Written & reviewed by Dr Bahl
Dr Bahl is a Specialist Grade Doctor in Urology with 30 years of medical experience, including 15 years specialising in urology and men's sexual health. Every consultation and treatment session at Shockwave ReVibe Clinic is delivered personally by him.
ED Treatment Complete Guide Specialist AssessmentErectile dysfunction is the most common male sexual health condition I see in my clinic in Notting Hill Gate — and one of the most mismanaged. Not because treatment is unavailable, but because most men are offered medication as a first and only option, without any attempt to understand what is causing the problem in the first place.
If you are searching for erectile dysfunction treatment in London, this guide is designed to give you a clear, clinically accurate picture of what ED is, why it happens, what the full range of treatment options looks like, and how to choose the right specialist and approach for your situation. I have written it the way I would explain it during a first consultation — directly, honestly, and without minimising what is actually a significant medical condition that deserves proper attention.
What Is Erectile Dysfunction?
Erectile dysfunction (ED) is defined as the persistent or recurrent inability to achieve or maintain an erection sufficient for satisfactory sexual performance. The word "persistent" matters — most men experience occasional difficulty with erections, particularly during periods of stress, illness, or fatigue. This is not erectile dysfunction. ED is a consistent, ongoing problem that causes personal distress and affects quality of life.
ED is far more common than most men realise. An estimated 4.3 million men in the UK are affected, with prevalence rising sharply with age:
However, age is not a cause of erectile dysfunction. It is a risk factor. The causes are specific, identifiable, and in many cases treatable — regardless of age.
What Causes Erectile Dysfunction?
Understanding the cause of your ED is the most important step in finding the right treatment. ED is not a single condition — it has multiple potential causes, each requiring a different approach.
Vascular Causes (Most Common)
The majority of ED in men over 40 has a vascular cause. A normal erection requires the smooth muscle of the penile arteries to relax, allowing blood to flow into the corpus cavernosum under sufficient pressure. This process depends entirely on healthy endothelium — the inner lining of the blood vessels — and adequate production of nitric oxide.
When the endothelium is damaged or dysfunctional — as happens in cardiovascular disease, diabetes, hypertension, and smoking — the penile arteries become narrowed and less responsive. Blood flow is insufficient for a firm erection.
This is why erectile dysfunction is now considered an early warning sign of cardiovascular disease. A meta-analysis published in Circulation found that men with ED have a 44% increased risk of cardiovascular events — and that ED typically precedes cardiac symptoms by three to five years.
Conditions associated with vascular ED:
- Cardiovascular disease
- Type 2 diabetes
- Hypertension (high blood pressure)
- High cholesterol (dyslipidaemia)
- Obesity
- Smoking
- Peripheral vascular disease
Psychological Causes
Anxiety, depression, stress, relationship difficulties, and performance anxiety can all cause or worsen ED. Psychological ED is more common in younger men and tends to present with preserved morning erections and situational (rather than consistent) difficulty.
However, the relationship between psychological factors and ED is not always straightforward. Vascular ED frequently causes performance anxiety — which then compounds the physical problem. A man who struggles to achieve an erection due to poor blood flow begins to anticipate failure, which activates the stress response, further inhibiting erectile function. In many men, both psychological and physical factors are present simultaneously.
Hormonal Causes
Low testosterone (hypogonadism) can reduce libido and contribute to erectile dysfunction. Elevated prolactin and thyroid disorders can also affect sexual function. Hormonal causes are less common than vascular causes but are easily identified with a blood test.
Neurological Causes
Conditions affecting the nervous system — including multiple sclerosis, Parkinson's disease, spinal cord injury, and peripheral neuropathy — can impair the nerve signals required for erection. Neurogenic ED is also common following prostate surgery (radical prostatectomy), where the cavernous nerves responsible for erectile function may be damaged during the procedure.
Medication-Induced ED
A significant number of commonly prescribed medications can cause or worsen erectile dysfunction:
- Antihypertensives (particularly beta-blockers and thiazide diuretics)
- Antidepressants (particularly SSRIs)
- Antipsychotics
- Finasteride (used for prostate enlargement and hair loss)
- Opioid pain medications
- Some antihistamines
If ED began or worsened following the introduction of a new medication, this is always worth investigating with the prescribing doctor.
ED Treatment Options in London
London has a wide range of clinics and practitioners offering ED treatment. The quality, approach, and appropriate indication for each vary considerably. Here is an honest overview of all available options.
1. PDE5 Inhibitors (Viagra, Cialis, Levitra)
PDE5 inhibitors are the most widely prescribed treatment for ED and are usually the first treatment offered. They work by blocking the enzyme phosphodiesterase type 5, which breaks down cyclic GMP — the chemical messenger responsible for smooth muscle relaxation and blood inflow.
Important to understand: PDE5 inhibitors do not cause erections. They lower the threshold for one when sexual stimulation occurs. They do not address why the erection was difficult to achieve. They are symptomatic treatments — effective for the duration of the drug's action (4-6 hours for sildenafil, up to 36 hours for tadalafil), but with no lasting effect on the underlying condition. See our full comparison: Shockwave Therapy vs Viagra.
Response rates are approximately 60-80% in unselected populations, falling to 40-60% in men with diabetes or post-prostatectomy ED. Side effects include headache, flushing, nasal congestion, and visual disturbance. PDE5 inhibitors are absolutely contraindicated with nitrate medications (commonly prescribed for heart conditions).
2. Focal Shockwave Therapy
Low-intensity focal shockwave therapy (Li-ESWT) is the only currently available non-invasive treatment that addresses the vascular cause of ED rather than managing the symptom.
Focused acoustic energy waves are delivered to the erectile tissue and penile arteries, stimulating angiogenesis (growth of new blood vessels), endothelial repair (restoration of nitric oxide production), and neuroregeneration (regeneration of penile nerve fibres, relevant in post-surgical ED). A 2017 meta-analysis of 14 randomised controlled trials involving 833 patients confirmed significant improvement in erectile function scores following Li-ESWT, and the European Association of Urology formally recognises it as a therapeutic option for vasculogenic ED in its 2024 guidelines. For the full evidence review, see Shockwave Therapy for ED: What the Evidence Shows.
3. Testosterone Replacement Therapy (TRT)
Where testosterone deficiency is confirmed on blood testing, testosterone replacement can restore libido and may improve erectile function — particularly in combination with PDE5 inhibitors. TRT is appropriate only where deficiency is confirmed; it is not a general treatment for ED.
4. Vacuum Erection Devices (VEDs)
Vacuum devices create negative pressure around the penis, drawing blood in mechanically. A constriction ring at the base maintains the erection. Effective in many men where pharmacotherapy has failed, particularly in post-prostatectomy ED. Non-invasive and available without prescription. Not suitable for men with blood clotting disorders.
5. Penile Injections (Alprostadil)
Self-administered injection into the penile shaft causing a reliable erection in over 80% of users, including those who do not respond to oral medication. Requires specialist initiation and training. Effective but invasive — not the first choice for most men.
6. Penile Implants (Surgical)
Inflatable or semi-rigid prostheses inserted surgically. Reserved for men who have not responded to all other treatments. Highly effective but irreversible — no other erectile function remains following implantation. Appropriate only as a last resort.
7. Psychosexual Assessment and Management
Where psychological factors are the primary driver of ED, psychosexual assessment and management — delivered by a qualified practitioner — addresses the anxiety, relationship dynamics, and thought patterns that contribute to the dysfunction. Often most effective in combination with medical treatment.
