Erection problems – everything you need to know about symptoms, diagnosis and treatment.

1 – What is erectile dysfunction?

Erectile dysfunction (ED) is when a man has trouble getting or keeping an erection strong enough for sex. There are several reasons why this might happen, and they can range from physical health issues to emotional or psychological factors.

2 – How common is ED?

ED is a common condition. Studies show that about 30 million men in the United States alone experience some form of ED. In general, about 1 in 10 men will experience ED at some point in their lives.

3 – How does age affect ED and is it certain I will experience it as I get older?

Age is considered a strong risk factor. This means that as you get older, you are more likely to have ED, affecting around 5% of men in their 40’s and around 15% in their 70’s. In general, more than half of men over the age of 60 report some kind of ED.

However, ED is now seen as a condition that can happen to men at any age. Some studies suggest that ED is becoming more common in younger men due to rising rates of obesity and lifestyle-related diseases like diabetes which increase the likelihood of ED.

4 – Who is most likely to suffer from ED?

Outside of age (see above), men who are most likely to experience ED are those who suffer from chronic conditions like obesity, diabetes, heart disease and high blood pressure.

Lifestyle choices such as smoking, drinking and being overweight can increase the chances of developing ED, while anxiety, depression and stress (mental health) can all play a big role in causing ED. These psychological factors can be just as important as physical health problems.

Taking medications for things like depression, high blood pressure, or pain can also cause ED as a side effect.

5 – Why does ED occur?

There are several reasons why ED might happen, and they can range from physical health issues to emotional or psychological factors.

Physical health problems include:

• Blood flow issues. For an erection to happen, blood needs to flow to the penis. Conditions like heart disease, diabetes, or high blood pressure can affect this blood flow, making it harder to get an erection.
• Hormonal imbalances. Testosterone is the hormone that plays a key role in sexual function. If levels are low, it can cause problems with erections.
• Nerve damage. Any injury or health condition that damages the nerves, such as spinal cord injuries or diabetes, can interfere with the signals needed to get an erection.

Psychological factors include:

• Stress or anxiety. Worrying about work, money, or relationship problems can affect sexual performance.
• Depression. Feeling down can lower interest in sex and lead to ED.
• Relationship problems. Tension or lack of communication with a partner can also contribute to ED.

6 – Why is maintaining an erection important for men' s health and wellbeing?

Maintaining an erection is important for men’s health and wellbeing because of its broad physical, psychological, sexual and relational effects. For example:

• Indicator of overall health. Erectile function is closely linked to cardiovascular and circulatory health. Difficulty maintaining an erection can be an early warning sign of conditions like high blood pressure, diabetes, or atherosclerosis.
• Supports mental and emotional health. Regular sexual activity and the ability to maintain an erection can contribute to better mood, reduced stress, and lower rates of depression and anxiety. Sexual function is closely tied to self-esteem and masculine identity.
• Enhances intimacy in relationships. Being able to maintain an erection contributes to a satisfying sex life, which strengthens emotional and physical intimacy in relationships. It can help foster closeness, trust, and communication between partners.
• Hormonal balance. Sexual activity, including erections, can help maintain healthy testosterone levels. Testosterone plays a crucial role in energy levels, mood, muscle mass, and bone density in men.
• Quality of life and longevity. A satisfying sex life is linked to improved quality of life and even increased lifespan. Studies suggest that men who have regular, healthy sexual activity may enjoy better overall wellbeing and reduced risk of certain chronic diseases.

7 – What is the psychological impact of ED?

The psychological impact of ED can be profound. For many men, ED can affect self-image, confidence, mood, relationships, and overall quality of life including performance anxiety, depression and social stigma.

8 – Is ED serious or harmful to my health?

ED is not life-threatening in itself but it often signals deeper health or psychological problems that should not be ignored.

9 – Can ED affect fertility?

ED can affect fertility indirectly. ED does not usually affect sperm quality or production, but it can interfere with the ability to engage in sexual intercourse, which is necessary for natural conception.

10 – How is low testosterone linked to ED?

Mild to moderate testosterone deficiency (also called hypogonadism) may not cause ED by itself, but it can make ED worse. For example, it can affect sexual desire and erectile quality, especially in older men or those with other risk factors.

11 – How is the prostate linked to ED?

