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ERECTILE DYSFUNCTION (IMPOTENCE
Information about your condition from
The British Association of Urological Surgeons (BAUS)
You have been given this leaflet to provide you with
detailed information about erectile dysfunction.
We have consulted specialist surgeons during its
preparation, so it represents the best practice in UK
urology. You should use it in addition to any advice
already given to you.
To view this leaflet online, scan the QR code (right) or
type the short URL below it into your web browser:
KEY POINTS
• Erectile dysfunction is a common problem in men over the age of
40
• Lifestyle modification such as increasing activity, stopping
smoking, controlling high blood pressure and managing blood
sugar levels are helpful in all patients
• Specific first-line treatment with tablets can be started by your
general practitioner
• Some patients are not eligible for free treatment of their erectile
dysfunction under the NHS
What is erectile dysfunction?
Erectile dysfunction (impotence) is the inability to develop or keep an
erection sufficient for sexual intercourse. One in ten men (10%) suffer from
impotence and it is seen in almost one third (30%) of diabetic men.
The ability to develop an erection is an important part of a man’s overall
health, regardless of age. However, many men suffer erectile dysfunction in
silence, without seeking help or advice.
How do normal erections occur?
If he is to achieve an erection, a man needs:
Published: Jun 2024 Leaflet No: A24/079
Review due: Sep 2026 © British Association of Urological Surgeons Limited
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• an adequate circulating level of hormones;
• an adequate blood flow to the penis;
• intact nerves supplying the penis; and
• an appropriate sexual desire.
If there is a problem with one or more of these mechanisms, erection may
fail. During arousal, nerve impulses travel from the brain to the penis and
trigger smooth muscle relaxation in the penis. This encourages blood to
flow into the erectile tissues.
As the penis fills with blood, it enlarges and becomes erect. During
enlargement, the veins in the penis become compressed, blocking the flow
of blood out of the penis so that erection occurs. The penis remains erect
until orgasm and/or ejaculation is completed or sexual arousal ceases.
What physical causes are there for erectile dysfunction?
• Hormone imbalance – a deficiency of male hormones (such as
testosterone) can reduce your desire or interest in sexual function
• Nerve damage - this can result in reduced sensitivity, or reduced
signals to your penis to release the chemicals that cause an erection
to develop
• Disease of the blood vessels - blood vessels can become narrowed
and hardened with increasing age. This reduces blood supply to your
penis. If the blood supply is poor, your penis may not fill with blood,
the veins may not be compressed adequately, allowing blood to leak
out of the penis. You will not, therefore, be able to maintain an
erection.
Published: Jun 2024 Leaflet No: A24/079
Review due: Sep 2026 © British Association of Urological Surgeons Limited
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• Trauma - such as injury to your spinal cord
• Pelvic surgery - some cancer operations on the prostate, bladder or
bowel may result in nerve damage leading to erectile dysfunction
• Drugs - some drugs (especially those used to treat high blood
pressure, depression and anxiety and recreational drugs) may cause
erectile dysfunction
• Smoking and alcohol - those who smoke and drink are more likely
to suffer from erectile dysfunction.
In men with diabetes, the commonest causes of erectile dysfunction are
disease of the blood vessels and nerve damage (often in combination).
Can psychological problems cause erectile dysfunction?
Yes. It is not uncommon to see a combination of psychological and physical
causes, but pure psychological causes are seen in less than 1 in 10 (10%) of
all affected patients. Erectile dysfunction can be caused by stress,
depression, anxiety, relationship problems, embarrassment, guilt and other
psychological issues.
When a man has difficulty getting an erection, whatever the cause, he will
often experience pressure to perform. This can lead to a feeling of
inadequacy and a sense of loss of manhood (called performance anxiety).
These are all common emotions for men with erectile dysfunction.
What can I do about the problem?
It is important to share your concerns with your doctor or nurse, so they
can advise you about any tests which are needed. If possible, you should
include your partner in the discussions to allow you to work through your
concerns together.
There are some simple tests that your GP can do, such as blood tests to
measure your lipids (cholesterol), blood sugar (diabetes check), early-
morning fasting testosterone levels (hormone check) and measuring your
blood pressure. Blood tests should be carried out first thing in the morning,
(before 10am), and you should be starved from the night before.
Lowering cholesterol, high blood pressure, blood sugar levels (in diabetes)
and maintaining a healthy weight are an effective starting point in treating
your erectile dysfunction.
Once this assessment has been completed, other treatment options can be
discussed with your GP.
Published: Jun 2024 Leaflet No: A24/079
Review due: Sep 2026 © British Association of Urological Surgeons Limited
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What treatments are available?
It is up to you and your sexual partner to decide what treatment you
choose. Your specialist will give you guidance on what he/she feels is most
appropriate for you.
Specific treatment is only available on the NHS (Schedule 2) to patients
who:
• have diabetes mellitus, multiple sclerosis, Parkinson’s disease,
poliomyelitis;
• have renal failure treated by dialysis or transplantation;
• have had radical pelvic surgery (e.g. radical prostatectomy) or have
been treated for prostate cancer (using surgery and other
treatments);
• have had severe pelvic injury, single-gene neurological disease, spinal
cord injury or spina bifida; or
• are not included in the above categories but were receiving NHS
treatment (such as Caverject™, Viagra™ or Viridal™) for their erectile
dysfunction on or before 14 September 1998.
