While it’s perfectly natural to experience weaker erections with age, sometimes erectile dysfunction (ED) can be a red flag that you have an underlying health problem.

The good news is that provided you’re still having involuntary morning erections — even if not as often as before — you probably won’t have one of these more serious conditions.

High blood pressure

An estimated one in three men with high blood pressure has no idea they have it, and impotence could be a vital warning sign.

While it’s perfectly natural to experience weaker erections with age, sometimes erectile dysfunction (ED) can be a red flag that you have an underlying health problem

As we get older, our arteries become narrower and less elastic, which forces our blood pressure to rise gradually as the heart beats ever harder to get blood around the body. This damages the arteries, reducing blood flow to the penis.

NATURAL REMEDIES TO LIFT A CHAP'S LIBIDO L-arginine Studies show this amino acid can improve erections by boosting the production of nitric oxide, a natural chemical that dilates blood vessels to the penis. ‘We suggest this for men who are borderline in need of medical treatment or who use Viagra, but need more help,’ says Dr Graham Jackson, chairman of the Sexual Advice Association. £13.95 for 120 tablets (each tablet 750mg), healthspan.co.uk. Dosage: Three to four tablets daily. Vitamin D3 ‘This nutrient is linked with the production of testosterone in men,’ says Dr Geoff Hackett, consultant in sexual medicine at Heartlands Hospital, Birmingham. ‘I recommend patients have their vitamin D levels checked and take supplements if they are deficient.’ Super Strength Vitamin D3, £10.95 for 240 tablets, healthspan.co.uk. Dosage: One daily. Yohimbe ‘I prescribe this herb to male patients who have difficulty reaching climax,’ says Giulio Garaffa, a consultant urological surgeon at University College London Hospitals. The herb, which comes from the bark of an evergreen African tree, is thought to work by increasing blood flow and nerve impulses to the penis. It can interact with other medicines — particularly those for kidney problems — so should only be taken on the advice of a doctor. Biovea Yohimbe, £16.60 for 90 capsules, biovea.com/uk. Dosage: Four capsules one hour before sex. GinkGo Biloba This extract from the leaves of the ginkgo biloba tree is used for circulation problems, low energy levels and fatigue. Swedish research found that compounds in the leaves relax blood vessels while simultaneously improving sluggish circulation. Other studies that compared it with a placebo have found it helped treat sexual dysfunction and impotence in men, but experts remain ambivalent about its usefulness. Dr Jackson says it does no harm. £10.95 for 240 tablets (each tablet 120mg) from healthspan.co.uk. Dosage: One tablet a day. Ginseng Known as the ‘male remedy’ in China, there is evidence to suggest this herb can reduce stress by helping to mop up the stress hormones cortisol and adrenaline. A Korean trial found 60 per cent of patients taking ginseng were able to sustain an erection for longer during intercourse (compared to placebo). £8.95 for 120 tablets (each tablet 150mg), healthspan.co.uk. Dosage: One tablet, three times a day. Advertisement

What you can do: Ask your GP to check your blood pressure. Lifestyle changes such as increasing exercise and lowering salt intake may improve erectile dysfunction.

If you are already taking blood pressure medication and suffer from impotence, mention it to your doctor as some pills, such as Thiazide diuretics and beta blockers, can trigger or worsen it and your GP may be able to prescribe an alternative.

Heart disease

The many stresses of modern life, compounded with poor diet, lack of exercise, drinking and smoking, can put you at risk of high cholesterol and heart disease, both of which cause narrowing of the arteries, reducing blood flow to the heart — and to the penis.

So, weak erections can be an early sign of heart trouble.

‘The blood vessels in your penis are 1mm to 2mm wide, much smaller than those in the arteries to your heart (3mm to 4mm wide), so they show up signs of narrowing more quickly,’ says Dr Graham Jackson, a cardiologist and chairman of the Sexual Advice Association.

He warns that impotence occurs, on average, about three years before a heart problem appears, especially in men in their 40s or 50s. ‘Men with erectile dysfunction are 50 times more likely to have heart problems than men with normal heart function,’ he says.

What you can do: Get your heart and cholesterol levels checked. Improving your diet and boosting exercise levels can reduce your cholesterol levels. Your GP might also recommend a cholesterol-lowering statin drug.

‘There is some evidence that statins can help with erectile dysfunction,’ says Dr Edwards. ‘But some statins list erectile dysfunction among their possible side-effects.’

Diabetes

Half a million people in Britain are believed to have undiagnosed diabetes — a condition where your body cannot process the sugar in your blood effectively. Left untreated, this can lead to damage to the blood vessels and the nerves, and according to urologist Sudhanshu Chitale, this can cause poor blood flow to the penis, too.

