Erectile Dysfunction
Red Flags — the symptom that is also a warning
| Red flag | Why dangerous | Action |
|---|---|---|
| Organic ED as a cardiovascular sentinel | ED, particularly new-onset vasculogenic ED, is associated with increased cardiovascular risk and may precede clinically apparent cardiovascular disease — a population association, not an individual prediction. Treating the erection while ignoring the vascular risk misses the most important diagnosis. | Full CV risk assessment (QRISK); BP, lipids, glucose/HbA1c; treat risk factors; consider angina/exercise tolerance |
| Chest pain / exertional symptoms / very high CV risk | Undiagnosed coronary disease may be unmasked by the assessment or by the exertion of resumed sexual activity. | Assess cardiac symptoms; manage/refer per cardiac pathways before resuming activity if concern |
| Priapism — painful erection >4 hours | A urological emergency; prolonged priapism causes ischaemic damage and permanent ED. | Emergency urology/A&E; aspiration/treatment |
| Low mood / self-harm risk | ED and depression compound each other; the psychological and relationship impact can be severe and occasionally dangerous. | Screen mood; assess self-harm risk; treat/refer; mind SSRI sexual effects |
| Hypogonadism with pituitary features | Low testosterone with high prolactin, visual field defects or headache may indicate a pituitary tumour. | Confirm low morning testosterone + LH/FSH/prolactin; endocrinology if pituitary cause suspected |
| Peyronie's / penile or testicular lump / LUTS + abnormal prostate | Structural disease, and prostate pathology presenting alongside ED, need their own assessment/pathways. | Examine; urology referral; consider PSA + DRE in ED after discussion (NICE NG12) |
🧍 Masculinity & shame
ED can feel like a threat to identity. A calm, normalising, blame-free manner is therapeutic in itself and makes the rest of the assessment possible.
"This is one of the commonest things I see, and it's very treatable — there's absolutely nothing to be embarrassed about. I'm glad you brought it up."❤️ The cardiovascular link
Reframing ED as a useful early warning gives a positive reason to engage with risk-factor work and lifestyle change.
"The same blood vessels that supply the penis supply the heart — so this can actually be an early heads-up. Sorting your blood pressure, the smoking and your weight will help the erections and protect your heart at the same time."💞 Relationship strain
ED affects partners and relationships; acknowledging this — and offering to involve the partner or psychosexual support — addresses a key driver.
"This kind of thing can put a strain on a relationship — how are things between you? Sometimes it helps to involve your partner, and there's specialist support if that would be useful."🧠 Mood
Low mood both causes and results from ED; screening and treating it (mindful of SSRI sexual effects) is part of the plan.
"You mentioned feeling a bit flat — that often goes hand in hand with this. Can I ask a bit more about your mood, because treating that can really help too?"- Prescribing a PDE5i without CV risk assessment or a nitrate check
- Not distinguishing organic from psychogenic
- Missing mood/relationship impact
- Awkward or dismissive handling of a sensitive disclosure
Same day / 999
Immediate action- Priapism >4 hoursPainful sustained erection → emergency urology/A&E
- Active cardiac symptomsChest pain/unstable symptoms → cardiac pathway; defer sexual activity
- Severe depression / self-harm riskUrgent mental-health assessment
Soon
Days–weeks- Suspected angina / unstable CVD / uncertain exercise capacityCardiovascular assessment before sexual activity or PDE5i (Princeton III)
- Pituitary features / confirmed hypogonadismEndocrinology
- Peyronie's / penile or testicular lump / PDE5i failureUrology
GP Management
Primary care first-line- Organic ED + vascular riskPDE5i + QRISK + risk-factor treatment + lifestyle
- Psychogenic EDPDE5i ± psychosexual therapy; address stress/relationship
- Drug-induced EDReview/switch offending drug
- Treating ED while ignoring high cardiovascular risk
- Missing priapism or pituitary features
- No BP/metabolic assessment in organic ED
- Genital examination without consent/chaperone, or omitted when indicated
- No CV risk assessment / bloods in organic ED
- Diagnosing hypogonadism on a single non-morning sample
- Over-investigating an obvious psychogenic case
🚩 The discipline — don't just fix the erection
The trap is to treat the symptom (write a PDE5i) and miss the message (cardiovascular disease, sometimes depression, occasionally hypogonadism or a pituitary tumour). For David the formulation is: organic ED in a man with multiple untreated vascular risk factors and low mood — meaning a PDE5 inhibitor PLUS full cardiovascular risk assessment and risk-factor treatment, lifestyle change, and attention to his mood and relationship.
