Erectile dysfunction – Raising the issue

Having problems gaining an erection is becoming increasingly more common, particularly in men over the age of 40 years. Here at Behealthible, we want you to be confident on all things erectile dysfunction, so you are no longer gun-shy to raise this issue. #ASKAPHARMACIST

Erectile dysfunction poster
What is erectile dysfunction

What is erectile dysfunction? Erectile dysfunction symptoms

Erectile dysfunction, which is commonly referred to by its abbreviation ‘ED’, is defined as an inability to gain and/or maintain an erection that is firm enough for sex.

What is the science behind gaining an erection – Inside the penis, there are two long cylindrical masses of erectile tissue (simply put, a bunch of cells) called ‘corpora cavernosa’, which both contain a multitude of blood vessels, as well as one major artery in each corpus cavernosum. 

Upon becoming aroused, signals are sent from your brain to the excitatory nerves in the penis, which respond by releasing erection inducing chemical messengers (neurotransmitters) such as nitric oxide and acetylcholine. These chemical messengers then signal a type of muscle (smooth muscle) that act to apply pressure to blood vessels and organs.

In the case of gaining an erection, smooth muscles of the penile arteries react to these chemical messengers by dilating (relaxing) and filling with blood. This causes an increase in pressure within the penile blood vessels, causing the blood to become trapped in the corpora cavernosa, which keeps the penis erect. 

This mechanism of gaining an erection can help to explain the fundamental causes of erectile dysfunction, which relates to there being either too little blood flow to the penis in the first place to achieve an erection, or blood failing to remain within the corpora cavernosa for long enough for the maintenance of an erection.

Causes of erectile dysfunction

Causes of erectile dysfunction

As previously mentioned, the symptoms of erectile dysfunction include an inability to gain an erection or an inability to maintain an erection. The scientific mechanism by which erectile dysfunction occurs is seemingly straight forward, however, the causes that trigger this mechanism to occur can be more complex. For ease of understanding, the potential causes of erectile dysfunction are usually divided into those which are physical and those which are psychological.

Physical causes of erectile dysfunction

Physical causes of erectile dysfunction

Physical causes of erectile dysfunction are most commonly linked with medical conditions that negatively affect blood circulation, and as we’ve discussed previously, blood flow to the penis is essential to gain and maintain an erection.

Examples of such conditions include high blood pressure (hypertension), clogged blood vessels (atherosclerosis) which restrict blood flow, heart disease, and high cholesterol. In addition to circulatory problems, there may be other physical causes, for example, high blood sugar levels in diabetes can damage nerves throughout the penis, which in turn diminishes their ability to send the necessary chemical messengers required to gain an erection. High blood sugar can also adversely affect blood vessels.

Prescribed medication may also be a causative factor for erectile dysfunction, examples include diuretics (water pills), certain antidepressants (e.g. fluoxetine), antihistamines, just to name a few. To know if prescribed medicine(s) could be contributing to erectile dysfunction, be sure to look at the patient information leaflet provided with the medicine(s) and see if erectile dysfunction is a listed side effect.

A similar sentiment is also true for recreational drugs, and for this reason, we should also pay attention to the likes of smoking, drinking alcohol, as well as illicit drug use including marijuana and heroin, to name a few.

Obesity, alongside metabolic syndrome (having a combination of diabetes, high blood pressure, and obesity) can negatively impact blood pressure and cholesterol levels, possibly leading to erectile dysfunction. 

There are many other medical conditions that may play a role in erectile dysfunction, with some examples being Parkinson’s disease, multiple sclerosis, Peyronie’s disease (development of scar tissue inside the penis), amongst others. If you feel that a medical condition could be the/ a contributing factor, be sure to consult your doctor.

Psychological causes of erectile dysfunction

Psychological causes of erectile dysfunction

As we have come to know, sexual arousal begins in the brain by the realise of chemical messengers, and for this reason, physiological problems that can affect our normal brain function may also be contributing to erectile dysfunction. Some of the more common psychological factors include depression and anxiety, which contribute to erectile dysfunction by messing with libido (sexual desire), and in doing so making it more difficult for you to become aroused and as a result gain an erection.