Comparison of ED Treatment Options
| Treatment | Works On | Duration | Ongoing Use | Nitrate-Safe | EAU Endorsed |
|---|---|---|---|---|---|
| PDE5 Inhibitors | Symptom | 4-36 hours | Yes — every time | No | Yes |
| Focal Shockwave Therapy | Cause (vascular) | 12-24 months | No — finite course | Yes | Yes (2024) |
| TRT | Hormonal cause | Ongoing | Yes | Yes | Yes |
| Vacuum Device | Mechanical | During use | Yes — every time | Yes | Yes |
| Penile Injections | Vascular/neural | During use | Yes — every time | Yes | Yes |
| Penile Implant | Mechanical | Permanent | No | Yes | Yes |
| Psychosexual | Psychological | Variable | Depends | Yes | Yes |
How to Choose an ED Specialist in London
London has many clinics offering ED treatment. Here is what to look for:
Proper clinical assessment before treatment
Any reputable ED specialist will take a thorough history — medical, sexual, psychological — before recommending treatment. A clinic that recommends medication or shockwave therapy without assessment is not providing specialist care.
GMC-registered medical doctor
ED treatment involves prescription medication, clinical assessment, and where relevant, the management of underlying conditions like cardiovascular disease and diabetes. This requires a GMC-registered doctor — not a therapist, physiotherapist, or aesthetician.
Honest discussion of all options
A good specialist presents all treatment options — not just the one they offer. If a clinic only offers one treatment regardless of presentation, be cautious.
Validated assessment tools
The IIEF-EF (International Index of Erectile Function — Erectile Function domain) is the validated clinical tool for assessing ED severity and tracking treatment response. A specialist who uses this at baseline and follow-up is measuring outcomes objectively.
For shockwave therapy — focal not radial
If you are considering shockwave therapy for ED, confirm the clinic uses a focal device (not radial). The published evidence for ED is built entirely on focal shockwave. Radial devices cannot achieve the tissue depth required.
What Happens at an ED Consultation at Shockwave ReVibe Clinic
Every patient who comes to see me begins with a comprehensive clinical assessment. This is not a 10-minute appointment.
History taking
I cover your medical history, current medications, cardiovascular risk factors, symptom history (duration, severity, morning erections, situational vs consistent), relationship context, and psychological factors.
Validated assessment
The IIEF-EF questionnaire is completed at baseline, establishing an objective severity score that allows us to track improvement over the course of treatment.
Investigation
Depending on findings, I may recommend relevant blood tests — testosterone, thyroid function, fasting glucose, lipid profile — and where indicated, a penile Doppler ultrasound to assess arterial blood flow directly.
Treatment discussion
I present all relevant treatment options for your specific presentation. Where focal shockwave therapy is indicated, I explain the protocol, expected timeline, and realistic outcomes. Where medication is more appropriate, I prescribe accordingly. Where both are complementary, I explain how they work together. Lifestyle factors are part of this conversation too — see our guide on diet, exercise and sleep for erectile function.
Ongoing management
I reassess every patient at 12 weeks following any treatment course, using the IIEF-EF questionnaire and clinical review. Treatment response is documented objectively.
ED and Cardiovascular Health: What Every Man Should Know
I want to address this directly because it matters clinically.
If you are experiencing erectile dysfunction — particularly if you are over 40 and have risk factors such as high blood pressure, high cholesterol, obesity, or a family history of heart disease — ED may be the first symptom of underlying vascular disease affecting not just the penile arteries but the coronary and cerebral arteries as well.
A comprehensive ED assessment is therefore not just about sexual function. It is an opportunity to identify and manage cardiovascular risk at a stage where intervention is most effective. This is one of the reasons I strongly believe that men with ED should see a specialist rather than simply requesting a Viagra prescription from their GP.
Frequently Asked Questions
Is erectile dysfunction normal?
ED is extremely common — affecting an estimated 4.3 million men in the UK. It is not, however, an inevitable consequence of ageing that must simply be accepted. In the majority of cases, there is an identifiable cause and effective treatment available.
What is the most effective treatment for erectile dysfunction?
This depends on the cause. For vascular ED, focal shockwave therapy is the only treatment that addresses the underlying vascular pathology. PDE5 inhibitors (Viagra, Cialis) are effective symptomatically but do not modify the underlying condition. A proper assessment is required to determine which approach is most appropriate for your specific situation.