- Treating the erection and missing the cardiovascular diagnosis
- Calling it psychogenic without the supporting pattern
- Resuming activity with untreated high cardiac risk
- Not offering psychosexual support in clear psychogenic ED
Validate — name the request and say yes to it
David's expectation is reasonable: a PDE5 inhibitor is first-line for almost all ED, and he is very likely to be able to have one today. Saying so early takes the anxiety out of the consultation. If he senses the tablet is being held back until he "earns" it with blood tests, he may disengage and simply buy sildenafil from a pharmacy or, worse, an unregulated website — and the cardiovascular opportunity is lost.
"You were hoping for the tablets — and the good news is that, as long as you're not on certain heart medicines, I can prescribe them today. Thank you for bringing it up; it's one of the commonest things men see us about."Explain — why the symptom matters beyond the bedroom
The penile arteries are small, so they show the effects of furred, stiffened blood vessels earlier than the coronary arteries. Gradual ED with loss of morning erections in a 52-year-old smoker with raised blood pressure and a family history of early heart attacks is a cardiovascular warning. QRISK3 includes erectile dysfunction as a risk variable for exactly this reason (NICE NG238 recommends QRISK3 for cardiovascular risk assessment). Framed as good news — an early warning — this becomes motivating rather than frightening.
"The blood vessels that supply the penis are narrower than the ones that supply the heart, so they often show changes first. That makes this a useful early heads-up. With your dad and brother's history, I'd really like to use it to check and protect your heart — the same things that help your heart will help the erections too."Negotiate — a plan he can say yes to
Offer a package, not a lecture: a prescription today with a nitrate check and proper instructions; blood pressure and weight measured now; bloods (HbA1c, lipids, morning testosterone) booked; a QRISK3 calculation once results are back; and one lifestyle target he chooses. Keep it brief if he wants brief — the follow-up appointment is where the rest of the work happens.
"So how about this: I'll give you the tablets today and show you how to get the best out of them. I'll check your blood pressure now and book some blood tests, and when you come back in a few weeks we'll see how the tablets are working and go through your heart-risk score together. Does that sound fair?"Smoking damages the endothelium, reduces nitric oxide availability and accelerates atherosclerosis in the penile and coronary arteries alike. Nitric oxide is the signal that PDE5 inhibitors amplify — so smoking directly blunts the tablet's effect.
Very brief advice (ask, advise, act), then referral to local NHS stop smoking support: behavioural support plus varenicline, cytisinicline, combination nicotine replacement or a nicotine-containing vape gives the best quit rates (NICE NG209). For David, link it to what he cares about: "stopping is one of the best things you can do for your erections and your heart."
Regular aerobic exercise improves endothelial function, lowers blood pressure, improves insulin sensitivity and reduces visceral fat. Observational studies consistently link higher activity with lower ED risk, and trials show improvement in erectile function scores with supervised aerobic training.
David has a desk job and does little. Start with brisk walking — a lunchtime walk, getting off the bus a stop early — and build up to the UK CMO recommendation of 150 minutes a week of moderate activity plus two strength sessions. If he has any exertional chest pain, assess this before advising increased exertion.
Central obesity drives insulin resistance, hypertension and dyslipidaemia, and lowers circulating testosterone (lower SHBG and aromatisation of testosterone to oestradiol in adipose tissue). Weight loss improves all of these.
Record BMI and waist today. Offer the NHS Digital Weight Management Programme or local tier 2 service if eligible; a Mediterranean-style diet supports both weight and cardiovascular risk. In Esposito's RCT of obese men with ED, the intensive weight-loss and activity programme restored normal erectile function in about a third.
Acute intoxication impairs erection; chronic heavy drinking causes hypogonadism, peripheral neuropathy and raised blood pressure. Alcohol also adds calories and interacts with mood.