Previously the Department of Health guidance stated that prescribing for
those with erectile dysfunction causing “severe distress” should only be
done by specialist services.
It is now possible for patients with erectile dysfunction to be prescribed
generic sildenafil (also known as Viagra) from their own GP. This will allow
you to start treatment before attending a specialist service, if this is
required.
In summary, the basic treatment options are shown below. Click the
individual headings for further information elsewhere on the BAUS
website:
Psychosexual counselling
Some men need counselling and will
be referred to a specialist in this area.
Counselling can be part, or all, of the
treatment required.
Vacuum erection assistance devices
Vacuum erection assistance devices
(pictured right) are a non-invasive
method of obtaining and sustaining an erection in men with impotence
(erectile dysfunction). To use the device, you insert your penis into a
Published: Jun 2024 Leaflet No: A24/079
Review due: Sep 2026 © British Association of Urological Surgeons Limited
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cylinder with plenty of lubricating jelly that also provides a seal at its base.
You get an erection by creating a negative pressure inside the cylinder,
using a hand-operated or battery-powered pump. A ring is often placed
around the base of your penis to help maintain the erection.
Tablet treatment
First-line treatment for most patients is now tablet treatment using
sildenafil (generic or Viagra™), tadalafil (Cialis™), vardenafil (Levitra™) or
avanafil (Spedra™).
Your GP will prescribe the appropriate tablets for you in the first
instance. An NHS prescription only allows you to be given one tablet
per week, but generic sildenafil (i.e. tablets not trademarked as Viagra)
is not subject to these restrictions.
Hormone treatment
This is only offered to patients who are deficient in male hormones.
Medication can restore hormone imbalance and but does not always restore
potency.
Hormone treatment will not improve erections in men who do not have
hormone deficiency (and may even be harmful in this situation).
Self-injection therapy
This treatment involves injecting a drug
into the side of your penis each time you
want an erection.
The injection causes the muscles in your
penis to relax which encourages blood to
flow into your penis. If you choose this
option, we will train you to inject yourself.
Injection therapy is very effective but
some men find the idea difficult to accept,
particularly as a long-term treatment
option. Injections can be used up to twice
a week but you should never inject yourself more than once in any 24-hour
period.
As with all drugs, there are some side-effects. For example, your erection
may not go down and you then need to come to hospital to have it reversed.
Fortunately, this only happens in 1 in 100 patients (1%).
Published: Jun 2024 Leaflet No: A24/079
Review due: Sep 2026 © British Association of Urological Surgeons Limited
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Intra-urethral pellets or cream
This involves insertion of a pellet of prostaglandin into the urethra
(waterpipe).
Only 35 to 40% of patients get good quality erections, and the pellet can
cause pain or facial flushing.
Penile implants
This is an invasive surgical procedure which involves putting prostheses
(implants) into your penis to allow you to achieve erections for sexual
intercourse. These implants are available either as inflatable or malleable
(bendy) prostheses.
Penile implants are reserved for patients who have either tried and failed to
tolerate other medical treatments such as tablets, injections, vacuum
devices or pellets. They may also be used in patients with other conditions
in which erections have been affected, such as following priapism
(prolonged painful erections) or in men with Peyronie’s disease (curvature
of the penis).
The entire device is implanted into the body. It can be felt through the skin
but is not visible on the outside.
What sources were used to prepare this leaflet?
This leaflet uses information from consensus panels and other evidence-
based sources including:
• the Department of Health (England);
Published: Jun 2024 Leaflet No: A24/079
Review due: Sep 2026 © British Association of Urological Surgeons Limited
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• the Cochrane Collaboration; and
• the National Institute for Health and Care Excellence (NICE).
It also contains advice about the prescription of drugs. All NHS hospitals
have local arrangements with their Clinical Commissioning Groups (CCGs)
about which medicines can be used. Thus, some drugs mentioned cannot
be prescribed by local hospitals.
Your treatment will be planned with the doctors responsible for your care,
considering not only which drugs are, or are not, available at your local
hospital but also what is necessary to give you the best quality of care.
Healthcare professionals are advised to check prescribing arrangements
with their local hospital or CCG.
This leaflet also follows style guidelines from:
• the Royal National Institute for Blind People (RNIB);
• the Information Standard;
• the Patient Information Forum; and
• the Plain English Campaign.
DISCLAIMER
Whilst we have made every effort to give accurate information, there
may still be errors or omissions in this leaflet. BAUS cannot accept
responsibility for any loss from action taken (or not taken) as a result
of this information.
PLEASE NOTE: the staff at BAUS are not medically trained, and are
unable to answer questions about the information provided in this
leaflet. If you have any questions, you should contact your Urologist,
Specialist Nurse or GP in the first instance.
Published: Jun 2024 Leaflet No: A24/079
Review due: Sep 2026 © British Association of Urological Surgeons Limited