Erectile dysfunction is one of the most common conditions a doctor sees and one of the least often mentioned. It is not a question of desire, of willpower or of masculinity. An erection is a physical event that depends on blood vessels, nerves and hormones working together in sequence, and any one of the three can be interrupted by something ordinary, common and identifiable.
This guide sets out what causes it, why it is a medical matter rather than a character one, what a doctor actually does about it, and the part most articles leave out: when the symptom is a signal that something else in the body needs attention more urgently than the symptom does.
How common is erectile dysfunction?
Common enough that any doctor has this conversation many times a month. Research suggests that between 30 million and 50 million men in the United States have erectile dysfunction, that about 40% of men are affected at age 40, and that 70% report having it by age 70Source 1: Definition & Facts for Erectile Dysfunction. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health. Last reviewed October 2024.. The NHS describes it as very common, particularly in men over 40Source 4: Erectile dysfunction (impotence). NHS. Page last reviewed 28 July 2023..
The figure nobody publishes is how many of those men have said anything to a doctor. In Malta that number is pushed down by geography. The waiting room has eyes, the pharmacist may know the family, and a man who would not think twice about a chest infection can carry this one quietly for years.
Age raises the odds, but ageing is not the explanation. NIDDK states it directly: erectile dysfunction is not a routine part of agingSource 1: Definition & Facts for Erectile Dysfunction. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health. Last reviewed October 2024.. What rises with age is the number of other conditions a man is carrying, and it is those conditions doing the work.
Is an occasional problem the same as erectile dysfunction?
No. The NHS puts it plainly: most men occasionally fail to get or keep an erection, this is usually caused by stress, tiredness or drinking too much alcohol, and it is nothing to worry aboutSource 4: Erectile dysfunction (impotence). NHS. Page last reviewed 28 July 2023.. What defines the condition is a pattern, not an evening.
The condition means the difficulty persists: getting an erection sometimes but not every time, getting one that does not last long enough for sex, or being unable to get one at any timeSource 2: Symptoms & Causes of Erectile Dysfunction. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health. Last reviewed October 2024.. The threshold for speaking to a doctor is not severity, it is repetition. The NHS advice is to be seen if erection problems keep happening, because it may be a sign of a health condition that can be treatedSource 4: Erectile dysfunction (impotence). NHS. Page last reviewed 28 July 2023..
What causes erectile dysfunction?
An erection depends on blood arriving, staying, and being signalled to do both. Anything that affects blood vessels, nerves or hormones can interrupt that, and so can a number of medicines taken for entirely unrelated reasons. NIDDK groups the causes into fourSource 2: Symptoms & Causes of Erectile Dysfunction. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health. Last reviewed October 2024.:
- Diseases and conditions. Diabetes. Heart and blood vessel disease, including atherosclerosis, high blood pressure and stroke. Chronic kidney disease, obesity and chronic obstructive pulmonary disease. Hormone problems such as low testosterone and thyroid imbalance. Nerve damage from multiple sclerosis, spinal cord injury or pelvic surgery. Problems of the reproductive system such as an enlarged prostate or penile curvature.
- Medicines. Erectile dysfunction is a recognised side effect of a number of common prescription and over-the-counter medicines taken for other things entirely, including some taken for mood, for blood pressure, for allergies, for pain and for sleep.
- Mental health and emotions. Anxiety, depression and stress can cause the problem or make it worse, as can low self-esteem, loss of confidence, or feeling isolated.
- Lifestyle. Smoking, drinking too much alcohol, using recreational drugs, and not getting enough physical activity all contribute.
More than one of these is usually at work at the same time, which is the single most useful thing to understand before a consultation. A vascular cause and an anxiety cause can sit on top of each other, and addressing one while ignoring the other is how a man concludes that nothing helps.
Why is erectile dysfunction a medical matter and not a character one?
Because the mechanism is vascular. In the urological literature erectile dysfunction is regarded as a vascular impairment that shares many of its risk factors with cardiovascular disease, and the two are described as different manifestations of the same systemic disorderSource 5: Gandaglia G, Briganti A, Jackson G, Kloner RA, Montorsi F, Montorsi P, Vlachopoulos C. A Systematic Review of the Association Between Erectile Dysfunction and Cardiovascular Disease. European Urology. 2014;65(5):968-978.. Nothing in that sentence is about attraction, effort or masculinity.
The distinction is not offered as reassurance. It is clinical, and it changes what gets examined. Understood as a personal failing, the problem is managed with silence. Understood as a sign of endothelial dysfunction, it is managed with a blood pressure reading, a blood test and a proper conversation about the heartSource 5: Gandaglia G, Briganti A, Jackson G, Kloner RA, Montorsi F, Montorsi P, Vlachopoulos C. A Systematic Review of the Association Between Erectile Dysfunction and Cardiovascular Disease. European Urology. 2014;65(5):968-978..
The shame is understandable and it is also the expensive part, because it is what turns a six-month problem into a six-year one, and because the years in between are the years in which the thing underneath it goes unexamined.
When is erectile dysfunction a warning sign of something more serious?
Often, and this is the section worth reading twice. The arteries that supply erectile tissue are smaller than the coronary arteries, so the same degree of damage to the lining of the blood vessels reduces blood flow there first. That is why erectile dysfunction usually precedes cardiovascular disease and why it is treated as an early marker of itSource 5: Gandaglia G, Briganti A, Jackson G, Kloner RA, Montorsi F, Montorsi P, Vlachopoulos C. A Systematic Review of the Association Between Erectile Dysfunction and Cardiovascular Disease. European Urology. 2014;65(5):968-978.. A symptom that arrives ahead of the disease is a warning, and it is the reason a doctor takes it seriously rather than treating it as cosmetic.
The size of that association has been measured. A meta-analysis of twelve prospective cohort studies covering 36,744 men found the risk of cardiovascular disease was 48% higher in men with erectile dysfunction than in men without it, with coronary heart disease 46% higher and stroke 35% higher, and the finding held in the analysis restricted to studies that controlled for conventional cardiovascular risk factorsSource 6: Dong JY, Zhang YH, Qin LQ. Erectile Dysfunction and Risk of Cardiovascular Disease: Meta-Analysis of Prospective Cohort Studies. Journal of the American College of Cardiology. 2011;58(13):1378-1385..
Blood sugar is the other one. A change in sexual function can be a sign of diabetes, and men with diabetes may develop erectile dysfunction 10 to 15 years earlier than men without itSource 7: Diabetes, Sexual, & Bladder Problems. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health. Last reviewed June 2018.. For some men, the appointment about erections is the appointment that finds the diabetes, and that is the appointment doing its job.
What does a doctor actually do about it?
The work is diagnostic before it is anything else. A doctor takes a medical, sexual and mental health history, asks what prescription and over-the-counter medicines, vitamins and supplements are being taken, and checks for blood vessel and nervous system problems, hormonal problems, and physical problems such as penile curvatureSource 3: Diagnosis of Erectile Dysfunction. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health. Last reviewed October 2024.. Blood tests, including thyroid and prostate tests, are used to find the cause rather than to confirm a decision already madeSource 3: Diagnosis of Erectile Dysfunction. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health. Last reviewed October 2024..
Three questions are being answered at once: what is causing this, is something else going on that matters more, and is treatment appropriate and safe for this particular man. Only a doctor can answer the third, and the answer is sometimes no.
At Carisma Medical the consultation is 20 minutes on video with a Malta-registered doctor who has read the pre-assessment answers before the call, and the whole of it is set out on our erectile dysfunction page. Where the picture points at hormones rather than at blood vessels, that is a different assessment with a different starting point, and it begins with a blood test rather than with a prescription: see testosterone.
There is no route through this service that reaches a prescription without that conversation. If the honest answer is that a heart should be looked at in person before anything else happens, that is what gets said, and for some men it is the most useful thing the appointment ever produces.
What can be done without a prescription?
A fair amount, and the NHS lists it plainly: losing weight if overweight, stopping smoking, eating a healthy diet, exercising daily, and reducing stress and anxiety. It also advises drinking no more than 14 units of alcohol a week, and taking a break from cycling for anyone who cycles more than three hours a weekSource 4: Erectile dysfunction (impotence). NHS. Page last reviewed 28 July 2023..
None of that replaces finding out what is causing the problem, and it is not offered here as a substitute for being assessed. It is worth doing because those measures act on the same blood vessels the warning is about, which makes them useful whatever the consultation concludes.
How does an online consultation work in Malta, and what does it cost?
A free online assessment, then a slot chosen and paid for, then a 20-minute video call with a Malta-registered doctor who has already read the answers. If the doctor decides treatment is appropriate, the prescription is sent to the patient, who collects it at any pharmacy in Malta or Gozo they already use. The sequence is set out step by step on how it works and in our guide to seeing a doctor online in Malta.
A consultation is €59, and the assessment before it is free. Sexual health carries no monthly fee: it is bought one consultation at a time, so nothing runs in the background between appointments. If the doctor prescribes, the medicine is a separate purchase. Collect at any pharmacy in Malta or Gozo. You pay the pharmacy directly, at its own price. We never sell or ship medicine. That figure includes any tax. Full particulars are on the pricing page.
The fee is paid whether or not the doctor decides to prescribe, because the consultation is what was booked and the decision has to be a clinical one. The service is for adults aged 18 and over in Malta and Gozo, and the rest of what it covers sits under sexual health.