AUDIT-C, brief intervention, and a concrete target: David's 25 units is nearly twice the UK low-risk guideline. Suggest alcohol-free days and swapping to lower-strength drinks. Heavy drinking before sex also reduces the effect of a PDE5 inhibitor and increases dizziness.
Even purely organic ED produces performance anxiety and avoidance, which then maintain the problem. Relationship strain adds pressure. Psychosexual therapy (including sensate focus) addresses these, and works well alongside a PDE5 inhibitor.
Invite his wife to a future appointment if he would like. Signpost to local NHS psychosexual services where available, or to accredited therapists via the College of Sexual and Relationship Therapists (COSRT) and relationship support organisations such as Relate. Written information from the NHS website helps both partners.
Depression reduces desire and arousal and is itself worsened by ED. Obstructive sleep apnoea, common in overweight men, is linked with ED and low testosterone and raises cardiovascular risk.
David's "flat" mood needs a PHQ-9 and a sensitive question about hopelessness. If an antidepressant is needed, discuss sexual side effects openly (SSRIs commonly cause them; mirtazapine or bupropion are sometimes chosen for lower sexual side-effect profiles — specialist advice for bupropion, which is unlicensed for depression in the UK). Ask about snoring and daytime sleepiness (STOP-BANG/Epworth).
Generic sildenafil, on demand — dose per SPC
- Take about an hour before sex; onset is delayed by a heavy or fatty meal
- Needs sexual stimulation — it is not an aphrodisiac
- No more than one dose in 24 hours
- Titrate within the licensed range before judging failure; allow several attempts at the maximum tolerated dose
Generic tadalafil on demand or once daily; generic vardenafil — doses per SPC
- Tadalafil: long duration of action (up to ~36 hours) — suits men who want spontaneity; less affected by food
- Once-daily low-dose tadalafil suits frequent sexual activity; it is also licensed for LUTS due to BPH
- Vardenafil: similar to sildenafil in timing; caution with QT-prolonging drugs
- If one PDE5 inhibitor fails despite correct use, trying another is reasonable before referral
Urology / specialist ED service
- Alprostadil — intracavernosal injection, intraurethral pellet or topical cream (usually specialist-initiated; injection technique must be taught)
- Vacuum erection device — useful where drugs are contraindicated or ineffective
- Penile prosthesis — for refractory ED after full assessment
- Psychosexual therapy alongside any of these
- Contraindicated: any nitrate (GTN spray, isosorbide mononitrate/dinitrate) or nicorandil — profound, potentially fatal hypotension. Also recreational amyl nitrite ("poppers"). Ask directly; check the repeat list
- Contraindicated: riociguat (soluble guanylate cyclase stimulator for pulmonary hypertension); previous NAION (loss of vision from non-arteritic anterior ischaemic optic neuropathy)
- Avoid / seek cardiology advice: recent MI or stroke, unstable angina, hypotension, severe heart failure, or any patient in whom sexual activity is inadvisable
- Caution: alpha-blockers (doxazosin, tamsulosin) — symptomatic postural hypotension; stable on the alpha-blocker first, start at a low PDE5i dose and separate timing per SPC
- Caution: anatomical penile deformity (Peyronie's), conditions predisposing to priapism (sickle cell disease, myeloma, leukaemia), bleeding disorders/active peptic ulcer
- Interactions: strong CYP3A4 inhibitors (e.g. some HIV protease inhibitors, clarithromycin, ketoconazole) raise PDE5i levels — check SPC
- Generic sildenafil — any man with ED on the NHS, no endorsement (since 2014)
- Generic tadalafil and vardenafil — no SLS endorsement needed since 1 October 2025
- Branded products and other listed ED treatments — NHS only for men meeting Schedule 2 criteria (e.g. diabetes, multiple sclerosis, Parkinson's disease, poliomyelitis, prostate cancer, prostatectomy or radical pelvic surgery, severe pelvic injury, single-gene neurological disease, spina bifida, spinal cord injury, renal failure treated by dialysis or transplant), or in specialist services for men with severe distress; prescription endorsed "SLS"
- Check local ICB formulary — some advise a monthly quantity; OTC purchase is an option some men prefer for privacy
"Take one about an hour before sex — it works best on an empty stomach, as a big or fatty meal slows it down. You still need to be aroused; it won't cause an erection on its own. Don't take more than one in 24 hours. Give it at least four to six goes before deciding whether it works. Never use it with heart 'nitrate' sprays or tablets or with poppers. If an erection lasts more than four hours, go to A&E straight away, and if you get sudden loss of vision, stop the tablets and get urgent help."
