What is being described
Erectile dysfunction is the repeated inability, over at least three months, to get or keep an erection sufficient for satisfactory sex. The important word is repeated: an occasional failure after a heavy evening, a short night or a stressful period has no diagnostic value and happens to everyone. What counts is consistency and impact.
Frequency rises with age — around 10 % at forty, half of men after seventy — but one in four men seeking help for the first time is under forty, and in these younger men the mechanism is rarely the same.
Erection, in three lines
An erection is a vascular event under nervous control. Arousal releases a messenger, nitric oxide, which relaxes the smooth muscle of the penile arteries. Blood enters, the corpora fill, venous outflow closes. Anything that damages arteries, nerves, hormonal balance or the brain's command can interrupt that chain.
Causes, in order of frequency
- Vascular: the leading cause after forty. Penile arteries are narrow; they suffer before the coronaries. Erectile dysfunction appears on average three to five years before a cardiac event in men who will have one. That is why it warrants a cardiovascular assessment — the most important message on this page.
- Metabolic: diabetes (up to half of diabetic men), metabolic syndrome, obesity, sleep apnoea.
- Medicines: antihypertensives, particularly beta blockers and thiazide diuretics; serotonergic antidepressants; antipsychotics; prostate cancer treatments; some hair-loss treatments. Changing molecule is sometimes enough.
- Substances: tobacco, which damages the endothelium directly; chronic alcohol; cannabis; cocaine and amphetamines, which cause transient then lasting dysfunction; opioids, which collapse testosterone.
- Hormonal: testosterone deficiency, rarer than commonly said, but worth seeking when desire disappeared at the same time.
- Neurological and surgical: spinal injury, multiple sclerosis, pelvic surgery, prostatectomy.
- Psychological and relational: performance anxiety, depression, couple conflict, exhaustion. These dominate in young men. Heavy pornography use is regularly invoked; the data are debated, but the performance anxiety it feeds is not.
The sign that points the way
Spontaneous nocturnal and morning erections, and normal erections with masturbation, point to a psychological or relational cause. Their complete disappearance points to an organic one. Abrupt onset after a specific event is more likely psychological; gradual decline over months is more likely vascular.
When erection problems speak about the heart
The French health insurance service (Assurance Maladie) describes erectile dysfunction as a "sentinel symptom" of cardiovascular disease: it comes before cardiovascular problems, angina in particular. The explanation lies in atherosclerosis: in a man with risk factors, it affects all the arteries, and the arteries of the penile erectile tissue are generally blocked before the coronary arteries are. It is often suggested that these arteries, being smaller than the coronaries, show damage earlier; that is a proposed explanation, not something measured in each patient.
Studies point the same way. Among 300 patients whose coronary artery disease was confirmed by angiography, about half (49%) also had erectile dysfunction, which had come before the coronary symptoms in 67% of those cases, with an average delay of 38.8 months (Montorsi et al., Eur Urol, 2003). The Princeton III consensus places the interval between the onset of the problem and a coronary event at between two and five years (Nehra et al., Mayo Clin Proc, 2012). A meta-analysis of 12 prospective cohorts (36,744 participants) found, in the men affected, a relative risk of 1.48 for cardiovascular disease overall, 1.46 for coronary artery disease and 1.35 for stroke (Dong et al., J Am Coll Cardiol, 2011); another, covering 25 studies (154,794 people), gives 1.43 for cardiovascular disease and 1.59 for coronary artery disease (Zhao et al., J Sex Med, 2019). A relative risk of 1.5 means a risk raised by half compared with men without the problem, not an individual certainty.
What this means in practice: erectile dysfunction affects a little over one man in ten over a lifetime and is much more common from the age of 50 (the "at a given moment" frequency quoted earlier and this lifetime frequency do not measure the same thing). An occasional failure is commonplace. When difficulties last more than three months, the Assurance Maladie recommends talking to a doctor, and doing so is all the more useful if you smoke or have high blood pressure or diabetes: the doctor can then assess cardiovascular risk at the same time as erections. Erectile dysfunction does not by itself prove heart disease, and the reverse is not true either: only a medical work-up can settle the question.
The minimum work-up
It is simple and should not be skipped: blood pressure, waist, blood glucose, lipids, a morning testosterone if desire has fallen, genital examination, a full review of medicines taken. In men over forty, cardiovascular risk assessment is essential. Many men consult about erections and leave with a diagnosis of diabetes or hypertension: that is a benefit, not a setback.
