Erectile Dysfunction
Difficulty achieving or maintaining an erection — often an early sign of cardiovascular disease.
Overview
Erectile dysfunction (ED) affects ~40% of men by age 40 and 70% by 70. It is often vasculogenic — the penis is a sensitive 'vascular barometer' and ED may precede cardiovascular events by 3–5 years. Effective treatments range from lifestyle change and PDE5 inhibitors to penile prostheses.
Symptoms
- • Difficulty achieving an erection
- • Difficulty maintaining an erection sufficient for intercourse
- • Reduced firmness or duration
- • Reduced libido (suggests low testosterone)
- • Loss of morning/nocturnal erections (suggests organic cause)
Risk factors
- • Age >40
- • Diabetes, hypertension, dyslipidaemia, obesity
- • Smoking, excess alcohol
- • Sedentary lifestyle
- • Depression, relationship stress
Causes
- • Vasculogenic: atherosclerosis, hypertension, diabetes, smoking
- • Neurogenic: spinal cord injury, MS, post-prostatectomy
- • Endocrine: hypogonadism, hyperprolactinaemia, thyroid disease
- • Drug-induced: antihypertensives, antidepressants, finasteride, opioids, alcohol
- • Psychogenic: anxiety, depression, relationship issues (preserved morning erections)
🚨 Red flags — seek urgent care
- • