Erectile dysfunction
When tablets stop working, that is not the end of the options — and ED is often the first warning sign of a wider cardiovascular problem worth catching.
What erectile dysfunction is
Erectile dysfunction is the persistent inability to get or maintain an erection sufficient for satisfactory sexual activity. Occasional difficulty is normal and universal. Consistent difficulty over three months or more warrants assessment.
ED becomes more common with age but is not an inevitable part of ageing. It affects a significant proportion of men over 40, and a meaningful number of men in their twenties and thirties.
Why ED deserves a proper medical assessment
The arteries that supply the penis are considerably smaller than the coronary arteries. When atherosclerosis develops, these smaller vessels are affected first. This means erectile dysfunction frequently appears two to five years before a heart attack or stroke.
An ED consultation is therefore also a cardiovascular assessment. Blood pressure, cholesterol, blood sugar and testosterone all need checking. Men who are treated for ED without this workup may have an important diagnosis missed — and this is one of the main problems with buying tablets online without seeing anybody.
Causes
- Vascular — reduced arterial inflow or venous leak. The most common cause, and associated with diabetes, high blood pressure, high cholesterol and smoking.
- Neurological — diabetes, multiple sclerosis, spinal injury, or nerve damage from pelvic surgery, particularly radical prostatectomy.
- Hormonal — low testosterone, thyroid disorders, raised prolactin.
- Medication — some antidepressants, blood pressure drugs, finasteride and others.
- Structural — Peyronie's disease, previous priapism, or prior pelvic radiotherapy.
- Psychological — performance anxiety, depression, relationship difficulty and stress. Often a component alongside a physical cause rather than an alternative to it.
- Lifestyle — smoking, excess alcohol, recreational drugs, obesity, inactivity, poor sleep.
How I assess it
Assessment covers the history and pattern of your symptoms — including whether you still get night-time or early-morning erections, which is informative — your medical history, medication, and relationship context. Examination includes the genitalia, an assessment for Peyronie's plaques and, where appropriate, a prostate examination. Blood tests cover morning testosterone, glucose or HbA1c, lipids, and other hormones as indicated. Penile duplex ultrasound is used where the vascular status needs objective measurement, particularly before considering surgery.
If tablets have stopped working
Before concluding that oral medication has failed, it is worth checking that it has been used correctly — adequate dose, on an empty stomach for some drugs, with sexual stimulation, and given several attempts. A significant number of men labelled as “non-responders” have simply never been shown how to use the treatment properly, or have an untreated testosterone deficiency that prevents it working.
Treatment
Treatment follows a ladder, and most men do not need to climb all of it:
- Addressing the underlying cause — cardiovascular risk, glycaemic control, medication review, testosterone replacement where genuinely deficient, weight, alcohol, smoking and exercise. These are not token advice; they change outcomes.
- Oral PDE5 inhibitors — sildenafil, tadalafil and others, used either on demand or as a daily low dose.
- Vacuum erection devices — effective, drug-free, and particularly useful in penile rehabilitation after prostate surgery.
- Intracavernosal injection therapy — highly effective even where tablets have failed. Taught properly in clinic, it is far less daunting than it sounds.
- Intraurethral treatments for men who prefer not to inject.
- Psychosexual therapy, alone or alongside medical treatment.
- Penile prosthesis surgery — for men in whom other treatments have failed or are unsuitable. Modern inflatable implants have among the highest satisfaction rates of any treatment in men's health.
ED after prostate cancer treatment
Erectile dysfunction after radical prostatectomy or radiotherapy is common and has a different natural history from other causes, with recovery sometimes continuing over two years. Structured rehabilitation matters. I co-founded the Guy's Hospital Post Prostatectomy Service with consultant urologist Arun Sahai in 2019 specifically to address functional recovery after prostate cancer surgery; the service has won nine awards. See after prostate cancer surgery.
My practice
I am Director and Clinical Lead for the Andrology Prosthesis Centre at Guy's Hospital, a supra-regional network for prosthetic surgery spanning Guy's, King's College Hospital, Imperial College and Oxford, and a past National Chair of the BAUS Andrology section.
Frequently asked
Is erectile dysfunction usually psychological?
Less often than men assume. Most cases have a physical component, frequently vascular, with a psychological element layered on top. Sudden onset with preserved morning erections points more towards a psychological cause; gradual onset with loss of morning erections points towards a physical one. Both can be treated.
Will testosterone treatment fix my ED?
Only if you are genuinely testosterone deficient on properly taken morning blood tests, and even then it more often improves libido than erections directly. Testosterone is not a general ED treatment, and it suppresses sperm production — so it must not be started without a fertility discussion if you want children.
How long does a penile implant last?
Modern three-piece inflatable implants are durable devices, with the large majority still functioning many years after surgery. They can be revised or replaced if a mechanical failure occurs. Satisfaction rates for both men and partners are high, but the decision is irreversible — the natural erection mechanism cannot be restored afterwards — so it is discussed at length beforehand.
Does shockwave therapy work for ED?
Low-intensity shockwave therapy shows promise in men with mild to moderate vascular ED, but the evidence base is still developing and results vary between protocols and devices. It is not effective for severe ED or after radical prostatectomy. I will be straightforward about what the evidence currently supports.
Can I be seen discreetly?
Yes. Consultations are private, in outpatient facilities at The Shard or Canary Wharf, and video consultations are available for the initial discussion and for reviewing results. Correspondence goes wherever you ask it to go.
Speak to my team
Appointments at The Shard and Canary Wharf are arranged by my PA, Jeanette Bush. Tell us briefly what the problem is and we will find the right clinic slot for you.