Prostate health problems (like cancer or cancer treatment) can significantly affect erectile function. Up to 60–80% of men experience ED immediately after prostate cancer surgery, while radiation therapy can also damage blood vessels and nerves, leading to gradual ED.

12 – How is weight linked to ED?

Being overweight or suffering from obesity is a strong risk factor for ED. Excess body fat—especially around the abdomen—affects vascular, hormonal, and psychological health, all of which are critical to normal erectile function.

13 – How is diabetes linked to ED?

Type 2 diabetes is strongly associated with ED. Diabetes causes nerve damage (neuropathy) and further impairs blood flow—both common causes of ED.

14 – Is ED always a psychological problem?

Absolutely not. Research has shown that physical causes make up approximately 70% of ED cases. Impaired blood flow, problems in nerve signaling, or hormone imbalances are the key physical mechanisms of ED. However, it’s worth noting that even when the root cause is physical, psychological effects (like anxiety, shame, or depression) play a reinforcing role.

15 – What is the difference between a ‘normal’ erection and a dysfunctional one?

The physiology of an erection involves a complex process that begins with sexual arousal and results in the increased blood flow to the penis, causing it to become erect. Here’s a simplified overview of how it works:

• Sexual stimulation: The process starts with physical or psychological stimulation, which activates the brain and sends signals through the nervous system to the penis.
• Nerve signals: These signals cause the nerves in the penis to release chemicals, particularly nitric oxide, which relaxes the smooth muscle in the walls of the blood vessels (arteries) supplying the penis.
• Blood flow increases: As the smooth muscles relax, the blood vessels dilate, allowing increased blood flow into two spongy chambers in the penis called the corpora cavernosa.
• Engorgement: The blood fills these chambers, causing them to expand and the penis to become rigid. The corpus spongiosum, another spongy tissue surrounding the urethra, also fills with blood but to a lesser degree, helping to protect the urethra and maintain its function.
• Constriction of veins: As the corpora cavernosa fills with blood, the veins that usually drain blood out of the penis are compressed, trapping blood inside and maintaining the erection.
• Return to flaccidity: After ejaculation or cessation of sexual stimulation, the blood vessels constrict and the smooth muscles tighten, allowing the blood to flow out of the penis and causing it to return to its flaccid state.

Disruptions in any of these processes—whether from health conditions, medications, or psychological factors—is a sign of ED.

16 – What should I do if I’m experiencing symptoms of ED?

If you’re experiencing symptoms of ED, speak to your GP or reach out to a medical professional who can take a full sexual and medical history, identify physical or psychological causes, order blood tests and prescribe first-line treatments such as PDE5 inhibitors.

Here at Heracles, we provide online men’s health services in partnership with our network of highly-experienced, fully-licensed doctors as a way to bridge the gap between inconvenient waiting times and the care that you need.

17 – Can ED be cured?

The good news is, ED is treatable in nearly all cases, and many men find solutions with the help of a doctor. For some men, ED is completely curable when the underlying cause is temporary, reversible, or modifiable.

18 – What is the long-term impact of ED if left untreated?

If ED is left untreated, the long-term impact can go beyond sexual performance and seriously affect a man’s physical, emotional, and relational health. Given that ED is often a broader indicator of underlying conditions such as vascular disease, ignoring the root cause of ED may worsen conditions such as heart disease, high blood pressure and diabetes over time.

19 – How is ED diagnosed?

Diagnosing ED involves a thorough evaluation to determine its underlying cause, whether it's physical, psychological, or a combination of both. The tests a doctor performs for ED depend on the patient's symptoms, medical and sexual history, and risk factors. Here's a brief outline of the tests and diagnostic procedures commonly used:

• Medical History. The doctor will ask questions to understand the duration, onset and frequency of ED symptoms, as well as past sexual function, satisfaction and any changes in libido. A full medication review, lifestyle evaluation and psychological factors are common lines of enquiry.
• Physical Examination. In some instances, a doctor may conduct a physical exam to help rule out any physical causes for ED such as heart disease (e.g. blood pressure), genital abnormalities, testicular size, vascular system and neurological function.
• Blood Tests. Blood tests are performed to check for underlying health conditions that could contribute to ED such as: hormone levels (testosterone, thyroid function and prolactin), lipid profile (cholesterol), blood glucose (fasting blood glucose and HbA1c) and a complete blood count (CBC).
• Urinalysis. Can help identify underlying diabetes (by detecting high blood sugar) or kidney disease, which could be contributing to ED
• Nocturnal Penile Tumescence (NPT) Test. This test is used to assess whether a man is having normal nocturnal erections (erections that occur during sleep, particularly during REM sleep).
• Penile Doppler Ultrasound. This test is used to evaluate blood flow to the penis and can help identify vascular issues causing ED.
• Intracavernosal Injection Test. This test involves injecting a medication, usually alprostadil (or a combination of medications, such as Trimix), directly into the penis. The injection causes the blood vessels in the penis to dilate, allowing blood to flow in and produce an erection.
• Dynamic Infusion Cavernosometry and Cavernosography (DICC). This test is used in more complex cases to evaluate venous leakage. A catheter is inserted into the penis, and fluid is infused to measure how the penis fills with blood and how long the erection lasts.
• Psychological Assessment. Psychological testing or counseling may be recommended to assess stress, anxiety, depression, or relationship issues. This can include questionnaires or an interview with a therapist to evaluate any emotional, mental, or relationship issues that may be contributing to ED.

20 – Do I need to see a doctor to be diagnosed?

A doctor’s consultation is not compulsory for the diagnosis or treatment of ED. However, we strongly advise speaking to a medical professional or your GP for a thorough evaluation of your case before commencing any treatment.

21 – What is the diagnosis protocol for ED at Heracles?

At Heracles, we begin the process by asking you to fill in the IIEF5 medical questionnaire. Depending on your score, we may prescribe you treatment. We also offer optional, add-on blood tests and a doctor’s consultation both of which we advise for a thorough evaluation of your case.

22 – What is the IIEF5 questionnaire?

The IIEF questionnaire (International Index of Erectile Function) is a standardized, validated tool used by healthcare providers to assess male sexual function, especially in the context of ED. It is widely used in both clinical settings and research.

23 – Why should I add on blood tests?

We advise you to include blood tests because ED can be a symptom of underlying medical conditions—many of which are detectable through blood work. Identifying the root cause of ED is essential for effective, targeted treatment rather than just symptom management.

24 – What’s included in the blood tests?

At Heracles, our optional, add-on blood tests for ED include: total testosterone, free testosterone, albumin, SHBG (Sex Hormone Binding Globulin), HbA1c, and lipids (cholesterol).

25 – Why should I add on a doctor’s consultation?

We advise you to include a doctor’s consultation in order to get to the root cause of your ED symptoms. Physical issues (heart disease, hormonal imbalances etc), lifestyle considerations (diet, exercise, smoking, alcohol etc) and mental health (stress, depression, anxiety etc) can go undetected when symptoms are managed with first-line treatment alone.

26 – What’s included in the doctor’s consultation?

Our doctors and medical experts will ask you targeted questions and a chance to discuss your medical and sexual history, your IIEF5 score and any relevant blood test results in order to build a thorough, root-cause picture of your ED case and treatment plan. You will also have the opportunity to ask any questions you might have.

27 – What’s the best treatment for ED?

There are several treatments available for ED and the right one depends on what's causing it, as well as your preferences and ability to adhere to the treatment. Here’s a breakdown of the most common treatment options:

Lifestyle changes. Making healthier lifestyle choices can help tremendously with ED, especially if it is caused by factors like obesity, diabetes or poor blood flow. This might include:

• Losing weight if you're overweight.
• Eating a healthier diet with more fruits, vegetables, and less junk food.
• Exercising regularly to improve blood flow and overall health.
• Quitting smoking and cutting back on alcohol to improve circulation.

Medications. The most common treatment for ED is medication that helps increase blood flow to the penis. These are called PDE5 inhibitors (taken orally) and they work by making it easier to get and maintain an erection. Here are the main types:

• Viagra (sildenafil)
• Cialis (tadalafil)
• Levitra (vardenafil)
• Spedra (avanafil)

Usually, these medications are taken as a pill before sexual activity. However, each of these medications has slightly different features, such as the onset of action and how long they last, so the choice of which one to use depends on individual preferences, lifestyle, and how your body responds.

It’s important to talk to a doctor before starting any of these medications, as they can interact with other drugs and may not be safe for people with certain health conditions (like heart problems).

