Sexual Health · Full case
Erectile Dysfunction
Erectile Dysfunction · Clinical Reasoning Framework v2
GP & SCA · NICE CKS / BSSM · Cardiovascular sentinel · Organic vs psychogenic · PDE5 inhibitors · Hypogonadism · QRISK
ED = vascular warningErectile dysfunction is an early marker of endothelial/vascular disease — it can precede a cardiac event by 2–5 years. New ED, especially of gradual organic onset, mandates full cardiovascular risk assessment (QRISK), not just a sildenafil prescription
Organic vs psychogenicGradual onset, absent morning/spontaneous erections, age and vascular risk factors point to ORGANIC ED. Sudden onset, preserved morning erections, situational pattern, relationship/stress factors point to PSYCHOGENIC ED
PDE5i first-lineA phosphodiesterase-5 inhibitor (sildenafil — now available without prescription in pharmacies, tadalafil, etc.) is first-line for most ED, regardless of cause, alongside treating the underlying drivers and lifestyle change. Sildenafil is generic and inexpensive
Nitrates = absolute noPDE5 inhibitors are absolutely contraindicated with nitrates and nicorandil (profound hypotension). Caution with alpha-blockers and recent cardiovascular events. Always check the cardiac drug list before prescribing
Check testosteroneMeasure morning (9–11am) fasting total testosterone, with low libido/fatigue or PDE5i failure. Confirm low results on a repeat with LH/FSH, prolactin and SHBG before diagnosing hypogonadism — and consider a pituitary cause
Treat the driversDiabetes, hypertension, hyperlipidaemia, smoking, alcohol, obesity and sedentary lifestyle all cause/worsen ED. Many drugs contribute (thiazides, beta-blockers, SSRIs, finasteride, antipsychotics). Optimising these often improves erections
Don't miss depressionED and depression are bidirectionally linked; SSRIs both cause and result from sexual dysfunction. Screen mood, relationship distress and the psychological impact — and ask, sensitively, about self-harm where mood is low
Sudden painful = red flagA sustained painful erection (priapism >4 hours) is a urological emergency. Peyronie's disease (painful curvature), penile/testicular lumps, or trauma have their own pathways. ED with prominent LUTS + abnormal prostate → consider prostate pathway
📋 Clinical Stem — Erectile Dysfunction
A 52-year-old man, embarrassed and reluctant, who books a "quick" appointment and only at the end mentions 6 months of erectile difficulty — with several untreated vascular risk factors
David Okonkwo, 52, comes in nominally about a repeat prescription, and as he is about to leave says, "while I'm here… things aren't working in the bedroom." On gentle questioning he describes 6 months of gradually worsening erectile difficulty, now affecting most attempts, with loss of his early-morning erections. He is a smoker, has untreated borderline-high blood pressure noted opportunistically last year, a strong family history of heart disease, a desk job and little exercise, and his waist is expanding. He drinks 25 units a week. His mood is "a bit flat" and it is straining his relationship. He hopes for "those blue tablets" and to keep the conversation brief.
This stem tests the ability to: create a safe, non-embarrassing space for a sensitive presentation raised as a "by the way"; recognise gradual-onset ED with loss of morning erections in a man with multiple vascular risk factors as ORGANIC and as a cardiovascular sentinel symptom that mandates full CV risk assessment (QRISK), not merely a PDE5i prescription; screen and act on mood; perform the relevant examination and investigations (BP, BMI/waist, glucose/HbA1c, lipids, morning testosterone); prescribe a PDE5 inhibitor safely (nitrate/nicorandil check); and address lifestyle and the underlying drivers. The SCA challenge is to honour his wish for "the blue tablets" and a brief consultation while doing the cardiovascular and psychological work the symptom demands.
Scenario A — Organic ED + vascular risk (this stem) Gradual onset, lost morning erections, vascular risk factors. PDE5i + full CV risk assessment (QRISK), treat risk factors, lifestyle, screen mood. The symptom is a window onto cardiovascular health.