Say the nitrate question out loud and the priapism and vision warnings clearly — these are the marks that show safe prescribing. Mention that generic sildenafil is available on the NHS for any man.
"This one lasts much longer — up to a day and a half — so you don't have to time it so precisely, and food matters less. Because it stays in your system, if you ever get chest pain, tell the ambulance crew or hospital that you've taken it, as they must not give you a nitrate spray."
Generic tadalafil no longer needs SLS endorsement on NHS prescriptions (Drug Tariff, October 2025). Offering it as a choice for spontaneity shows shared decision-making.
"This works the same way as the others, just with a slightly different timing and side-effect pattern. The same rules apply: arousal is still needed, one dose a day at most, never with nitrates or poppers."
Knowing that "one PDE5 inhibitor failed" is not the same as "PDE5 inhibitors failed" — check technique first, then consider switching agent before referral.
"Testosterone only helps if your level is genuinely low — we'll check it twice in the morning first. If you do start it, we'll need regular blood tests to check your blood count and prostate marker. If you use the gel, cover the area and wash your hands so it doesn't pass to anyone else."
Don't offer testosterone for ED with a normal level, and don't diagnose deficiency on a single afternoon sample. Mention fertility and the monitoring commitment.
"This works directly on the penis rather than through the blood stream. The clinic will show you how to use it. The most important rule is that an erection lasting more than four hours is an emergency — go straight to A&E."
In an SCA case with a man on a nitrate, knowing that alprostadil or a vacuum device is the route forward (via urology) shows you haven't left him without options.
ED rarely affects only erections. It touches a man's sense of himself, his relationship, his mood and sometimes his work. David minimised it by raising it at the door; the consultation's job is to show him it matters and that help is straightforward.
Identity & Masculinity
Many men experience ED as a loss of masculinity or as a sign of ageing. Shame delays presentation, often for years, and drives men towards unregulated online products of uncertain content. A matter-of-fact, normalising manner is itself therapeutic.
"Lots of men your age have this, and it says nothing about you as a man — it's usually about blood flow, and it's very treatable."Relationship & Partner
Partners may misread ED as loss of attraction or infidelity; avoidance of intimacy follows and the strain feeds performance anxiety. Involving the partner, where the man wishes, often improves outcome and gives the partner a chance to ask questions.
"Sometimes partners worry it's about them. Would it help for your wife to come to the next appointment, so she can hear it's a physical problem and what we're doing about it?"Mood & Self-Worth
ED and depression are linked in both directions, and men are less likely to report low mood. David's "fed up" is worth a PHQ-9 and a gentle question about hopelessness. If an antidepressant is needed, discuss sexual side effects openly so he doesn't stop it silently.
"You said you've been feeling fed up. How low has it got? Have there been times you've felt hopeless or that life isn't worth it?"Work & Stress
A desk job with long hours encourages inactivity, snacking and drinking to unwind — all drivers here. Work stress also feeds psychogenic components. Practical changes (walking meetings, lunchtime walks, fewer evening drinks) fit into a working week.
"What's a realistic change you could make during the working day — maybe a walk at lunchtime to start with?"Driving
ED itself has no DVLA implications. Relevant only indirectly: warn that PDE5 inhibitors can cause dizziness or visual disturbance — don't drive if affected. If the cardiovascular assessment finds angina, DVLA car-licence rules for angina apply (stop driving while symptomatic at rest or at the wheel); if any condition affecting fitness to drive is found, advise per DVLA guidance.