Therapy and counseling. If ED is caused by stress, anxiety, or relationship problems, seeing a therapist or counselor might help. Sex therapy or couples counseling can help address psychological issues or help men feel more confident about sex. This can be a good option if ED is linked to emotional or mental health struggles, like depression or performance anxiety.

Vacuum erection devices. A vacuum pump is a device that helps create an erection by drawing blood into the penis. It's a non-invasive option that can work well for men who don’t respond to medications. The pump is used before sex and is followed by placing a ring at the base of the penis to help keep the blood in.

Penile injections. Injections for ED are another treatment option when oral medications like PDE5 inhibitors don't work or are not suitable. These injections are usually administered directly into the corpus cavernosa, which are the two main chambers of the penis that fill with blood during an erection. The injections help trigger an erection by increasing blood flow to the area.

28 – What treatment options for ED are available at Heracles?

At Heracles, we are able to offer you PDE5 inhibitors in the form of convenient and highly effective pills. We have three options available, each of them slightly different:

• Sildenafil (Viagra). Sildenafil is the most well-known PDE5 inhibitor. It helps relax the blood vessels in the penis, allowing more blood to flow into it during sexual stimulation. Typically taken about 30 minutes to an hour before sex and lasts approximately 4-6 hours.
• Tadalafil (Cialis). Works similarly to sildenafil but has a longer duration of action (up to 36 hours), earning it the nickname "the weekend pill." Can be taken as needed and is fast-acting.
• Tadalafil daily. A lower dose version of our standard tadalafil has been formulated for daily use, providing continuous readiness for sex. Best for frequent sex (2+ times per week) as it helps with spontaneity.

29 – How long does it take to see results from PDE5 inhibitors?

Pretty quickly! Sildenafil and tadalafil (standard) take effect within 60 minutes after ingestion. Tadalafil daily (lower dose) can take a few days to build up in your system.

30 – How safe are PDE5 inhibitors?

PDE5 inhibitors are generally safe for most healthy men, including older adults. They are well-tolerated when used appropriately—especially under medical supervision. But, like all medications, they have risks and contraindications, particularly in certain health conditions or with specific drug combinations.

31 – Are there any side-effects to taking PDE5 inhibitors?

Like all medications, PDE5 inhibitors have some side effects. Most are mild and short-lived. They include:

• Headache
• Flushing
• Nasal congestion
• Indigestion
• Dizziness
• Back pain (esp. with tadalafil)
• Vision changes (blue tint or sensitivity – mostly with sildenafil)

32 – Who can NOT take PDE5 inhibitors?

Anyone who is taking nitrates for angina (chest pain) and other heart conditions must not take PDE5 inhibitors due to a dangerous drop in blood pressure.

Anyone who has or has had the following conditions must not take PDE5 inhibitors:

• Severe heart or liver disease
• Recent stroke or heart attack
• Severe low blood pressure
• Rare eye disorders (e.g. retinitis pigmentosa)
• Allergic reactions or past serious side effects

Anyone who is taking alpha-blockers (e.g. for an enlarged prostate) must consult with a doctor before use as they may cause low blood pressure.

Anyone who is taking CYP3A4 inhibitors (e.g. some antibiotics, antifungals, HIV meds) must consult with a doctor before use as they may increase levels of PDE5 in the blood.

33 – Can I take PDE5 inhibitors if I have a heart problem?

It depends on the heart problem. If you are on medication like nitrates, you must not take PDE5 inhibitors due to a dangerous drop in blood pressure. If you have had a heart attack in the past, you must not take PDE5 inhibitors.

For any other heart-related problem (like stable heart disease), you may be able to take PDE5 following additional tests and under medical supervision. You must consult with a doctor before use.

34 – Can I consume alcohol while taking PDE5 inhibitors?

Yes, you can drink alcohol while taking PDE5 inhibitors, but with caution. Excessive alcohol can interact with these medications and increase the risk of side effects, especially those related to blood pressure. Light to moderate drinking (1-2 drinks) while taking PDE5 inhibitors is considered generally safe. If you are concerned about your alcohol consumption while taking PDE5 inhibitors, please consult with a doctor.

35 – How can I change my lifestyle to support ED treatment?