Scenario B — Psychogenic ED Younger man, sudden onset, preserved morning/spontaneous erections, situational (fine with masturbation, not with partner), performance anxiety/relationship stress. PDE5i can help, but address psychological factors ± psychosexual therapy.
Scenario C — Hypogonadism Low libido, fatigue, reduced morning erections, ± small testes. Morning total testosterone (repeat low + LH/FSH/prolactin/SHBG); exclude pituitary cause; consider testosterone replacement under guidance; PDE5i response may be blunted if very low.
Scenario D — Drug-induced ED Onset after starting a thiazide, beta-blocker, SSRI, finasteride or antipsychotic. Review and, where possible, switch the offending drug; don't just add a PDE5i over the top.
Scenario E — Red-flag urology Priapism >4h (emergency), Peyronie's (painful curvature), penile/testicular lump, or ED with prominent LUTS + abnormal prostate → respective urological/prostate pathways.
Key variables to adapt for Onset (gradual organic vs sudden psychogenic); morning erections (lost = organic; preserved = psychogenic); vascular risk factors and QRISK; medication review (ED-causing drugs); libido/fatigue → testosterone; mood/relationship distress; nitrate/nicorandil use (PDE5i contraindication); age; LUTS; priapism/Peyronie's red flags; the "by the way" presentation and embarrassment.
Steps:
1
Step 1
History — Organic vs Psychogenic · Vascular Risk · Mood · Drugs · ICE
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The history has two big jobs: work out whether the ED is organic or psychogenic (which the pattern usually tells you), and recognise that organic ED is a cardiovascular sentinel — a reason to assess David's whole vascular risk, not just write a prescription. Layered onto that are the drivers (drugs, alcohol, mood) and the human reality of an embarrassed man who raised this as he was leaving.
🎓 SCA framing — make it easy to talk about, then widen the lens
"I'm really glad you mentioned it — it's very common and very treatable, and there's no need to feel awkward. There's a tablet that helps most men, and I'd also like to use this as a chance to check your heart health, because the two are closely linked. Shall we do both?"
David wants "the blue tablets" and a quick exit. The skill is to normalise the topic, validate him for raising it, and connect the symptom to his cardiovascular health so the broader assessment feels like care, not obstruction.
1A — Characterise the ED and screen the drivers
1B — Red flags
🚨
Red Flags — the symptom that is also a warning
| Red flag | Why dangerous | Action |
|---|---|---|
| Organic ED as a cardiovascular sentinel | ED is an early manifestation of systemic endothelial disease and can precede myocardial infarction/stroke by 2–5 years. 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; prostate assessment (PSA/DRE) if LUTS/abnormal exam |
1C — ICE
💭 Ideas
"What do you think is behind it — and what were you hoping we could do?"
David likely sees this as a mechanical problem with a tablet solution, and may not realise it is linked to his heart health. Surfacing his idea lets you give the tablet he wants AND introduce the cardiovascular link as a positive ("this is a chance to protect your heart"), so the wider assessment feels relevant rather than imposed.
😟 Concerns
"Has this been worrying you — about your health, or about the relationship?"
His concerns may be about masculinity, the relationship, ageing, or a fear of serious illness. Naming them — and the strain on his relationship and mood — makes him feel understood and opens the door to addressing the psychological dimension, not just the physiology.
🎯 Expectations
"You mentioned the tablets — let me explain how they work and what else will help them work better."
He expects a quick prescription. Naming this lets you deliver it (most men can have a PDE5i) while framing lifestyle change, risk-factor treatment and mood as the things that make the tablets work better and protect his health — a deal he can buy into.
1D — Psychosocial context
🧍 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?"🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills
Key phrases that score
"Do you still get firm erections first thing in the morning?" — the question that separates organic from psychogenic.
"The blood vessels to the penis and the heart are the same — so this is a chance to protect your heart too." — frames the CV work as care.