"The tablets can occasionally cause dizziness or blurred vision — if that happens, don't drive until it's settled."Cost, Privacy & Online Buying
Some men prefer to buy sildenafil privately to avoid a GP record or embarrassment. Pharmacy supply is legitimate, but unregulated online "herbal" products may contain undeclared PDE5 inhibitors — dangerous for anyone on nitrates. Generic sildenafil on NHS prescription is inexpensive and comes with the cardiovascular check.
"You can get it from a pharmacy if you'd prefer, but please avoid internet products — some contain hidden ingredients that are dangerous with heart tablets."Today — Safe Prescription + Baseline
Nitrate/nicorandil/riociguat and alpha-blocker check; cardiac symptoms asked about; PDE5 inhibitor prescribed with counselling. BP, BMI, waist recorded; IIEF-5 baseline. Bloods booked: HbA1c, lipids, U&E, morning total testosterone (7–11am) ± FBC/TFTs. PSA + DRE considered (NICE NG12 lists ED as a reason to consider them) with informed discussion. Home or ambulatory BP arranged if clinic BP raised (NICE NG136). Stop-smoking referral offered. PHQ-9.
4–6 Weeks — Response & Results
IIEF-5 re-scored; how the tablet was used (timing, food, stimulation, number of attempts, dose); side effects. Results reviewed: HbA1c, lipids, testosterone (repeat if low, with LH/FSH, prolactin, SHBG). QRISK3 calculated and statin discussed if ≥10%. BP diagnosis confirmed and treatment agreed. Mood and relationship revisited. Titrate or switch PDE5 inhibitor if needed.
3 Months — Risk-Factor Progress
BP on treatment; lipids if statin started (NICE NG238 advises checking non-HDL cholesterol at about 3 months, aiming for a >40% reduction); smoking status; alcohol; weight and waist; activity. If a second PDE5 inhibitor has failed despite correct use and testosterone is normal → urology/specialist ED referral. Psychosexual referral if anxiety or relationship difficulty persists.
If on Testosterone — Structured Monitoring
Testosterone, haematocrit and PSA at baseline, around 3–6 months after starting and then at least annually, plus symptom review. Haematocrit above 0.54 → act (dose reduction, formulation change, pause or venesection with specialist advice). Rising PSA or abnormal DRE → urology per NICE NG12.
Annually — Cardiovascular & ED Review
BP, lipids, HbA1c, weight, smoking and alcohol; QRISK3 if not on a statin; medication review (any new nitrate, nicorandil or alpha-blocker changes PDE5 inhibitor safety); IIEF-5; mood. ED is a long-term cardiovascular marker — the review never drops the heart half of the job.
Memory rule — "two jobs at every review"
At every ED review: Is the treatment working? (IIEF-5, technique, side effects, dose) and Is the heart being looked after? (BP, lipids/QRISK3, HbA1c, smoking, alcohol, weight). Then re-check the interaction list — a new GTN spray or nicorandil prescription makes a previously safe PDE5 inhibitor dangerous.
| Target / medicine | Test | Timing | Action threshold |
|---|---|---|---|
| ED response | IIEF-5 score; technique review | Baseline; 4–6 weeks; each review | Inadequate response → check use, dose, food timing, stimulation, testosterone; switch agent; refer if 2 agents fail with correct use |
| PDE5 inhibitor safety | Medication list; cardiac symptoms; BP | Every review and every new prescription | New nitrate/nicorandil/riociguat → stop PDE5i. New alpha-blocker → caution. Chest pain on exertion/sex → assess as possible angina |
| Blood pressure | Clinic BP → ABPM/HBPM | Today; confirm diagnosis; then per NICE NG136 | Hypertension confirmed → lifestyle + treatment to target; choose agents that avoid worsening ED where possible |
| Cardiovascular risk | Lipids, QRISK3 | At diagnosis; annually | QRISK3 ≥10% → offer atorvastatin 20 mg after lifestyle discussion (NICE NG238); non-HDL check at ~3 months |
| Glycaemia | HbA1c | At diagnosis; annually or per risk | ≥48 mmol/mol (repeat to confirm if asymptomatic) = diabetes; 42–47 = non-diabetic hyperglycaemia → prevention programme |
| Testosterone (suspected deficiency) | Total testosterone 7–11am, fasting; SHBG | Initial; repeat if low | Low on two samples → LH/FSH, prolactin; borderline → calculated free testosterone; secondary/pituitary features → endocrinology |
