Erectile dysfunction treatment in London

Erectile dysfunction — difficulty getting or keeping an erection firm enough for sex — is one of the most common reasons men come to see us, and one of the least often talked about. It affects a substantial proportion of men over 40, and becomes more common with age.

What causes erectile dysfunction?

An erection depends on healthy blood vessels, intact nerves, adequate hormone levels and the right psychological state. A problem in any one of those systems can cause ED, and in many men more than one factor is at work.

Vascular causes

The most common physical cause. The arteries that supply the penis are narrow, so they show the effects of atherosclerosis — furring and stiffening of the artery walls — earlier than larger vessels elsewhere in the body. High blood pressure, high cholesterol, diabetes and smoking all contribute.

Hormonal causes

Low testosterone (hypogonadism) can reduce both libido and erectile function. Thyroid disorders and a raised prolactin level are less common but important to exclude, because they are treatable.

Neurological causes

Diabetes, multiple sclerosis, spinal injury, and surgery or radiotherapy to the pelvis — including treatment for prostate cancer — can all interrupt the nerve signals involved in an erection.

Medication side effects

A number of commonly prescribed drugs can cause or worsen ED, including some antidepressants, beta blockers, thiazide diuretics and anti-androgens. This is frequently overlooked, and sometimes the answer is as simple as reviewing what you are already taking with the doctor who prescribed it.

Psychological causes

Anxiety, depression, stress and relationship difficulties are genuine causes, not a lesser category. Performance anxiety in particular can create a self-sustaining cycle. Psychological and physical causes very often coexist, and treating only one of them tends to disappoint.

How we assess erectile dysfunction

Your consultation is unhurried and entirely confidential. It normally includes:

• A full history — when the problem started, whether it came on suddenly or gradually, whether you still get night-time or early-morning erections, and what medication you take. A sudden onset with preserved night-time erections points in a different direction from a gradual decline.
• A physical examination — including examination of the penis and testes, and assessment of your blood pressure and peripheral pulses.
• Blood tests — typically a morning total testosterone, HbA1c (for diabetes), a lipid profile, and thyroid and prolactin levels where indicated.
• Validated questionnaires — such as the International Index of Erectile Function (IIEF), which gives us an objective baseline to measure treatment against.
• Penile Doppler ultrasound — used in selected cases where a vascular cause is suspected, this measures blood flow into and out of the penis directly.

The point of this is not to accumulate tests. It is to answer a specific question: why is this happening to you, in particular — so that what we do next is aimed at the actual problem.

Treatment options

Treatment is chosen with you, based on the cause we identify, how severe the problem is, and what fits your life. Almost all men can be helped.

Addressing the underlying cause

Where a reversible cause is found — low testosterone, an unrecognised diabetes, a medication side effect — treating it can improve erectile function on its own. Stopping smoking, reducing alcohol, losing weight and taking regular exercise have a genuine, measurable effect, and they also reduce your cardiovascular risk.

Oral medication (PDE5 inhibitors)

Sildenafil, tadalafil, vardenafil and avanafil work by increasing blood flow into the penis in response to sexual stimulation. They are effective for a majority of men and are usually the first treatment tried. They must not be taken with nitrate medication for angina. If tablets have not worked for you before, it is worth knowing that the commonest reasons are an inadequate dose, incorrect timing, or too few attempts — not that the drug cannot work.

Vacuum erection devices

A mechanical pump that draws blood into the penis, held in place with a constriction ring. Drug-free, reusable and effective, particularly for men who cannot take PDE5 inhibitors, and useful in penile rehabilitation after prostate surgery.

Intracavernosal injection therapy

A very small dose of alprostadil injected into the side of the penis, self-administered after training in clinic. It works independently of nerve signalling, so it is effective for many men in whom tablets have failed — including after prostate surgery. Most men find it far less daunting than it sounds, and the first dose is always given under supervision.

Topical and intraurethral alprostadil

Alprostadil is also available as a cream applied to the tip of the penis, or as a small pellet inserted into the urethra. These suit men who prefer to avoid injections.

Penile prosthesis

An implant placed inside the penis, offering a reliable erection on demand. It is a definitive surgical option, generally considered when other treatments have failed or are unsuitable, and reported patient satisfaction is high. Because it involves replacing the erectile tissue, it is not reversible — which is precisely why it warrants a careful discussion with a surgeon who does this regularly.

Psychosexual therapy

Where anxiety, depression or relationship factors are contributing, talking therapy — alone or alongside medical treatment — is effective, and we can offer this to you if we think you will benefit from this approach.

Why see a consultant urologist for this?

Erectile dysfunction is often managed in primary care, and for many men that is entirely appropriate. A specialist referral makes a difference when:

• Tablets have not worked, or you cannot take them
• The problem started suddenly, or you are young
• There is penile curvature or pain, suggesting Peyronie's disease
• ED has followed prostate surgery, radiotherapy or pelvic trauma
• You have low testosterone and want it properly investigated before starting replacement
• You want to discuss second-line treatment such as injection therapy or a prosthesis

Our consultants practise at Guy's & St Thomas' — the No. 1 urology service in Europe in Newsweek's 2025 rankings — and take referrals from other urologists for exactly these situations.

Frequently asked questions

References and further reading