Almost every man has the occasional bad night. Tiredness, stress, alcohol, illness and anxiety can easily affect erections.

Erectile dysfunction (ED), sometimes still called impotence, is when that starts to become a pattern. It can mean struggling to get an erection, but just as often it means getting hard and then losing it or finding that erections are no longer quite firm enough for sex. Some men notice fewer morning erections, while others still have completely normal erections when they wake up or masturbate, despite having problems during sex.

If it keeps happening, is clearly getting worse or is starting to affect confidence, relationships or your enjoyment of sex, it is worth having it assessed.

ED may be physical, psychological or, very commonly, a mixture of both. Physical causes can include cardiovascular problems, diabetes or low testosterone, while psychological issues such as stress, anxiety, low mood and relationship difficulties can affect erections too.

At H3 Health, the Sexual Function Clinic takes a detailed look at what has changed, what may be the causes and which treatment options are most appropriate.

What actually happens at a sexual function consultation?

Expect a fairly frank conversation about your erections as the questions will go well beyond a yes-or-no answer to, “Can you get an erection?”

The pattern matters. Can an erection be achieved but not maintained? Has the firmness changed? Are morning erections still present? Is more direct stimulation needed than before? Is the problem the same during masturbation and partnered sex?

Sexual function is also broader than erections alone; so sexual desire, ejaculation and orgasm are relevant too. Men sometimes describe several different changes in sexual function as “ED”, but they don't necessarily have the same cause or need the same treatment.

When it started, and whether the change was sudden or gradual, can tell you quite a lot.

A sudden change may point more towards psychological or relationship factors, such as stress, low mood, a new relationship, relationship difficulties or fear of disappointing a partner.

Performance anxiety can then become part of the problem. One difficult sexual experience can fuel anxiety about the next one. Instead of concentrating on arousal and enjoying sex, attention shifts to the erection itself and the thoughts start racing:

Am I hard enough? Am I losing it? Is it going to happen again?

That anxiety can make erections less reliable and sometimes lead to losing the erection altogether, creating a cycle that can be difficult to break. Sex can very quickly start to feel more like a test than a pleasure.

Changes in medication are worth considering at the same time. Some medicines used for blood pressure, mood and other long-term conditions can affect sexual function, so whether anything was started, stopped or changed around the time the problem began can be an important clue.

A slower decline in erection quality — particularly if it happens in different situations and morning erections have reduced as well — may make a physical cause more likely. It can also be a reason to look more closely at your wider health.

What do erections have to do with wider health?

An erection depends heavily on blood flow. The arteries supplying the penis need to open up and allow enough blood into the erectile tissue to create and maintain firmness.

Anything that affects those blood vessels can therefore affect erections. High blood pressure, raised cholesterol, smoking, diabetes and excess weight can all play a part. Diabetes is particularly important because it can affect both the blood vessels and the nerves involved in producing an erection.

This is one reason erectile dysfunction can sometimes act as an early warning sign for heart and blood vessel health. It is sometimes described as a “canary in the coal mine”: erection problems may appear before someone is aware of problems elsewhere in the circulation.

That doesn’t mean that having ED means you have heart disease. But ED and heart disease share many of the same risk factors, and erection problems can sometimes appear several years before more obvious heart or circulation problems.

So a persistent or unexplained change in erections is a good opportunity to look beyond the erection itself — checking things such as blood pressure, cholesterol, blood sugar and other cardiovascular risk factors where appropriate.

Hormones are important too.

Low testosterone can sometimes be an underlying cause of erectile dysfunction or contribute to it. It is particularly worth considering when ED comes with other changes such as a drop in libido, fewer morning erections, low energy or reduced strength.

In those cases, checking testosterone can help explain what is going on and can affect the treatment options.

What can actually be done about erectile dysfunction?

Physical and psychological factors often overlap, so treatment may need to address more than one thing. A small physical change can knock confidence and trigger performance anxiety, while stress or anxiety can make erections that were already becoming less reliable even harder to maintain.

That is why the consultation looks at all the likely contributors together — physical health, hormones, medication, lifestyle, stress, confidence and relationship factors — before deciding what is most likely to help.

If another medication appears to be contributing, it is worth reviewing why it is being taken and whether there is an alternative. Depending on the situation, the dose may be adjusted, the medicine changed or occasionally stopped altogether. Some blood pressure medicines, antidepressants and other long-term treatments can affect sexual function. If one looks likely to be contributing, it may be possible to reduce the dose, change to an alternative or sometimes stop it altogether, after discussing it with the doctor who prescribed it.

If poor blood flow seems to be part of the problem — for example alongside high blood pressure, raised cholesterol, diabetes, smoking or excess weight — then those risk factors need addressing too. That might mean medication to improve blood pressure, cholesterol or diabetes, lifestyle changes such as regular exercise, losing weight where needed, stopping smoking and improving diet, or a combination of both.

Improving those factors helps protect the blood vessels generally and may also improve erectile function or help stop it getting worse.

Many men will also need treatment specifically to improve blood flow to the penis. Tablets are usually the first medical option. Some are taken before sex, while a low-dose daily treatment can suit men who prefer more spontaneity.