For the first time in medical history, chronic disease is catching up with age as a risk factor for ED. Lifestyle changes have become a core part of treating ED—not just as a complement to medication, but often as a first-line treatment, especially for mild-to-moderate cases. Here’s what you can change to get the most out of your ED treatment:

• Lose excess weight in order to reduce your risk of cardiovascular disease and diabetes, as well as improve testosterone levels, factors which are all involved in the onset of ED.
• Exercise regularly. Aim for 45-60 minutes a session, 4-5x a week. Focus on a combination of resistance training and aerobic activity in order to improve blood flow, enhance testosterone and support weight loss. Studies show that exercise can improve ED severity in 40–50% of men with mild-to-moderate symptoms.
• Eat a heart-healthy diet. The Mediterranean diet with a focus on vegetables, legumes, dairy, nuts, fish and lean meats, is one of the best researched diets, with a multitude of health benefits. Most importantly, reduced heavily processed foods, which are high in added fats/trans fats and high in added sugar.
• Quit smoking. Smoking damages blood vessels and impairs nitric oxide, which is vital for erections. Smoking is also pro-inflammatory.
• Limit alcohol. The healthiest amount of alcohol is no alcohol. A few social drinks at weekends may be ok for some but if your ED symptoms are severe to begin with, consider quitting altogether.
• Improve sleep. Often overlooked, 7-8 hours sleep per night is vital for every function in the body, including testosterone production. Why? Poor sleep can lower testosterone, worsen anxiety, and impair blood vessel function, all of which are barriers to the blood flow required for a healthy erection.
• Reduce stress and anxiety. An obvious one, but essential in managing the psychological and emotional factors involved in ED. What’s more, psychological stress activates the sympathetic nervous system (the "fight or flight" response), which can inhibit erections. Consider therapy (CBT), mindfulness techniques, breathing exercises, yoga and more time in nature. Consider counseling if you have relationship issues.

36 – What’s the best diet alongside PDE5 inhibitors?

A Mediterranean-style diet is the best evidence-backed diet to enhance the effectiveness of PDE5 inhibitors and treat ED overall. It supports blood flow, nitric oxide production, hormonal health, and cardiovascular stability—all essential for erectile function and PDE5 drug response.

However, any diet that supports similar principles as the Mediterranean diet is ideal for ED treatment. The key is to avoid processed foods, trans fats (seed oils) and sugar.

As part of your treatment plan at Heracles, you will get access to nutrition education and lifestyle advice to support your ED medication. We cover more than just the basics of a healthy diet, enabling you to fuel your body for high performance and longevity.

37 – How can I support my mindset to get the most out of my treatment?

PDE5 inhibitors medications work physically—but the brain plays a huge role in how well they function. Here’s how to mentally set yourself up for success:

• Think of ED treatment as support, not a crutch.
• Set realistic expectations. PDE5 inhibitors don’t create arousal–you need to be in the mood and have stimulation. It might take a few tries to get the dose and timing right.
• Breathe and relax before sex. Performance anxiety activates your sympathetic nervous system (fight-or-flight), blocking arousal.

As part of your treatment plan at Heracles, you will get access to mindset techniques and mental health ‘hacks’ to support your ED medication. ED may be a physical manifestation but psychology plays a huge role–we will teach you how to get in the driver’s seat of your sexual performance.

38 – Are PDE5 inhibitors addictive?

No, PDE5 inhibitors do not cause dependence, cravings, or withdrawal symptoms on a physical level, unlike substances like nicotine, opioids, or alcohol.

However, some men may develop a psychological reliance on PDE5 inhibitors if they lack confidence in their natural erections or use them to deal with performance anxiety.

We advise you to use PDE5 inhibitors only when prescribed and medically needed, and when combined with lifestyle changes (diet, exercise, stress reduction) to address the root cause.

39 – What do I do if I have an adverse reaction to PDE5 inhibitors?

If you experience:

• Chest pain or tightness
• Severe dizziness or fainting
• Difficulty breathing
• Swelling of face, lips or throat
• Sudden vision or hearing loss
• Painful or prolonged erection (priapism >4 hours)

Stop taking the medication and seek urgent medical help.

If you experience:

• Headache
• Flushing
• Nasal congestion
• Upset stomach
• Back or muscle pain (especially with tadalafil)
• Sensitivity to light or vision changes (blue-tinted vision)

Contact your doctor or GP. You may need a dose adjustment or a different PDE5 drug.