| On testosterone | Testosterone, haematocrit, PSA | Baseline; ~3–6 months; then at least annually | Haematocrit >0.54 → act (BSSM 2023). PSA rise or abnormal DRE → urology per NICE NG12 |
| Mood | PHQ-9 (± GAD-7) | Baseline; reviews | Moderate/severe depression → treat per NICE NG222; any hopelessness/suicidal thoughts → same-day risk assessment |
⚠ Scenario-specific phrases — use these verbatim
What to document
- PDE5i with no nitrate check / no CV or lifestyle plan
- Ignoring mood and the relationship
- No priapism safety-net or review
Who you are
David Okonkwo, 52, works a desk job. You came in about a repeat prescription and only mentioned the erection problem as you were about to leave, because you find it embarrassing. It's been gradually getting worse over about 6 months and now happens most times; you've noticed you don't really get morning erections any more. You smoke ~15 a day, drink ~25 units a week, don't exercise, and your waistband's getting tight. A nurse mentioned your blood pressure was "a bit high" last year but nothing was done. Your dad and brother both had heart attacks in their 50s. Your mood's been a bit flat and it's causing tension with your wife. You want the tablets and, honestly, to keep this short.
Hidden concerns (reveal if explored)
Embarrassment/masculinity (main): you feel awkward and a bit less of a man. A calm, matter-of-fact doctor puts you at ease.
Relationship: it's straining things with your wife; you'll admit this if asked gently.
Health fear: with your family history you do worry about your heart but haven't connected it to this. If the doctor explains the link, you're motivated.
Mood: a bit low; if asked, you'll say you're "not depressed exactly, just fed up."
Clinical details if asked
- Gradual onset ~6 months; now most attempts; lost morning erections; same in all situations
- Libido a bit reduced; energy okay-ish; no testicular changes you've noticed
- Smoker ~15/day; alcohol ~25 units/week; sedentary; central weight gain
- BP "a bit high" last year, untreated; strong family history of heart disease (father, brother MIs in 50s)
- No nitrate/nicorandil; not on any heart tablets; no chest pain on exertion that you've noticed
- Mood flat; relationship strained; no thoughts of self-harm
- No priapism, no penile curvature/lumps; no urinary symptoms
Reactions at key moments
- On the heart link: surprised but takes it seriously given your family history; becomes more willing to address blood pressure/smoking.
- On lifestyle: a bit defensive about smoking, but open if not lectured.
- On mood: will open up a little if asked kindly.
- Challenge line: "Look, can't you just give me the tablets? I haven't really got time for all the blood tests and lifestyle stuff."
Resolution: David is satisfied if the GP: (1) responds warmly and without embarrassment, and gives him a PDE5 inhibitor (after checking he's not on a nitrate/nicorandil); (2) recognises the gradual organic pattern as a cardiovascular sentinel and arranges a full CV risk assessment (BP, lipids, HbA1c, QRISK) and risk-factor treatment; (3) addresses lifestyle (smoking, alcohol, weight, activity) without lecturing; (4) screens his mood and the relationship sensitively; (5) safety-nets (priapism) and arranges review. He disengages if he's handed a prescription with no nitrate check and no attention to his heart or mood, or if the topic is handled awkwardly.
Gradual onset, lost morning erections, vascular risk factors. = CV sentinel → QRISK, treat BP/lipids/diabetes, lifestyle. Check morning testosterone if low libido/fatigue.
Sudden, situational, preserved morning erections, performance anxiety/relationship. PDE5i can help; address psychological factors ± psychosexual therapy.
PDE5 inhibitor first-line (sildenafil/tadalafil) — counsel on use; try several times at adequate dose. ⛔ Absolute contraindication: nitrates & nicorandil. Treat drivers: BP, lipids, diabetes, switch ED-causing drugs. Lifestyle: stop smoking, reduce alcohol, weight, activity. Mood/relationship: screen and treat. If PDE5i fails: optimise + urology (intracavernosal, vacuum, implant). Confirmed hypogonadism → testosterone (specialist). Priapism >4h = emergency.