Nerve damage is a significant cause of erectile dysfunction (ED), affecting the complex pathways required for normal erectile function. When nerves connecting the brain, spinal cord, and penis are damaged, the signals necessary to achieve and maintain an erection may be disrupted or lost. This neurogenic erectile dysfunction can result from various conditions including diabetes, spinal cord injuries, multiple sclerosis, pelvic surgery, and other neurological disorders. Understanding the relationship between nerve damage and erectile function is essential for appropriate diagnosis and treatment. This article explores how nerve damage causes ED, common underlying causes, diagnostic approaches, and available treatment options within the UK healthcare system.

How Nerve Damage Causes Erectile Dysfunction

Yes, nerve damage can cause erectile dysfunction (ED). Achieving and maintaining an erection is a complex process that requires intact nerve pathways between the brain, spinal cord, and penis. When these nerves are damaged, the signals necessary for an erection may be disrupted or lost entirely.

The mechanism of a normal erection involves both psychological and physical stimulation triggering nerve signals that travel down the spinal cord to the pelvic region. These signals cause the smooth muscle in the corpora cavernosa (the erectile tissue of the penis) to relax, allowing blood to flow in and create rigidity. Simultaneously, veins that normally drain blood from the penis become compressed, trapping blood within the erectile tissue. This process involves both parasympathetic (S2-S4) and sympathetic (T11-L2) nerve pathways, with nitric oxide release triggering a cascade of events leading to smooth muscle relaxation via the cGMP pathway.

When nerve damage occurs, this finely tuned system breaks down. The nerves may fail to transmit signals effectively, preventing the release of nitric oxide and other neurotransmitters essential for smooth muscle relaxation. Without adequate nerve function, blood vessels cannot dilate properly, and insufficient blood reaches the penis to produce or sustain an erection.

Nerve-related erectile dysfunction is classified as neurogenic ED. The severity depends on the extent and location of nerve damage. Some men experience partial erectile function, whilst others may lose the ability to achieve erections entirely. Nerve damage affecting erections typically occurs alongside other neurological symptoms, though occasionally ED may be an early manifestation of an underlying neurological condition.

Common Causes of Nerve Damage Affecting Erections

Multiple conditions and circumstances can damage the nerves responsible for erectile function. Diabetes mellitus is one of the most prevalent causes of neurogenic erectile dysfunction in the UK. Prolonged elevated blood glucose levels cause diabetic neuropathy, which can affect the peripheral nerves controlling erections. According to Diabetes UK, up to 50% of men with diabetes experience some degree of erectile dysfunction, with nerve damage being a significant contributing factor.

Spinal cord injuries represent another major cause, with the level and completeness of injury determining erectile function. Injuries above the sacral spinal cord (S2-S4) may preserve reflex erections but impair psychogenic erections, whilst lower injuries can affect both. Pelvic surgery, particularly radical prostatectomy for prostate cancer, carries a risk of nerve damage. Surgeons attempt nerve-sparing techniques, but the proximity of neurovascular bundles to the prostate means some degree of nerve injury remains possible.

Multiple sclerosis (MS) damages the myelin sheath surrounding nerves throughout the central nervous system, disrupting signal transmission. The MS Society UK reports that erectile dysfunction affects approximately 50-90% of men with MS at some point. Other neurological conditions include:

• Parkinson's disease – affecting autonomic nervous system function

• Stroke – potentially damaging brain regions involved in sexual arousal

• Pelvic trauma – from accidents or fractures affecting nerve pathways

• Chronic alcoholism – causing peripheral neuropathy through toxic and nutritional mechanisms

Surgical complications beyond prostate surgery, including colorectal procedures, cystectomy and extensive pelvic operations, may inadvertently damage the pudendal or pelvic nerves. Radiation therapy to the pelvic region can also cause delayed nerve damage. Less commonly, conditions such as herniated discs affecting sacral nerve roots or cauda equina, or vitamin B12 deficiency leading to neuropathy may contribute to erectile difficulties. Some medications, including certain chemotherapy agents, can also cause peripheral neuropathy affecting erectile function.

Symptoms and Diagnosis of Nerve-Related Erectile Dysfunction

Neurogenic erectile dysfunction typically presents with specific patterns that may help distinguish it from vascular or psychological causes. Men often report a gradual onset of difficulty achieving erections, though sudden onset can occur with acute nerve injuries such as spinal trauma. The inability to achieve erections in any circumstance—including during sleep or upon waking—suggests an organic cause like nerve damage, as opposed to psychological ED where morning erections may be preserved.

Accompanying symptoms often provide diagnostic clues. These may include:

• Reduced penile sensation or altered sensitivity

• Numbness or tingling in the genital area, perineum, or lower limbs

• Bladder or bowel dysfunction – urgency, incontinence, or constipation

• Loss of ejaculatory control or absent ejaculation

• Muscle weakness or coordination problems in the legs

Diagnosis begins with a comprehensive medical history and physical examination. Your GP or specialist will enquire about the onset and pattern of erectile difficulties, associated symptoms, medical conditions (particularly diabetes and neurological disorders), medications, surgical history, and lifestyle factors. A focused neurological examination assesses reflexes, sensation in the genital and perineal region (saddle area), and anal sphincter tone.

