Erection problems and what they can say about your health

It used to work without thinking about it. Now it's unreliable, and you've started to wonder whether it's stress, age, the relationship, or something else. Often it is just stress. Now and then it's the first sign of something worth knowing about elsewhere in the body.

The NHS is clear that most men occasionally fail to get or keep an erection, usually because of stress, tiredness or drinking too much, and that this is nothing to worry about. If it keeps happening, it might be a sign of a health condition that can be treated. The NHS list of causes runs from cardiovascular disease, diabetes, hormone problems and medicines to stress and anxiety.

If you'd rather skip the reading, you can book a discreet GP assessment at our Harley Street clinic from £150, or call 0207 499 1991. Blood tests and pharmacy charges are separate when they're needed.

Why can erection problems point to the heart?

An erection is a blood-flow event. The arteries in the penis open, blood flows in and stays there, and nerves and hormones coordinate the whole thing. So a change in firmness can be your circulation talking, rather than a loss of desire.

Those arteries are small. The same slow narrowing that puts strain on the heart and brain shows up in small vessels too, which is why the NHS names high blood pressure and high cholesterol among the causes of frequent erectile difficulty. It's also why a GP at Medical Express Clinic checks cardiovascular risk first, and why a heart concern found along the way can go on to our cardiology clinic, where a consultant appointment is £250.

The pattern gives clues as well. If you still wake with erections, or the difficulty only happens with a partner, there may be a stronger psychological part to it. A gradual loss in every setting more often has a physical cause. Neither pattern is a diagnosis by itself, so the conversation comes before any prescription.

If you have chest pain, severe breathlessness or think you're having a heart attack, call 999 or go to A&E. Go to A&E too if an erection lasts more than four hours, or if you suddenly lose your vision or hearing.

How does blood sugar come into it?

Diabetes is on the same NHS list because high blood sugar can damage both the blood supply and the nerves an erection depends on. Some men already know they have diabetes and notice erections changing as their control slips. For others, the bedroom is the first place a blood sugar problem shows itself.

Blood tests are arranged when they would change the plan. If diabetes, circulation or a hormone cause looks likely from your history, the GP may suggest them, including a separate heart health panel. If you'd like a wider look at your heart and metabolic health in one visit, our comparison of the Essential and Advanced MOT sets out the tests in each, at £495 and £999.

Hormones sit in the same group. Low desire, low energy or a history that points towards testosterone can justify a testosterone blood test as part of the assessment. If testosterone replacement is already what you want to discuss, that's a separate visit, covered on our male hormone replacement page.

Can my medicines affect erections?

Yes. The NHS notes that erectile difficulty can be a side effect of some medicines, and that a doctor may switch you to a different one if your current prescription is the cause. Blood pressure treatment and other long-term medicines are common examples, so bring a full list, including inhalers and sprays.

The most important safety check involves nitrates. Nitrate heart medicines and erection tablets such as sildenafil and tadalafil both widen blood vessels, and taken together they can drop your blood pressure to a dangerous level, so they must never be combined. That includes a leftover tablet from a friend. If you use a GTN spray, an isosorbide tablet or any other nitrate for angina, mention it at the start, because it shapes the whole prescribing conversation.

What part do stress and anxiety play?

The NHS puts depression, anxiety and stress on the same list as diabetes and blood pressure, and one can sit on top of the other. Poor sleep, relationship strain or too much alcohol can add to narrowed arteries, so the GP looks for the mix that applies to you rather than picking one explanation.

Counselling and therapy can help when emotional or mental health is part of the picture. The NHS notes these services can involve a long wait, and the heart, blood sugar and medicine checks are worth doing in the meantime.

What happens at the appointment?

It starts as a confidential conversation. The GP asks what has changed and what else is going on: when the difficulty started, whether morning erections are still there, your libido, any pain or deformity, your medicines including heart and blood pressure treatment, and circulation risks such as diabetes, high blood pressure, cholesterol and smoking.

An examination is used only if it would help. The doctor explains it first, and you can ask to pause at any point. The NHS describes basic checks such as blood pressure and an examination of the genitals to look for an obvious physical cause, with a prostate examination considered if you also need to pass urine more often than usual.

When do tablets come in?

When the assessment supports it, the usual first treatment is an oral PDE5 medicine. Sildenafil and tadalafil are the two names patients ask about most. After reviewing your health, medicines and cardiovascular risk, the GP may prescribe one where it's clinically appropriate, and explains how to take it, the common side effects and the important interactions first. These tablets need sexual stimulation to work.

If tablets aren't suitable, or you've taken them correctly with little benefit, the GP can investigate further and refer you to an appropriate specialist, with your history and any results already in hand. Treatment here focuses on the GP assessment and first-line oral medicines.

A few things that help

• If you have recent blood results, bring them, and mention any diabetes, high blood pressure, high cholesterol or known heart disease. Those facts change both the safety conversation and whether tests would help.
• If you've tried a tablet before, tell the GP which one, the dose and how you took it. That's far more useful than knowing it simply didn't work.
• If you want to start on your own, the NHS list is the one a GP will come back to: lose weight if you're overweight, stop smoking, eat a healthy diet, exercise daily, try to reduce stress and anxiety, and keep alcohol to no more than 14 units a week. If weight has been hard to shift, our guide to who weight loss injections suit explains how a doctor decides.
• If you cycle for more than three hours a week, the NHS suggests stopping for a while to see whether it makes a difference.
• If you're thinking of buying tablets online, the NHS warns that many sites sell fake medicines, and an unregulated tablet may not be safe with your heart drugs. Check the seller's registration with the General Pharmaceutical Council, the Care Quality Commission and the GMC.

All of these help, alongside a cardiovascular check.

Which appointment fits what you're noticing?

Most men start with the GP assessment, and the table shows which appointment fits other symptoms.

Matching what you've noticed to the right appointment

Related reading: what a low testosterone result means for treatment and where to start with a heart concern.