Why you get erectile dysfunction and what actually works

That is the heart of it. An erection is a surge of blood into two spongy chambers, switched on by a gas called nitric oxide that the lining of the arteries releases on demand. Anything that damages that lining, or narrows the arteries it sits in, quietly throttles the supply. Everything that follows in this guide is really about protecting those vessels and that switch.

Diet to help with erectile dysfunction

If an erection is a vascular event, then the diet that keeps your arteries healthy is the diet that helps your erections. This is not folklore. It is one of the better evidenced areas in the whole field, and the headline is simple. What is good for your heart is good for the rest of you.

The strongest evidence is for a Mediterranean style of eating, built around vegetables, fruit, whole grains, legumes, nuts, olive oil and fish, with little ultra processed food, sugar or red and processed meat. In a two year trial in men with metabolic syndrome, those moved onto a Mediterranean diet showed a clear improvement in erectile function, alongside better function in the lining of their blood vessels and lower inflammation. The diet was, in effect, repairing the machinery the interactive above describes.

A second strand of evidence points to flavonoids, the natural compounds that give many plants their colour. A study following more than 25,000 men for a decade found that those who ate the most flavonoid rich foods were significantly less likely to develop erectile dysfunction, with the benefit strongest for anthocyanins and flavanones. In practice that means:

• Berries, especially blueberries, blackberries and strawberries.
• Citrus fruit, apples, pears and grapes.
• Leafy greens and beetroot, which are rich in natural nitrates the body turns into the same nitric oxide that opens the arteries.
• Dark leafy vegetables, tomatoes, nuts and olive oil as everyday staples rather than treats.

Just as important is what to crowd out. Diets heavy in ultra processed food, sugary drinks, and large amounts of red and processed meat are linked with more erectile dysfunction, largely through weight gain, diabetes and artery damage. For men carrying extra weight, losing it is one of the most reliable non drug ways to improve erections, because it attacks several causes at once.

The takeaway. Eat for your arteries. A mostly plant based, Mediterranean pattern with plenty of colourful fruit and vegetables is the single most evidence based dietary change, and the results build over months, not days.

Supplements for erectile dysfunction

This is the area with the most marketing and the least regulation, so it pays to be clear eyed. A handful of supplements have genuine, if modest, evidence behind them. None is a substitute for seeing a doctor, and a few of the products sold online are downright dangerous.

The supplements with the most credible research are:

• L-citrulline. An amino acid the body converts into L-arginine and then into nitric oxide, the erection switch. Small trials suggest a couple of grams a day can give a mild improvement, and it is absorbed better than L-arginine itself.
• L-arginine, especially combined with Pycnogenol (a pine bark extract). On its own L-arginine is unconvincing, but a meta analysis of the two taken together found a meaningful improvement in erectile function.
• Panax ginseng, sometimes sold as Korean red ginseng. Several trials and a meta analysis report improved erections, with around 60 per cent of men in one study noticing a difference.

The honest summary is that these can help mild cases at the margins, the effects are smaller than prescription medicines, and the quality of the studies is mixed. They are worth a conversation with a pharmacist or doctor, particularly if you take other medication, but they are not a first line treatment.

Exercises to help with erectile dysfunction

Exercise helps in two completely different ways, and the best results come from doing both. The first is general fitness for your circulation. The second is targeted training of the muscles that actually pump and trap blood in the penis.

Aerobic exercise for circulation

Regular aerobic exercise, the kind that gets you breathing harder, improves the health of the lining of your blood vessels and their ability to release nitric oxide. That is the exact mechanism the interactive above turns on. Reviews of the trials consistently find that moderate to vigorous aerobic activity improves erectile function, with one practical target being around 40 minutes of brisk activity, such as fast walking, cycling, swimming or running, four times a week. As with diet, it is doing your heart and your erections the same favour at the same time. One useful note for keen cyclists is to make sure the saddle is not putting prolonged pressure on the perineum, the area between the legs, which can occasionally contribute.

Pelvic floor exercises, also called kegels

Most people think of pelvic floor exercises as something for women after childbirth. In fact they are one of the better proven non drug treatments for men. In a British randomised trial, men with erectile dysfunction who did pelvic floor exercises for six months did markedly better than a control group. About 40 per cent regained normal erectile function and a further 35 per cent improved. These muscles squeeze blood into the erect penis and help stop it draining away, so strengthening them genuinely matters.

Here is how to do them correctly.

1. Find the right muscle. The easiest way is to imagine you are trying to stop yourself passing wind, and at the same time stop your urine mid flow. The muscle you clench is the pelvic floor. Use the urine test only once to identify it, not as a regular exercise.
2. Get the technique right. Squeeze and lift that muscle, hold for a slow count of five to ten seconds, then relax for the same length of time. Do not hold your breath, and do not clench your buttocks, thighs or stomach instead. You should feel a lift internally, not a visible squeeze.
3. Mix slow and fast. After the slow holds, do a set of quick, sharp squeezes and releases. Both types are useful.
4. Build up the reps. Aim for around three sets of eight to twelve squeezes, twice a day. You can do them lying down at first, then progress to sitting and standing, which is harder.
5. Be patient. Like any muscle training, it takes weeks. Most men who stick with it notice a difference somewhere between four and twelve weeks.