What you can do: Poorly controlled diabetes can lead to irreversible ED. If you are diagnosed with, or already have, diabetes, keeping your blood sugar levels stable (through diet and possibly medication) may help prevent impotence. However, Mr Chitale warns: ‘More than 50 per cent of diabetics will have ED at some point, and it becomes more common as they grow older.’

Enlarged prostate

The prostate is a small, doughnut-shaped gland that sits under the bladder, around the urethra.

Prostate problems are common with age — typically these are prostatis, a bacterial infection which causes the gland to become swollen, and an enlarged prostate, which is linked to testosterone.

Both can trigger pain, difficulty passing urine and temporary problems with erectile dysfunction.

What you can do: Prostatis can be treated with antibiotics (it usually clears within four weeks) and an enlarged prostate may shrink after a course of finasteride or dutasteride (drugs that block the effects of testosterone, reducing the gland’s size).

Treatments for prostate cancer — surgery, radiotherapy, ultrasound, cryotherapy and hormone therapy — can trigger erection problems.

Early prostate cancer can be treated surgically with a nerve- sparing technique, which gives a better chance of erections afterwards.

Sex is not a subject we tend to talk about freely, but many of us suffer from sexual problems, with up to half of all women and at least ten per cent of men thought to be affected

Low testosterone

ALL OVER IN A FLASH Premature ejaculation is defined by reaching orgasm too quickly during sex, but there is no strict definition of ‘too quickly’. A long-term problem can be linked to bad early sexual experiences or abnormal nerve signals. However, if the condition develops later in life, then health problems such as type 2 diabetes, high blood pressure or excessive drinking (more than three or four units of alcohol a day) could be to blame. Stress and depression can also play their part. If you are concerned, talk to your GP, who may prescribe dapoxetine (a mild anti-depressant, brand name Priligy) which can help if taken a few hours before sex. Advertisement

This hormone drives desire and the ability to have erections.

Levels drop naturally with age — by 75, a man’s levels may be half of what they were when he was 20 — but they vary widely with the individual, and experts believe low testosterone only rarely causes erectile dysfunction.

What you can do: Ask your GP to check your testosterone levels — this involves a blood test.

A reading of 12 nannomols per litre is considered normal, and eight or below is considered low.

If low, your GP might offer you testosterone replacement therapy (TRT) in the form of tablets, gel, injections or patches.

Every man is different, though, and Dr Jackson says: ‘If your levels are between eight and 12, you might want to think about treatment.’

You can buy testosterone treatment through private clinics or online, but Neal Patel, a pharmacist with the Royal Pharmaceutical Society, recommends seeking your GP’s advice.

‘If it seems too easy or too cheap, be wary,’ he says. ‘You might be getting a fake.’

CASE STUDY: WE BOUGHT VIAGRA ON THE WEB Simon Letwin, 56, who lives with his wife Rachel, 51, near Knutsford, Cheshire, developed erection problems after he turned 50. He says: For around five years, it had been getting more and more difficult to achieve a proper erection — and if I did, it rarely lasted as long as it used to and sometimes not long enough. Rachel was very understanding, but she badgered me to go to our GP, which I did. I was happy to be declared healthy, but I just didn’t feel I could talk openly with my GP about my flagging sex life. I resigned myself to the fact that this was just going to be an annoying inevitability of old age — but Rachel read a magazine article about getting Viagra online and persuaded me to try. I was nervous about buying drugs off the internet, but the whole process seemed very well organised and above board. She signed us up to an online pharmacy (drthom.com) and filled in a detailed health questionnaire about any existing conditions and medication I might be on. We got an email back within the hour saying I was OK to buy the drugs. We then went back online and chose from the selection — Viagra, Levitra or Citalis. We were told our ‘prescription’ (four Viagra pills for £47) would be ready for us to collect — and pay for — at our local branch of Lloyds Pharmacy. We couldn’t believe it was so easy. It wasn’t. When Rachel went to collect the pills, there was confusion because she’d filled in the questionnaire and it turns out I should have filled in the form and picked up the drugs — not her. There was a kerfuffle behind the counter while they checked our prescription and the pharmacist took Rachel aside and whispered: ‘You do know these are for men, not women, don’t you?’ Rachel found it really embarrassing. She then had to go home and start the whole process again. The next hurdle was finding the right time to use the drugs. For us, sex normally happens at the end of a boozy night out. But the instructions say the pills should be taken on an empty stomach, and without alcohol, taking away some of the spontaneity. My fears that I might end up with an uncontrollable 48-hour erection were — mercifully — unfounded. About an hour after taking the pill, my face became red and flushed and I developed a mild headache. This lasted into the next day. The erection bit worked marvellously. It stayed in place just as long as I needed it, then went away. Rachel declared the whole process a resounding success. Names have been changed. Advertisement

Pill or jab - what's right for YOU?

Though erectile dysfunction is very common, especially with age, men often delay seeking help.

‘It often takes them two or three years to see a doctor, and it is usually the spouse who books the appointment,’ says Graham Jackson, chairman of the Sexual Advice Association.

‘Don’t go to the internet for advice — go to a healthcare professional who can screen for any possible health conditions and offer expert advice.’

If your GP suspects contributing health problems, you may be referred to a specialist (perhaps a cardiologist or urologist).

Impotence is also linked to psychological triggers such as stress or depression — you may be referred for cognitive behavioural therapy (CBT) and sex therapy (one-to-one counselling, which may include your partner).

There are also a number of drug and surgical options.

Treatment for erectile dysfunction is available on the NHS if your sex problem is linked to certain health conditions, such as diabetes, or is causing serious distress. If you don’t qualify for NHS help, a wide range of treatments are available privately.

VIAGRA-TYPE DRUGS

WOULD BEST SUIT: First treatment option for erectile dysfunction.

Your GP may prescribe Viagra (the brand name for the generic drug sildenafil), Cialis or Levitra.

The tablets, which take 30 to 60 minutes to work, relax the blood vessels in the penis, so improving blood flow, making an erection (if stimulated) more likely.

The effects of Viagra and Levitra can last for eight hours, Cialis for up to 36 hours, but an erection will only last as long as stimulation is maintained.

On the NHS you can be prescribed a maximum four tablets per month. If you don’t qualify for free treatment, you can ask your GP to write you a private prescription (which may cost a small fee).

Viagra takes 30 to 60 minutes to work and relaxes the blood vessels in the penis, improving blood flow

You can buy Viagra or sildenafil from online pharmacies such as pharmacy2u.co.uk or drthom.com (Viagra, Cialis and Levitra cost £47 for four tablets, sildenafil is £33 for four tablets). You will need to fill in a detailed questionnaire, which will be assessed by a GP before permission can be given for you to buy the drugs. These can then be posted or you can collect them from a Lloyds pharmacy.

Viagra-type drugs should be taken only with a doctor’s advice and are not suitable for men with serious heart conditions or who are taking nitrate medicine for angina (which, in combination with Viagra-type drugs, can lower blood pressure to dangerous levels).

The active ingredient makes all blood vessels dilate, so can also cause mild short-term redness, flushing or a headache.

JABS AND PELLETS

WOULD BEST SUIT: Men with age-related ED or diabetes who have not responded to drugs.

It might sound a toe-curling solution, but injections into the penis of alprostadil, a synthetic chemical that helps produce an erection, can be effective for men who have not been helped by Viagra or similar drugs.

An erection should occur within 15 minutes and last up to an hour. It works by relaxing the muscles and the blood vessels, improving blood flow to the penis.

Though erectile dysfunction is very common, especially with age, men often delay seeking help (file picture)

Alprostadil also comes as a pellet that’s pushed into the end of the urethra, where it dissolves, though this is less effective than the jab. The pellets are available privately (with a prescription from your doctor or from an online GP). However, 10 per cent of users experience a burning pain on use.

Alprostadil is available as a cream (sold as Vitaros). A study in the Journal of Sexual Medicine in 2009 found that 74 per cent of the 1,200 men who used it had better erections than placebo users, with few side-effects.

But as Professor Geoff Hackett, a consultant in urology and sexual medicine at Heartlands Hospital, Birmingham, says: ‘Early signs suggest it may be similar to pellets, which are not that effective.’

Alprostadil can be bought on private prescription for £10 for a single-dose injection and £14 for a single pellet. Vitaros cream costs £12 for a single application.

HORMONES

WOULD BEST SUIT: Men with who have poor response to ED drugs, and who also suffer fatigue.

Men’s levels of testosterone can decline with age or as a result of diabetes, heart disease, obesity and stress.

If you have a distinct drop in libido or erectile dysfunction, your GP may give you a blood test to check your levels and prescribe supplementation.

This comes as a tablet (which is wedged next to the gum to melt over 12 hours), injections (administered by a nurse, lasting up to three months) and gels, which you rub into the chest or arm.

Dr Malcolm Carruthers, medical director for the Centre for Men’s Health in London, says: ‘Testosterone can be highly effective and safe, and potentially life-changing for men and their partners.’

However, the treatment remains controversial, with some experts concerned about links to cancer and heart disease.

Professor Fred Wu of Manchester University urges caution: ‘There are studies showing people with low testosterone have higher mortality rates, but there are also studies suggesting the reverse,’ he says. ‘There have been no long-term studies and we have to be careful about who we give testosterone treatment to.’

Testosterone gel is available online (Tostran 2 per cent gel, £36 for 60g) with a GP’s prescription.

SURGERY

WOULD BEST SUIT: Men with pelvic/spinal injuries.

In extreme cases, surgical implants can be considered, but rarely on the NHS (£4,500 privately). Performed under a general or spinal anaesthetic, this involves inserting semi-rigid or inflatable silicone implants into the shaft of the penis.