Erectile Dysfunction

See also Ejaculatory & Libido Disorders for premature/delayed ejaculation and low sexual desire — a 2023 AJGP article classifies all of these, plus Peyronie’s disease, together as “male sexual dysfunction.”

The consistent or recurrent inability to attain or maintain a penile erection adequate for sexual activity. May be organic (anatomic, vasculogenic, neurogenic, endocrine, drug-related), psychogenic (generalised or situational), or mixed — organic ED commonly develops a secondary psychogenic component over time.

Demographics: very common and increases with age — one study of men over 45 found a 60% self-reported prevalence; another, of men aged 35–80, found 23.3%.

Risk factors

• Age.
• Atherosclerosis risk factors — smoking, diabetes, cardiovascular disease, dyslipidaemia, hypertension.
• Neurological conditions — MS, Parkinson’s, stroke, Alzheimer’s, spinal cord injury.
• Pelvic surgery — prostatectomy, radiotherapy, trauma.
• Endocrine — hypogonadism, hyperprolactinaemia, thyroid dysfunction (see endocrinology-diabetes’s male hypogonadism page for the testosterone-deficiency workup itself).
• Medications — antihypertensives (especially beta-blockers), psychotropics (especially antipsychotics, then SSRIs/other antidepressants), anticonvulsants, antiandrogens, corticosteroids, chronic opioid use.

History and examination

The key history step is simply raising the topic — routinely asking about sexual function in consults helps men voice concerns they wouldn’t otherwise mention. Assess penile hardness, ability to achieve penetration, ejaculation, orgasm, and any pain or deformity.

Examination is not usually diagnostically helpful on its own, but assess cardiovascular risk factors (BP, BMI, waist circumference), look for penile plaques (Peyronie’s), and check for small testes/reduced androgenisation suggesting hypogonadism.

Investigations

Individualise to the suspected cause, but test everyone for:

• Morning testosterone (hypogonadism).
• TSH (thyroid dysfunction).
• HbA1c or fasting glucose (diabetes).
• Lipid profile (dyslipidaemia).

Management

Optimise modifiable risk factors: smoking cessation, healthy diet, exercise, reduced alcohol, avoiding recreational drugs; treat BP/dyslipidaemia/diabetes; assess for underlying CVD if there’s a high index of suspicion (e.g. stress testing).

Treat reversible causes: low testosterone, medication-induced ED (consider alternatives), or psychogenic ED (consider referral to a therapist).

First-line pharmacotherapy: PDE5 inhibitors.

• Contraindications: nitrate use (topical or oral), severe heart failure, unstable angina (or angina with sexual activity), resting hypotension, recent stroke or MI.
• Patient instructions: take 1 hour before sexual activity (2 hours for tadalafil/Cialis); take on an empty stomach (fatty food slows absorption); try at least 3 times before concluding it hasn’t worked.
• Cost: sildenafil is cheap, being off patent. Tadalafil has also been off patent in Australia since ~2018, making both on-demand and daily dosing substantially cheaper than when this note was originally written — no longer a major cost barrier compared with sildenafil.

If first-line therapy fails: refer to urology for vacuum devices, intracavernosal injections, or penile implants.