The takeaway. Brisk aerobic exercise repairs the supply line, and daily pelvic floor exercises strengthen the pump. Both are free, both have trial evidence, and neither has side effects.

The psychology of erectile dysfunction

An erection starts in the brain, which is why your state of mind can switch it on or shut it down regardless of how healthy your arteries are. This is the part many men most need to hear and least want to discuss.

The most common pattern is performance anxiety. A single disappointing experience, perhaps caused by tiredness or alcohol, plants a fear of it happening again. The next time, that fear floods the body with adrenaline. Adrenaline is the opposite of what an erection needs. It tightens the very arteries that are supposed to relax and open, so the worry becomes self fulfilling. One bad night turns into a pattern, and the pattern feels like proof that something is permanently wrong, when really it is a feedback loop that can be broken.

Other psychological drivers include depression and anxiety, which dampen desire and arousal, as can the antidepressants used to treat them, ongoing stress from work or money, and relationship difficulties where unspoken tension shows up in the bedroom. Heavy pornography use is debated rather than proven, but some men do find that very frequent solo use leaves real life encounters feeling muted, and that cutting back helps.

What helps is rarely a pill. It is:

• Talking to your partner. Taking the pressure off, and taking penetration off the table for a while, removes the stage on which the anxiety performs.
• Psychosexual therapy or counselling, including cognitive behavioural approaches, which directly target the anxiety loop. A GP can refer you.
• Sensate focus, a structured set of touch based exercises couples do together that deliberately rebuild intimacy without the goal of an erection, which paradoxically lets the erection return.
• Treating any underlying depression or anxiety, and reviewing whether a medication is contributing.

There is no shame in any of this. The brain is part of the body, and a mind under pressure is one of the most fixable causes of all.

Medication and medical treatments for erectile dysfunction

When lifestyle change is not enough, or when a man wants help while the slower changes take effect, modern medicine is very good at restoring erections. The important thing to understand is that these treatments mostly fix the symptom. They do not cure the underlying cause, which is why the rest of this guide still matters.

Tablets, the PDE5 inhibitors

The familiar pills, sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanafil (Spedra), all work the same way. Remember that nitric oxide opens the arteries by raising a messenger called cGMP. These drugs block the enzyme that breaks cGMP down, so the natural erection signal lasts longer and works harder. They are effective for around 70 per cent of men.

Two things are worth knowing. First, they do not create desire and they do not work without arousal. They amplify a signal, they do not generate one. Second, tadalafil lasts far longer than the others, up to around 36 hours, and can be taken as a low daily dose, which some couples prefer for spontaneity.

In New Zealand there are two practical points. None of these medicines is funded by Pharmac for ordinary erectile dysfunction, so you pay for them privately. And sildenafil can now be supplied directly by specially trained pharmacists, without a doctor’s prescription, to men aged 35 to 70 after a short consultation that includes a blood pressure check and some questions about your health and other medicines. Otherwise, a GP can prescribe any of them.

Common side effects are usually mild and include headache, facial flushing, a blocked nose and indigestion. They are a strong reason to involve a health professional rather than an unregulated website.

Other medical options

If tablets do not suit or do not work, there are well established alternatives, almost all arranged through a doctor:

• Vacuum erection devices. A pump draws blood into the penis and a ring holds it there. Cheap, drug free and effective for many men.
• Injections or pellets. A medicine called alprostadil can be injected into the side of the penis or inserted as a tiny urethral pellet. It works even when tablets do not.
• Testosterone replacement, but only for the minority of men with a genuinely low, tested level.
• Penile implants, a surgical option reserved for severe cases that have not responded to anything else.

You may also see clinics advertising shockwave therapy. It is an interesting area of research but is not yet an established, proven treatment, and it is not cheap.

When to see a doctor

It is worth seeing your GP about erection problems that have lasted more than a few weeks, and not only to get a prescription. New, unexplained erectile dysfunction can be the earliest sign of cardiovascular disease, sometimes appearing years before a heart attack or stroke, precisely because the small arteries of the penis clog before the larger ones around the heart. Erection trouble can also be the first hint of undiagnosed diabetes. Treating it as a simple plumbing nuisance can mean missing a valuable warning.

A good consultation is straightforward and not embarrassing. The doctor will ask about your general health, your medicines and your mood, check your blood pressure, and usually arrange blood tests for blood sugar, cholesterol and sometimes testosterone. From there you will work out together whether the priority is lifestyle, medication, the psychological side, or all three.

Please do not self diagnose by buying pills from an unregulated website. You miss the health check that is often the most important part, and you risk the dangerous fakes described earlier.