Can erectile dysfunction be cured?
For some men with mild to moderate vasculogenic ED, focal shockwave therapy produces improvement that persists for 12-24 months without further treatment — representing genuine restoration of function rather than symptom management. For others, ongoing treatment or medication is required. The honest answer is that "cure" depends on the cause, severity, and individual response to treatment.
Does Viagra always work for ED?
No. Response rates are approximately 60-80% in unselected populations, dropping to 40-60% in men with diabetes or post-prostatectomy ED. Men who do not respond to PDE5 inhibitors are described as non-responders. Focal shockwave therapy has been shown to restore PDE5 inhibitor responsiveness in 57% of non-responders.
Is ED a sign of heart disease?
Not automatically — but it can be. ED and cardiovascular disease share the same vascular mechanism (endothelial dysfunction), and ED frequently precedes cardiac symptoms by several years. Men with ED and cardiovascular risk factors should have a cardiovascular risk assessment as part of their ED evaluation.
Do I need a GP referral to see an ED specialist privately?
No. At Shockwave ReVibe Clinic, you can book directly without a GP referral. Initial consultation: £59.
Is ED treatment confidential?
Completely. Your consultation, assessment, and any treatment at Shockwave ReVibe Clinic are entirely private. Your records are never shared without your explicit consent. Many men prefer to keep sexual health concerns entirely separate from their GP — this is your right.
What is the difference between focal and radial shockwave therapy for ED?
The published evidence for shockwave therapy in ED is based entirely on focal shockwave devices, which penetrate to depths of up to 12cm — sufficient to reach the penile arteries and erectile tissue. Radial shockwave devices reach a maximum of 3-4cm and cannot deliver therapeutic energy to the relevant tissue. Only focal shockwave is validated for ED.
How quickly does focal shockwave therapy work for ED?
The biological processes stimulated by shockwave therapy — angiogenesis, endothelial repair — take time to complete. Results typically consolidate over 6-12 weeks following the final treatment session. Some men notice improvement during the course; others see the full benefit in the weeks after completing treatment.
Can ED affect mental health?
Yes, significantly. ED is associated with reduced self-esteem, depression, anxiety, and relationship difficulties. These psychological consequences can then worsen the ED itself, creating a reinforcing cycle. Addressing the physical cause of ED frequently produces significant improvements in psychological wellbeing and relationship quality alongside the restoration of sexual function.
References
- Feldman HA et al. (1994). Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. Journal of Urology, 151(1): 54-61.
- Vlachopoulos C et al. (2010). Prediction of cardiovascular events and all-cause mortality with erectile dysfunction. Circulation, 121(22): 2377-2385.
- Lu Z et al. (2017). Low-intensity extracorporeal shock wave treatment improves erectile dysfunction: a systematic review and meta-analysis. International Journal of Impotence Research, 29(3): 95-99.
- Gruenwald I et al. (2012). Low-intensity extracorporeal shock wave therapy — a novel effective treatment for erectile dysfunction in severe ED patients who respond poorly to PDE5 inhibitor therapy. Journal of Sexual Medicine, 9(1): 259-264.
- Gruenwald I et al. (2014). Shockwave treatment of erectile dysfunction. Therapeutic Advances in Urology, 5(2): 95-99.
- Fojecki GL et al. (2017). Effect of low-energy linear shockwave therapy on erectile dysfunction. Journal of Sexual Medicine, 14(5): 671-680.
- Patel P et al. (2019). Low-intensity shockwave therapy for erectile dysfunction: a review of the current evidence. Urology, 129: 8-14.
- Dhaliwal A, Gupta M (2023). PDE5 Inhibitors. StatPearls, NCBI Bookshelf.
- European Association of Urology (2024). EAU Guidelines on Sexual and Reproductive Health. EAU Guidelines Office, Arnhem, The Netherlands.
Last reviewed: August 2026