare channels following appropriate medical assessment.

If you experience a suspected side effect from any ED medicine, you can report it via the MHRA Yellow Card Scheme at yellowcard.mhra.gov.uk or through the Yellow Card app.

Understanding Treatment Success Rates and Expectations

Realistic expectations are essential for treatment satisfaction, as the definition of "success" varies among individuals and depends on the underlying cause of ED, treatment modality, and personal circumstances. For PDE5 inhibitors, overall response rates range from 60–70%, though this varies by cause. Men with psychogenic ED typically experience higher success rates, whilst those with severe diabetes, extensive vascular disease, or post-prostatectomy ED may have lower response rates. It is important to understand that these medicines require sexual stimulation to work—they do not produce spontaneous erections—and that several attempts (typically 4–8 doses) with correct timing and technique may be needed before determining treatment failure.

Practical optimisation tips for PDE5 inhibitors include:

• Taking sildenafil on an empty stomach (high-fat meals may delay its effect)

• Allowing adequate time before sexual activity (sildenafil and vardenafil: 30–60 minutes; tadalafil: 30 minutes to 12 hours; avanafil: 15–30 minutes)

• Avoiding excessive alcohol, which can impair erectile function

• Trying the medicine on multiple occasions before concluding it is ineffective

Treatment success should be measured holistically, considering not only the ability to achieve penetrative intercourse but also improvements in confidence, relationship satisfaction, and overall quality of life. Some men may achieve erections sufficient for sexual activity but not as firm as they desire, which may still represent a meaningful improvement. Partner involvement in treatment discussions can enhance outcomes, as relationship dynamics significantly influence sexual satisfaction.

Combination approaches may be necessary for some men. For instance, lifestyle modifications combined with medication often produce better results than either intervention alone. When first-line treatments prove inadequate, sequential trials of different PDE5 inhibitors, dose optimisation, or progression to second-line therapies (such as intracavernosal injections or vacuum devices) may be appropriate. NICE Clinical Knowledge Summary guidance supports a stepwise approach, with more invasive options reserved for those who do not respond to conservative measures. Referral to urology may be needed if first-line approaches are inadequate.

Psychological factors significantly influence treatment outcomes. Performance anxiety, relationship difficulties, or depression may persist even when physical erectile capacity improves, potentially limiting treatment success. In such cases, psychosexual counselling or cognitive behavioural therapy may be beneficial, either alone or alongside physical treatments. The NHS provides access to psychosexual therapy services, though availability varies by region.

Men should understand that ED treatment is often an ongoing process requiring patience, open communication with healthcare providers, and sometimes adjustment of therapeutic strategies to achieve optimal outcomes.

Frequently Asked Questions