What helps without a prescription
Three interventions have measured effects: stopping smoking, regular physical activity — aerobic exercise improves erectile function with an effect comparable to a drug in sedentary men — and weight loss where there is excess. Treating sleep apnoea, where present, also clearly helps. These act over weeks to months, and they improve cardiovascular risk at the same time.
PDE5 inhibitors: sildenafil and the rest
Sildenafil — marketed as Viagra and, since the patent expired, as many generics — was discovered by accident: it was being studied as a treatment for angina. It belongs to the phosphodiesterase type 5 inhibitors, which stop the breakdown of the messenger released by arousal. Hence a poorly understood point: they do not create desire and trigger nothing on their own. Without sexual stimulation nothing happens. A tablet taken “to see”, without arousal, gives the impression the treatment does not work.
- Sildenafil: works in thirty to sixty minutes, lasts four to six hours. A fatty meal delays it markedly.
- Tadalafil: slower to start but lasts up to thirty-six hours, which separates the dose from the occasion; a low daily dose also exists.
- Vardenafil and avanafil: intermediate profiles, avanafil being the fastest.
Effectiveness is real — around two thirds to three quarters of men respond — but lower with long-standing diabetes or after prostatectomy. Four attempts at an adequate dose are needed before concluding failure.
Side effects and contraindications
The commonest effects are mild: headache, flushing, blocked nose, indigestion, muscle aches with tadalafil, a slight blue tinge to vision with sildenafil.
Combinations that are forbidden
- Nitrates prescribed for angina — glyceryl trinitrate, isosorbide — in every form, including the emergency spray. The drop in blood pressure can be fatal. A man taking nitrates must not take sildenafil, and vice versa.
- Poppers, which are also nitric oxide donors. This is the commonest accident in party settings, because both circulate at the same events.
- Some pulmonary hypertension treatments and alpha blockers prescribed for the prostate, which need close supervision.
Other interactions matter: azole antifungals, some macrolide antibiotics and antiretrovirals strongly raise concentrations and require a reduced dose; grapefruit does the same. The doctor must know everything being taken.
A consultation is needed before considering these treatments after a recent heart attack or stroke, with unstable angina, severe heart failure, low blood pressure, poorly controlled arrhythmia, inherited retinal disease or a history of ischaemic optic neuropathy. A painful erection lasting more than four hours — priapism — is a surgical emergency: delay causes permanent damage.
The other treatments
- Intracavernosal injections of alprostadil: highly effective, including when tablets fail, and quickly learned.
- Urethral gel, a less effective alternative without a needle.
- Vacuum pump and ring: no medicine, useful especially after prostatectomy.
- Penile implant: a surgical option with high satisfaction when everything else has failed.
- Sex and couple therapy, alone or alongside. It is first-line in young men with no risk factor, and it works better when the partner is involved.
- Testosterone replacement, only for a deficiency confirmed on two morning samples, and with prostate monitoring.
Buying online: the trap
Sildenafil is among the most counterfeited medicines in the world. Analyses of seized tablets regularly find wrong doses, active ingredient absent or in excess, and contaminants: plaster, printing ink, amphetamines, antidiabetics. The risk is not only the product: it is the absence of any examination. Buying online also means forgoing the cardiovascular assessment that would have caught the hypertension or diabetes behind the symptom.
Where can you get it without a prescription?
Almost nowhere. Four countries have opened a route without a doctor's prescription, and always through a pharmacy consultation: the United Kingdom since 2018 (sildenafil 50 mg, sold as Viagra Connect), Poland since May 2016, New Zealand since 2014 — through a specifically trained pharmacist, and only for men aged 35 to 70 — and Norway since January 2020.
Everywhere else a prescription remains compulsory for every PDE5 inhibitor. A website offering sildenafil without a prescription from one of those four countries is not thereby allowed to ship it to you: the rule that applies is the one where you live.
Price and reimbursement vary widely. Sildenafil generics cost a fraction of the brand, and most health systems do not cover these treatments, although England's NHS does fund generic sildenafil.
Talking about it in the couple
Silence does more damage than the symptom. With no explanation, the partner almost always reads the failure as lost desire for them, and performance anxiety installs on both sides. Simply saying that this is a medical problem being investigated defuses most of that misunderstanding.