There is also an established link between stress and erectile dysfunction. When stressed, your body increases the production of the hormone ephedrine, which has a constrictor effect on blood vessels. This is problematic, considering the exact opposite is required to achieve an erection, whereby blood vessels need to be dilated (relaxed)

Treatment for erectile dysfunction

Each individual case of erectile dysfunction may be caused by one or many different factors, and for this reason it is essential that we gain an insight into what the most probable cause/causes may be, prior to deciding treatment. This is so that we can better tailor treatment for the best outcome.

In most cases, a simple physical examination and review of the presenting symptoms is enough to diagnose erectile dysfunction, however, if an underlying health problem is suspected, the doctor may request additional testing.

Treatments for erectile dysfunction

Treatments for erectile dysfunction

There are various methods available to help treat and manage erectile dysfunction, most common of which are covered below.

Medication used in the treatment of erectile dysfunction

Medication used to treat erectile dysfunction

The most widely available, and understandably popular option is the use of oral erectile dysfunction medication, owing to their ease of use, availability and proven track record. The most commonly prescribed and purchased erectile dysfunction medication belong to the drug class phosphodiesterase type 5 (PDE5) inhibitors, of which sildenafil belongs to, or as it is more commonly known Viagra. Other examples within this drug class include tadalafil (Cialis) and vardenafil (Levitra), which all work by the same mechanism (read below).

So how do these PDE5 erectile dysfunction medicines work? – In simple terms, upon taking this medication, and then becoming sexually aroused, the nerves in your penis will begin to release a chemical called nitric oxide. The release of this chemical will then cause the release of another chemical called, cGMP, which has the effect of causing the blood vessels in the penis to expand (dilate), in turn increasing blood flow to the penis.

This is the innate mechanism by which men gain an erection, however with the help of medicines such as Viagra, the chemical cGMP is prevented from being degraded and removed from the penis. As a result, the duration of blood flow to the penis is prolonged, as a result prolonging the erection, and in turn sexual satisfaction.

Psychotherapy to help manage erectile dysfunction

Psychotherapy used to treat erectile dysfunction

As we now know, psychological conditions such as depression, anxiety, and even stress can contribute to erectile dysfunction, and because of this, psychological therapies that aim to help address these negative thought patterns may be of great benefit in treating erectile dysfunction. The most commonly used form of psychological therapy is cognitive behaviour therapy (CBT), sometimes available as part of the NHS. For more information on CBT visit 

Lifestyle changes to help erectile dysfunction

Lifestyle changes to help treat erectile dysfunction

Examples of lifestyle factors that may contribute to erectile dysfunction include being obese, an unhealthy diet, a sedentary lifestyle (i.e. no exercise), and drinking too much alcohol. By understanding these risk factors, and making the necessary lifestyle changes, you can correct any underlying health problems which may be contributing to erectile dysfunction.

When we think of riding a bike, we naturally think of health and well-being, and rightfully so. However, did you know that excessive bike riding may be contributing to erectile dysfunction?

The reason why bike riding could be a cause of erectile dysfunction relates to the idea that when you sit on a bike for long periods of time, the seat and how it is structured will put pressure on your perineum, which is the area between your anus and penis The perineum is filled with arteries which supply oxygen-rich blood to your penis and nerves which provide sensation to your penis.

We hope that you can now make an association between these effects and erectile dysfunction.

Cycling is a hobby enjoyed by many, and it would unfortunate if we had to give this up completely for the sake of an erection. Instead, by adopting some minor changes we can continue cycling, but in a manner that puts less strain on the perineum, with some changes being: opting for a wider seat, wearing padded shorts, taking more breaks during long rides, standing and riding where possible, and anything else you feel will help to relieve pressure on the perineum.

Vacuum pumps used in the treatment of erectile dysfunction

The use of a vacuums pump for erectile dysfunction

Vacuum pumps are used to encourage blood flow to the penis analogous to how the PDE5 medicines work and is used as an effective method in most men. Vacuum pumps can be opted for when medication is not suitable or hasn’t worked, but bear in mind that vacuum pumps are not always available on the NHS.

Can I purchase Viagra over the counter

Can I buy Viagra over the counter and is it safe?

Viagra tablets were reclassified from a prescription only medicine (POM) to a pharmacy (P) medicine by the MHRA (Medicines & healthcare regulatory agency) as of 2017, meaning they were now available for purchase from a pharmacy. 

According to the MHRA, the decision to make Viagra an over the counter medication was made following a reassuring assessment of the safety of the Viagra, advice from the Commission on Human Medicines, and a public consultation in 2017, which all had positive outcomes. 

