Getting erections when you want them, and ejaculating, actually involves very complicated physiology. When you look at how complicated it all is, it’s is a wonder anyone can do it.

Part of erections is in your control, but part of it is not. It involves the autonomic nervous system, which is, as the name suggests, autonomous. You don’t directly control it. There is not a guy on planet earth who can say, I’m going to get an erection….NOW! I’m going to ejaculate…NOW!

Most of erection problems are ‘multifactorial.’ There are usually combinations of two or three of the problems below. The doctor should check these various possibilities, which will vary from man to man, because it determines correct treatment.

Psychogenic factors means that biggest sex organ, the brain, is messing things up by overthinking things. Or confidence is shot. Or perhaps you are depressed or really angry or fed up with your other half, or so on. In the 1970s we used to get psychologists involved, and if there is some trauma that may still be required. But if it’s just performance anxiety, as it often is in men under 30, we might cheat now and just get him a couple of good erections, eg with tablets. Think of golf: if you can’t sink a putt, you hate the stupid game. Sink a couple of long ones and, hey, you love it again, can’t wait to get out there. Same with sex.

Hormonal factors such as low testosterone are worth testing for, especially if sex drive is really low.

Vascular factors get more likely after age 50. The same things that block heart vessels also block penis vessels. Diabetes, smoking, high blood pressure, cholesterol, being fat and so on. The opposite is also true…if a man of that age develops vascular erection problems, he probably should get his coronaries checked too, before he has one.

Neurogenic factors, ie nerve damage. This happens a bit with all men with age, ie most men after age 50 need extra stimulation to, um, get there. But it can be severe in diabetes, and after prostate surgery, or with spinal injury or surgery. But there are usually still ways and means to get an erection, even in this situation.

Drugs. Some prescription tablets can affect erections, including some from the blood pressure or antidepressant group. Others cause problems ejaculating, either stopping you getting over the edge, or else a ‘dry’ ejaculation which has shot backwards into the bladder. Step 1 is to discuss it with your doctor. Don’t just stop tablets, that may make an worse problem. An even bigger problem is non-prescription tablets, especially recreational stimulants and ‘gym’ drugs. These can create problems very difficult to set right. Ask your doctor, in confidence.

The treatment of erection problems depends on what is causing it. It might involve slimming down, getting fit, working through that anger, getting better sleep, switching tablets, trying one of the various tablets that help erections, vacuum pumps, or injections into the penis. That last option might sound awful, but is actually pretty simple once you’ve been shown, and does take all the performance anxiety out of it.

Buyer beware. There are many treatments available that are essentially unproven. For instance, while some men might swear that their expensive course of penile shock wave therapy was brilliant and insist it was worth all the money they paid, the evidence for such treatments is pretty thin. That’s okay if a treatment costs $30 and has no side-effects, but it’s quite a risk if it costs thousands. If you are required to sign up to a contract, or to make a long term financial commitment, forget it.

It can be pretty complicated working out erection problems, and may involve a bit of trial and error. Coming too quickly, or too slowly, or not at all, are variations that need particular advice and are treated differently. Seeing a doctor who knows the area and can give impartial advice is a good place to start.