Erectile dysfunction: causes, fixes and getting harder

Here is a secret nobody says out loud at the pub: almost every man has gone soft at the wrong moment. Too many pints, a stressful week, a new partner you really fancy. It happens, and it is not erectile dysfunction.

Erectile dysfunction, or ED, means ongoing trouble getting or keeping an erection firm enough for satisfying sex. Doctors start to call it ED when the problem happens more often than not, or keeps coming back over weeks or months. It can be mild, where you are a bit less rock hard than you used to be, or more complete, where getting hard at all is a struggle.

It is very common. The Massachusetts Male Aging Study found that around half of men aged 40 to 70 had some degree of erectile dysfunction, and it becomes more likely with age. It is not an inevitable part of getting older, though, and it is treatable at any age.

If you are reading this at 2am after a bad night, breathe. One soft moment does not mean you have erectile dysfunction, and even if you do, you are in very large company with very good options.

An erection is mostly a plumbing job run by your brain. When you get turned on, by a touch, a smell, a dirty thought, your brain sends signals down the nerves to the penis. These trigger the release of nitric oxide, which relaxes the smooth muscle in the blood vessel walls.

As those muscles relax, the arteries widen and blood rushes into two spongy chambers inside the penis. As they fill, they squeeze the veins that normally drain blood away, trapping it in place. That is what keeps you hard.

When arousal fades or you come, the process reverses. Muscles tighten, blood drains away and you go soft again. Losing an erection is not failure, it is just the system switching off, sometimes a little too early when stress jumps in.

So a good erection needs healthy nerves, healthy blood vessels, the right hormones and a mind that is not flooded with stress. A glitch in any one of these can get in the way, which is why erectile dysfunction often has more than one cause.

In men over 40, the most common causes of erectile dysfunction are physical, especially anything that affects blood vessels. Psychological factors often pile on, because one disappointing night creates worry that makes the next one harder.

• Heart disease, high blood pressure and high cholesterol
• Type 2 diabetes, which affects both nerves and blood vessels
• Smoking, heavy drinking and recreational drugs
• Carrying extra weight and not moving much
• Low testosterone or other hormone problems
• Some medicines, including certain antidepressants and blood pressure drugs

Stress, anxiety, depression and relationship problems belong on that list too. Surgery or radiotherapy for prostate or bowel cancer can also damage the nerves involved. Most men have a mix, which is good news, because it means there are several levers you can pull at once.

Erectile dysfunction in young men is more common than most guys realise, and it tends to have a different flavour. Performance anxiety is a big one. You worry about losing it, adrenaline floods your system, adrenaline squeezes blood away from your penis, and you lose it. Then you worry more next time.

Alcohol, tiredness, recreational drugs and some medicines play a part too. Porn-related ED gets heated debate online. The research is still unsettled, but some men find that frequent, very intense solo sessions make partnered sex feel less arousing for a while. Cutting back for a few weeks is harmless to try and may help you tune back into real touch.

A good clue is whether you still wake up hard or get firm when you masturbate. If you do, the plumbing probably works and your head is doing more of the damage. Even so, a check-up is sensible, because young men can have physical causes too.

This is the bit many men never hear. The arteries in the penis are smaller than the ones feeding the heart. If they start to narrow or stiffen, erection problems can show up years before chest pain or a heart attack.

Research has found that men with erectile dysfunction have a higher risk of later heart disease, and doctors now see ED as a good reason to check blood pressure, cholesterol and blood sugar. Your penis can be an early messenger for your heart.

So rather than feeling embarrassed, think of a GP visit about ED as a full MOT. Treating the underlying problem can protect your heart and make you harder at the same time. Not a bad deal.

Diabetes deserves a special mention. High blood sugar damages both nerves and blood vessels, so erection trouble is often one of the first signs. Getting your sugar under control can protect your erections as well as your eyes, kidneys and feet.

The most common erectile dysfunction treatment is a tablet from the PDE5 inhibitor family, such as sildenafil (Viagra) or tadalafil (Cialis). They help the blood vessels in the penis relax and stay open when you are aroused. They do not give you an erection out of nowhere, so you still need desire and touch. In the UK, a version of sildenafil is available from pharmacies after a short consultation.

Sildenafil usually works for a few hours, while tadalafil can last up to a day and a half, which some couples love because it feels less planned. A low daily dose of tadalafil is another option. Common side effects include headache, flushing, indigestion and a stuffy nose. It can take a few tries to find the right dose, so do not give up after one go.

If tablets do not suit you, options include a vacuum pump, injections or a small pellet placed in the urethra, and for some men a penile implant fitted by a surgeon. Implants sound dramatic but have high satisfaction rates. If anxiety or relationship strain is involved, sex therapy alongside medicine often gives the best results.

Want to know how to get harder erections without a pill? Look after your blood vessels, because what is good for your heart is good for your hard-on. Studies have shown that weight loss and regular exercise can improve erectile function in overweight men, sometimes enough to make a real difference without medicine.

• Stop smoking, which damages blood vessels directly.
• Cut back on alcohol, especially before sex.
• Move more, with brisk walks, cycling or swimming most days.
• Eat more vegetables, fruit, whole grains and oily fish.
• Prioritise sleep, since testosterone is made largely while you sleep.
• Train your pelvic floor, which a UK trial found helped many men with ED.

To find your pelvic floor, squeeze the muscles you would use to stop peeing midstream. Hold for a few seconds, relax, repeat. Do a few sets a day and give it a few months. Bonus: stronger pelvic floor muscles can make orgasms feel more intense too.

Plenty of men hunt for ED natural remedies before seeing a doctor. A few have some evidence. Korean red ginseng has shown modest benefits in small trials, and L-arginine, an amino acid involved in making nitric oxide, may help a little in some men. Results are mixed and much weaker than prescription medicine.

The bigger risk is with herbal sex pills sold online or in corner shops. Regulators regularly find hidden prescription drugs in them, sometimes in unsafe doses. That is especially dangerous if you take nitrate heart medicine.

Be sceptical of anything promising instant results, permanent enlargement or a cure in days. If you want to try a natural option, ask a pharmacist first, buy from a reputable source, and treat it as an extra rather than a replacement for a proper check-up.

And remember, the most effective natural remedy is still the boring trio: move more, smoke less, drink less. No capsule can beat healthier arteries.

Many men put this off because they dread the conversation. In reality, GPs talk about this all the time, and it is usually a short, matter-of-fact appointment. Nobody is going to laugh.

Your doctor will ask how long it has been happening, whether you still get morning erections, and about your general health, medicines, drinking and smoking. You will probably have your blood pressure checked and a blood test for sugar, cholesterol and sometimes testosterone.

An examination is occasionally needed. If something more complex is going on, you may be referred to a urologist or a psychosexual therapist. Either way, you walk out with a plan.

You can also get advice from a pharmacist, a sexual health clinic or a reputable online service. Just avoid websites that sell erection pills without asking about your health, because that question is there to keep you safe.

ED can knock your confidence, and partners sometimes worry they are no longer desirable. Both feelings are normal, and both ease when you talk about it openly. It is almost never about attraction.

Great sex is not only about penetration. Go down on your partner, use your hands, bring in a toy, take a long shower together. Taking the pressure off your penis often makes erections more likely to come back, and plenty of couples find their sex life gets more creative, and hotter, as a result.

Tell your partner what is happening rather than going quiet. Something like: I am getting this checked, it is not about you, and I really want you. That one sentence can turn worry into teamwork.

Try framing it as a shared project rather than one person's failure. Go to an appointment together if that feels right. With the right treatment and a bit of patience, most men get back to sex they really enjoy.