Investigations recommended by NICE for erectile dysfunction include blood pressure measurement, cardiovascular risk assessment, fasting glucose or HbA1c to screen for diabetes, lipid profile, and morning testosterone levels (measured between 9-11 am). If testosterone is low, this should be repeated and may require additional tests including LH, FSH, prolactin, and thyroid function. When nerve damage is suspected, additional specialist tests may include:

• Neurophysiological studies – such as pudendal nerve conduction studies (rarely required)

• MRI of the spine or brain – if structural neurological pathology is suspected based on examination findings

• Nocturnal penile tumescence testing – occasionally used to distinguish organic from psychological causes

Referral to urology or neurology specialists is appropriate when neurogenic ED is suspected, particularly if accompanied by other neurological symptoms. If you experience sudden onset saddle anaesthesia, new bladder or bowel dysfunction, or severe back pain with leg weakness, seek immediate emergency care (call 999 or go to A&E) as these may indicate cauda equina syndrome—a medical emergency requiring urgent intervention.

Treatment Options for Nerve Damage and Erectile Dysfunction

Treatment for neurogenic erectile dysfunction requires a tailored approach addressing both the underlying nerve damage and erectile symptoms. The extent of nerve injury and potential for recovery significantly influence treatment selection and outcomes.

Phosphodiesterase type 5 (PDE5) inhibitors remain the first-line pharmacological treatment, even in neurogenic ED. Medications such as sildenafil, tadalafil, vardenafil and avanafil work by enhancing the effects of nitric oxide, promoting smooth muscle relaxation and increased blood flow to the penis. These medications require sexual stimulation to be effective and are contraindicated in patients taking nitrates or riociguat. Caution is needed when used with alpha-blockers due to potential blood pressure effects. Common side effects include headache, facial flushing, indigestion, nasal congestion and, occasionally, visual disturbances. In the UK, sildenafil 50mg may also be available through pharmacy supply following pharmacist assessment.

When oral medications prove insufficient, second-line treatments include:

• Intracavernosal injections – alprostadil injected directly into the penis produces erections independently of nerve signals by directly relaxing smooth muscle. Success rates are high, though the injection technique requires training. Side effects include pain at the injection site and, rarely, priapism (seek emergency care for erections lasting >4 hours).

• Vacuum erection devices – mechanical devices creating negative pressure to draw blood into the penis, with a constriction ring maintaining the erection. These are non-invasive and suitable when medications are contraindicated. Caution is advised in men with bleeding disorders or on anticoagulants.

• Intraurethral alprostadil – a pellet inserted into the urethra, absorbed into erectile tissue

For severe, treatment-resistant cases, penile prosthesis implantation offers a definitive solution. Inflatable or semi-rigid implants provide mechanical rigidity, with high satisfaction rates reported. This surgical option is typically reserved for men who have not responded to conservative measures.

Managing the underlying condition is equally important. Optimising diabetic control can slow neuropathy progression, whilst physiotherapy and rehabilitation following spinal injury may improve outcomes. For men with confirmed hypogonadism, testosterone replacement therapy may be considered, often in combination with PDE5 inhibitors. Psychological support and relationship counselling complement medical treatments, as erectile dysfunction significantly impacts quality of life and intimate relationships. The NHS provides access to psychosexual therapy services, which can be beneficial even when organic causes predominate.

When to See a Doctor About Erectile Dysfunction

Seeking medical advice for erectile dysfunction is important, particularly when nerve damage may be involved. Many men delay consultation due to embarrassment, but early assessment enables timely diagnosis of potentially serious underlying conditions and access to effective treatments.

You should contact your GP if:

• Erectile difficulties persist for more than a few weeks or are worsening

• ED is accompanied by other symptoms such as numbness, tingling, or weakness in the legs or genital area

• You experience bladder or bowel problems alongside erectile dysfunction

• There is loss of sensation in the genital region or perineum

• Erectile dysfunction develops following surgery, injury, or starting new medications

• You have diabetes or known neurological conditions and notice changes in erectile function

Seek immediate emergency care (call 999 or go to A&E) if you experience:

• Sudden onset of numbness around the genitals, buttocks, or inner thighs (saddle anaesthesia)

• New bladder or bowel dysfunction – inability to urinate, loss of bladder or bowel control

• Severe back pain with leg weakness and erectile dysfunction

• Painful, persistent erection lasting more than four hours (priapism)

These symptoms may indicate serious conditions such as cauda equina syndrome, which requires emergency treatment to prevent permanent nerve damage.

Your GP consultation will involve discussing your symptoms, medical history, and lifestyle factors in confidence. Physical examination and initial blood tests can often be arranged during the same visit. Your GP can initiate treatment with PDE5 inhibitors if appropriate or arrange referral to specialist services including urology, neurology, or diabetes clinics depending on suspected underlying causes.

Remember that erectile dysfunction is a common medical condition affecting many men, particularly over the age of 40. Healthcare professionals are experienced in managing this sensitive issue with discretion and professionalism. Early intervention not only improves erectile function but may also identify important health conditions such as diabetes, cardiovascular disease, or neurological disorders that benefit from prompt treatment. The NHS provides comprehensive support, and effective treatments are available regardless of the underlying cause.

If you experience side effects from any medications prescribed for erectile dysfunction, report these to your healthcare professional and consider using the MHRA Yellow Card Scheme to report suspected adverse drug reactions.

Frequently Asked Questions