"Are you on any heart tablets like a nitrate or nicorandil?" — the safety check before a PDE5i.
Deductions
- 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
🔴 Red
PDE5i prescribed with no CV assessment / no nitrate check; organic vs psychogenic not explored; mood ignored; dismissive manner
🟠 Amber
ED characterised; PDE5i offered; some risk factors noted but no QRISK/lifestyle plan; mood touched on; ICE partial
🟢 Green
Organic ED identified; full CV risk assessment (QRISK) + risk-factor treatment + lifestyle; nitrate check; testosterone if indicated; mood screened; PDE5i prescribed safely; ICE all three; sensitive, normalising manner
2
Step 2
Triage — Emergency · Urgent CV/Endocrine/Urology · Routine
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Almost all ED is managed routinely in primary care. The triage task is to catch priapism (emergency), the high cardiovascular risk or cardiac symptoms that need addressing before resuming activity, the pituitary/endocrine cause, and the urological red flags — while recognising the routine majority who need a PDE5i plus risk-factor work.
🔴 Emergency
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
🟠 Urgent / Refer
Soon
Days–weeks- High CV risk / suspected anginaOptimise/refer before resuming activity
- Pituitary features / confirmed hypogonadismEndocrinology
- Peyronie's / penile or testicular lump / PDE5i failureUrology
🟢 Routine
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
🎓 SCA Checkpoint — Step 2Tasks
Triage rationale
"This is very treatable and we'll manage it here. The most important thing today is to check your heart health properly, because the two are linked — and to make sure the tablet is safe with your other medicines."
Deductions
- Treating ED while ignoring high cardiovascular risk
- Missing priapism or pituitary features
3
Step 3
Examination — Cardiovascular · Genital · Endocrine Signs
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Examination is focused: cardiovascular (because that is the real diagnosis behind organic ED), genital (structure, testes, prostate by symptoms), and signs of endocrine disease.
🎓 SCA Checkpoint — Step 3TasksGlobal Skills
Narration that scores
"I'd like to check your blood pressure, weight and waist, and — with your consent and a chaperone — examine you to rule out any local cause. That helps me be sure we're treating the right thing."
Deductions
- No BP/metabolic assessment in organic ED
- Genital examination without consent/chaperone, or omitted when indicated
4
Step 4
Investigations — Vascular Risk Bloods · Morning Testosterone · QRISK
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The investigations in ED are essentially a cardiovascular and endocrine work-up: glucose/HbA1c, lipids and a QRISK assessment for the vascular dimension, and a morning testosterone (with confirmatory tests) where libido is low or PDE5 inhibitors fail.
🎓 SCA Checkpoint — Step 4Tasks
Key reasoning
"I'll check your blood sugar, cholesterol and a morning testosterone, and work out your heart-risk score — that tells us what to treat alongside the tablets."
Deductions
- No CV risk assessment / bloods in organic ED
- Diagnosing hypogonadism on a single non-morning sample
- Over-investigating an obvious psychogenic case
5
Step 5
Diagnosis — Organic · Psychogenic · Hypogonadal · Drug-Induced
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Name the type of ED and — crucially in organic ED — name the cardiovascular risk it represents.
🚩 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.
🎓 SCA Checkpoint — Step 5Tasks
Explaining it plainly
"The pattern fits a circulation-related cause rather than a purely 'in the head' one. The tablets will help — and just as importantly, this is a signal to look after your heart, so we'll tackle the blood pressure, smoking and weight together."
Deductions
- Treating the erection and missing the cardiovascular diagnosis
- Calling it psychogenic without the supporting pattern
6
Step 6
Referral — Cardiology · Endocrinology · Urology · Psychosexual
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Most ED is managed in primary care. Referral is for high cardiovascular risk/cardiac symptoms, confirmed/complex hypogonadism, urological disease or PDE5i failure, and psychosexual/relationship difficulty.