They do not simply switch an erection on — sexual stimulation is still needed. How they are taken matters as well. Dose, timing, food, alcohol and whether the treatment has actually had a proper trial can all affect how well it works.

If tablets are not suitable or genuinely do not work, there are other established options, including vacuum erection devices, injectable treatments and specialist urological treatments for more severe ED.

If your blood tests show low testosterone, testosterone replacement therapy may improve libido and, in some men, erectile function as well. It can also help with other symptoms of testosterone deficiency, such as low energy or reduced strength. H3 Health has a dedicated testosterone clinic, so this can be assessed and managed alongside any other factors contributing to ED.

Where psychological factors are contributing, treatment may focus on anxiety, confidence, stress or difficulties within the relationship. Talking openly with a partner can sometimes take away a surprising amount of pressure.

H3 Health has its own mental health service, with a psychologist who can help where stress, anxiety or relationship factors are affecting sexual function. If more specialist psychosexual therapy is needed, the doctor can also arrange an appropriate referral.

Physical and psychological factors often overlap, so treatment may need to address both. A physical change in erections can knock confidence and lead to performance anxiety, while stress or anxiety can make an underlying physical problem worse.

The bigger picture

Erectile dysfunction is rarely just about the erection itself. Blood flow, hormones, medication, anxiety and relationship factors can all play a part, and often more than one is involved.

That is the advantage of being assessed through H3 Health's Sexual Function Clinic. Our doctors have a special interest and experience in men's health and sexual function, and can look at the medical, hormonal and psychological factors together. Treatment can be managed through H3 where appropriate, with referral for more specialist care if needed.

ED is common, but it shouldn't simply be put up with. If something has changed and keeps happening, it's worth finding out why.

Book a sexual health specialist consultation.

Frequently asked questions

Is it normal to occasionally lose an erection?

Yes. It happens to most men at some point and doesn't necessarily mean anything is wrong. Stress, tiredness, illness and too much alcohol are all common short-term reasons.

The important thing is not to let one difficult experience become a prediction about the next one. Once the thought becomes “What if I lose it again?”, attention can shift from enjoying sex to monitoring the erection — which can make the problem more likely to happen again.

If it starts happening repeatedly or becomes a concern, it is worth having it assessed.

What are the common physical causes of ED — and can they improve?

Problems with blood flow are among the most common physical causes. High blood pressure, raised cholesterol, diabetes, smoking and excess weight can all affect the blood vessels needed for a firm erection. Diabetes can also affect the nerves involved in sexual function.

Other causes include certain medications, neurological conditions, previous pelvic or prostate surgery and hormonal problems.

Some of these factors can be improved. Exercise, losing weight where needed, stopping smoking and better control of blood pressure, cholesterol and diabetes may all help erectile function as well as general health.

Lifestyle changes won't reverse every physical cause of ED, and some men will still need specific treatment, but they are an important part of managing the problem.

If I still have morning erections, does that mean the problem is psychological?

Not necessarily.

Good morning or spontaneous erections can be a useful clue because they show that the physical mechanisms needed to produce an erection are capable of working.

But they don't prove that the problem is psychological. They are just one part of the picture, alongside general health, medication, sexual desire, relationship circumstances and what happens during sex.

Can anxiety really cause erectile dysfunction?

Yes. Performance anxiety can have a surprisingly powerful effect on erections.

Once someone starts worrying about whether they will get or keep an erection, attention moves away from arousal and towards monitoring what is happening. That can make erections less reliable and create a cycle that is difficult to break.

Psychosexual therapy can be very helpful where anxiety, confidence or relationship factors have become part of the problem, and it can be used alongside medical treatment.

Does erectile dysfunction mean I have low testosterone?

No.

Low testosterone can contribute to ED, particularly when there are other changes such as a drop in libido or fewer morning erections. But erectile dysfunction has many possible causes.

If the history suggests that hormones may be involved, checking testosterone can help establish whether it is part of the problem.

Is erectile dysfunction a sign of heart disease?

Not necessarily. Having ED does not mean that you have heart disease.

However, erection problems and heart disease share several of the same risk factors, including high blood pressure, raised cholesterol, diabetes, smoking and excess weight.

For that reason, persistent or unexplained ED can be a useful prompt to check heart and blood vessel health rather than simply treating the erection.

What if tablets haven't worked?

Don't assume that means they have failed.

The first thing to look at is how the treatment was actually used. Was the dose appropriate? Was it taken at the right time? Depending on the treatment, a large or high-fat meal can delay how quickly it works. Too much alcohol can make getting an erection more difficult regardless of the tablet. And oral ED treatments still need sexual stimulation — they don't simply produce an automatic erection.

It is also quite common for someone to try treatment once or twice, be disappointed and give up. Sometimes it needs a proper trial; sometimes a different treatment is a better fit.

And sometimes the tablet isn't really the main issue. An underlying physical problem, low testosterone, another medication or performance anxiety may still need addressing.

A disappointing first attempt and genuine treatment failure are not the same thing.