One man most people wouldn’t associate with poor performance in the bedroom is the cricket legend Sir Ian Botham. The sporting lothario’s autobiography is tellingly named Don’t Tell Kath, and one former lover even claimed that one romp with him was so animated it broke the bed. So, when Botham, 60, said last month he’d been having a treatment designed to help men suffering with erectile problems, people took note.

Over half of men aged 40-70 have experienced some form of erectile dysfunction (ED), with incidences increasing the older a man gets, according to a clinical review in the British Medical Journal. Sildefanil nitrate, which was patented 20 years ago in 1996 – commonly sold asViagra – and other similar drugs remain the most popular solution.

In the last decade, prescriptions for these drugs have more than doubled, from one and a half million in 2005 to over three and a half million in 2015, according to NHS Digital data, partly because the patent on Viagra recently expired. However, as Botham’s recent statement shows, there are other ways to fix impotence, beyond the little blue pills.

The trouble with Viagra

The physics of achieving enough “lift off” to sustain penetrative intercourse depends largely on the body being able to get an adequate blood supply to the penis. Erectile dysfunction often occurs because of a diminished blood flow, and Viagra works by restoring the supply. However, a growing body of evidence now suggests that impaired erections can also be a marker for heart disease, because if the blood vessels surrounding the penis are narrowed, it’s likely that those supplying the heart are, too. “The lining of vessels of the penis are very similar to those you get in the heart,” says Dr Asif Muneer, consultant urologist at Spire Bushey Hospital in London. “The evidence now suggests that erectile dysfunction could precede a heart attack in men by around 10 years.”

Last week, researchers at the Elpis General Hospital in Athens reported that statins, the cholesterol-lowering drugs prescribed to people at risk of heart disease, may help with ED. In their study of 100 men, those who took statins – which have attracted controversy over their side-effects – saw a 43 per cent improvement in their erectile function.

ED can also indicate undiagnosed diabetes, prostate problems, or side-effects of drugs such as antidepressants. That’s why it’s important to ensure your doctor does a thorough check-up for diabetes, heart disease and prostate problems before handing over a prescription.

The trouble with Viagra as the cure-all is that it treats only the symptom, says Professor Raj Persad, a consultant urologist at the NHS Bristol Urological Institute. “Viagra needs to have nerves intact and healthy blood vessels to make it work. If you keep using it without addressing what’s causing the damage to the blood vessels, you’ll end up with decreasing responses.”

Viagra can also have side-effects such as nasal stuffiness, headache and heartburn, not to mention the lack of spontaneity, although a new, once-a-day version has changed the latter. “It’s the same drug but at a lower dose,” says Dr Muneer. “It stays in your system longer so you can usually maintain an erection any time if you take it daily.”

Zapping away the problem

The treatment Ian Botham received was Low Intensity Shockwave Therapy (LIST) and has been touted as one of the first real alternatives to Viagra. It’s a painless, 20 minute procedure, in which doctors use an ultrasound probe to deliver 1,500 shocks to five separate points along the penis; a typical course is about four weeks, with a total of anything from four to 12 sessions.

The former cricketer had a treatment called Vigore, which costs £2,500-3000 privately – List is not available on the NHS. Though Botham has never suffered with erectile dysfunction himself, he said he’d used the treatment as a preventative measure.

List is still an experimental procedure, but some evidence suggests it works. In one 2015 study in the Scandinavian Journal of Urology, researchers took 112 men who were not able to have sex without medication and gave half five weekly doses of List and half a placebo. By the end, 57 per cent were able to have intercourse compared with nine per cent who received a placebo. List works by increasing blood flow to the penis by encouraging the growth of new blood vessels, says Prof Persad. “It was originally used to treat cardiac problems to stimulate the growth of blood vessels, which is why we know it works.” In most of the studies, though, the men didn’t stop taking their Viagra-type drugs, he says. “But the impressive thing was that List succeeded where Viagra was failing – 80 per cent of men who were deteriorating on Viagra responded to treatment with it.” It won’t work in all cases. “It’s best for the earlier stages of erectile dysfunction, and in 30 to 40 per cent of cases it won’t work if a man has diabetes or after prostate surgery or pelvic fracture.” Dr Muneer adds that there’s currently no evidence to suggest that it can work as a preventative measure, in the way Botham was said to have used it.

Is it the manopause?

Fatigue, tiredness and low libido isn’t only associated with mid-life flagging hormones in women. As men age, their testosterone declines, and some experts believe that testosterone replacement therapy – male HRT – could improve erections.

Dr Muneer says testosterone needs to be very low before it starts to cause ED. Your GP can do blood tests for testosterone levels, but you’ll need a referral to a urologist, who can monitor levels and prescribe replacement therapy in the form of gels, injections or patches, as side-effects can include a worsening of urinary flow, intensified snoring and increased aggression. “Sometimes I use it for people with confirmed low levels that have failed on sildenafil [Viagra-type drugs] and sometimes I use both together,” says Dr Muneer. While testosterone replacement might restore sexual desire, evidence suggests using it on its own probably won’t fix erectile dysfunction.

The psychology of ED

If your doctor has found nothing physically wrong, there may be a psychological reason for your erectile dysfunction, says Cate Campbell, a psychosexual therapist and author of The Relate Guide to Sex and Intimacy (£9.98 Relate). Men often beat themselves up over a failed attempt at intercourse or two, she says. “Lots of men I see think they should have the same sexual function they had when they were 18 at 58,” she adds. “But it’s normal for most men over 40 to find it harder to get and keep an erection, and for the time between climax and being able to get another erection to increase, for some up to 48 hours.”

But it can become a vicious and frustrating circle for couples. While excessive pornography use can change a man’s expectations of sex, making it harder to achieve and keep an erection – a problem Campbell is seeing in both younger and older men increasingly – the main psychological reason is performance pressure, usually as a result of a previous problem. “Once you’ve had a small problem, the idea that it can happen again just grows,” says Campbell. “How it’s handled in bed can make all the difference. If the woman says, 'Oh that’s fine,’ and then sulks or cries or accuses him of having an affair or not fancying her anymore, then that could lead to long-term ED. One way to deal with it might be 'Let’s have a cuddle instead and just focus on being close’.”

Sex therapy, costing anywhere from £40-200 a session, can teach men the psychological techniques to help them maintain their erections and also show couples – whether ED is in its early or late stages – the sex-based exercises to increase their intimacy and focus less on performance. “We can even teach men to climax without an erection,” says Campbell. Perhaps someone needs to patent that next.