🎓 SCA Checkpoint — Step 6Tasks
Knowing the thresholds
"If the tablets don't work, or if your heart assessment throws up concerns, there are next steps and specialists we can involve — but most men do well with the tablet plus the lifestyle changes."
Deductions
- Resuming activity with untreated high cardiac risk
- Not offering psychosexual support in clear psychogenic ED
7
Step 7
Management — PDE5 Inhibitor (Safely) · Risk Factors · Lifestyle · Mood
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Management has four parts: a PDE5 inhibitor prescribed safely; treatment of the underlying drivers (BP, lipids, diabetes, offending drugs); lifestyle change (the single most powerful long-term lever); and attention to mood and the relationship. For David, the prescription is the easy part — the cardiovascular and lifestyle work is the high-value medicine.
7A — The plan
🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills
A plan that scores
"Here's the plan: a tablet to take before sex — let me check it's safe with your other medicines and explain how to use it — plus sorting your blood pressure, help to stop smoking, cutting the alcohol, and a look at your mood. We'll review how the tablet works and your heart-risk numbers."
Deductions
- PDE5i with no nitrate check / no CV or lifestyle plan
- Ignoring mood and the relationship
- No priapism safety-net or review
Erectile Dysfunction — SCA Consultation Scorecard
NICE CKS/BSSM · CV sentinel + QRISK · Organic vs psychogenic · PDE5i safely · Mood
0/ 33 pts
Global Skills
Structure, language, responsiveness
0/7
Tasks
Clinical reasoning, diagnosis, management
0/15
Relating to Others
Communication, rapport, shared decisions
0/11
RAG Self-Assessment
🔴 Red
PDE5i prescribed with no CV assessment / no nitrate check; organic vs psychogenic ignored; mood missed; awkward/dismissive manner
🟠 Amber
ED characterised; PDE5i offered safely; some risk factors noted but no QRISK/lifestyle plan; mood touched on; ICE partial
🟢 Green
Organic ED + CV sentinel recognised; QRISK + risk-factor treatment + lifestyle; nitrate check; testosterone if indicated; mood screened; PDE5i safe; ICE all three; normalising manner
Complete the checklist to see your score and feedback
"Right, well, that's the prescription sorted… actually, doc, while I'm here — and this is a bit awkward — things haven't been working in the bedroom. I was hoping I could just get some of those blue tablets?"
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."
"Honestly doc, I just want the tablets so things work again — do we really need all this heart and blood-test business?"
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.
Clinic Quick Reference
Erectile Dysfunction — Clinical Decision Framework
NICE CKS / BSSM · CV sentinel · PDE5i · Hypogonadism
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🔍 1 — Organic vs psychogenic
Organic
Gradual onset, lost morning erections, vascular risk factors. = CV sentinel → QRISK, treat BP/lipids/diabetes, lifestyle. Check morning testosterone if low libido/fatigue.
Psychogenic
Sudden, situational, preserved morning erections, performance anxiety/relationship. PDE5i can help; address psychological factors ± psychosexual therapy.
💊 2 — Treat
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.
SCA Quick Reference
Erectile Dysfunction — Consultation Playbook
Normalise · treat the symptom · read the warning · safe PDE5i
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🎯 The three pivots that pass this case
1 · The sentinel
Organic ED = vascular disease. Do a full CV risk assessment (QRISK) and treat the risk factors — don't just prescribe.
2 · Safe prescribing
PDE5 inhibitor first-line, but check for nitrates/nicorandil first (absolute contraindication).
3 · The whole person
Screen mood and relationship, address lifestyle, and handle the disclosure warmly — ED is rarely "just" mechanical.
⛔ Don't prescribe a PDE5 inhibitor without checking for nitrates/nicorandil · Don't treat the erection and ignore the cardiovascular warning · Don't miss depression or relationship strain · Don't diagnose hypogonadism on a single non-morning sample · Handle the "by the way" disclosure with warmth, not awkwardness