According to the regulations which made Viagra available for purchase over the counter, they specified that the medicine must only be sold under the supervision of a pharmacist, and following a consultation process that will be used to assess whether the patient meets certain eligibility criteria (covered below).

Viagra is the brand name for the generic drug called sildenafil, which in the year 2020 is now available for purchase as a generic tablet (i.e. as sildenafil), as well as under different brand names other than viagra (e.g. Aronix). However, the same consultation process and eligibility criteria apply to these products that would apply to the sale of Viagra tablets. 

Subheadings - Viagra

Am I eligible to purchase Viagra over the counter?

In order to purchase Viagra (sildenafil) over the counter, you must first have a consultation with a pharmacist, who will ask you a number of questions in order to see if the sale of Viagra is suitable and safe.

The line of questioning may vary slightly from pharmacist to pharmacist, based on their clinical judgment, but as a basic overview we will highlight some questions you can expect to be asked:

Age – Viagra is only intended for men 18 years and older, who are experiencing symptoms of erectile dysfunction. Bear in mind that Viagra or any other form of sildenafil tablet will not be sold to those who present with no symptoms of erectile dysfunction. 

Check for cardiovascular health – Viagra (sildenafil) may be dangerous in patients with certain types of heart disease. This is due to its potential to affect a person’s blood pressure, whilst also having the potential to dangerously interact with a class of drugs called nitrates, commonly used in heart problems such as heart failure.

Check for concomitant medication use – Like will all medicine, Viagra (sildenafil) has the potential to interact with other medicines, as we have previously demonstrated with the nitrate drug class. This notion is also applicable to recreational drug use, which the pharmacist should also be made aware of. 

Check for concomitant conditions – There are a fair few conditions that will restrict the sale of Viagra, and necessitate referral to a doctor. A couple of examples include previously diagnosed liver disease, severe renal (kidney) impairment, Peyronie’s disease (or another penile deformity), bleeding problems (e.g. hemophilia), active stomach ulcers, amongst others which should be discussed during the thorough consultation process with a pharmacist.

Guide to get the most out of Viagra (sildenafil)

Viagra – A 5 part guide to the effective and safe use of Viagra 

Best time to take Viagra – Viagra should be taken approximately one hour before planned sexual intercourse. However, because Viagra has the potential to work within 30 minutes, you may even take the tablet as late as 30 minutes prior to sexual intercourse. 

How much viagra can I take – The maximum recommended dose of Viagra (sildenafil) over the counter is one 50 mg tablet per day.

Viagra and food? – Viagra can be taken with or without food, however, the type of food you eat may hinder how quickly Viagra is able to have its effect. Studies have shown that Viagra may take longer to work after a high-fat meal. 

Another important point is to avoid eating or drinking grapefruit or grapefruit juice whilst taking Viagra (sildenafil), as grapefruit may affect the body’s ability to remove sildenafil, in turn causing a boost in the levels of the drug in your body. With higher levels of circulating drugs throughout the body, there is an increased risk of side effects. 

Don’t give up after one try – Some people may need to take Viagra a number of times (not on the same day) before they can achieve a satisfactory erection. This may be due to a number of factors, with a common example being the timing of when you took the medicine, so don’t allow one or two bad experiences discourage you from giving the medicine another try. 

Is Viagra one enough– No, as Viagra will not stimulate an erection on its own, and instead requires you to be sexually aroused in order to have its effect. So make sure that you are in the mood to get the most out of the medicine.

Viagra side effects

Viagra side effects

Like with all medication, Viagra (sildenafil) has the potential to cause side effects. Most of the side effects experienced are usually short lived, and easily treated. Some examples of common side effects include – Dizziness, facial flushing, gastrointestinal discomfort, headaches, insomnia, nasal complaints, nausea, vision problems, amongst others.

Signs of a serious reaction to Viagra (sildenafil) which requires immediate medical attention

Chest pains, priapism (a prolonged erection of the penis, lasting longer than 4 hours), sudden decrease or loss of vision, signs of an allergic reaction, signs of a serious skin reaction, and if experiencing seizures or fits.


We hope that after reading this blog you feel more informed about erectile dysfunction, and with it being a common condition we shouldn’t feel ashamed or discouraged to raise the issue. By having a better understanding of the complex nature of erectile dysfunction, including its causes and treatment options, we are hopefully better able to deal with erectile dysfunction.

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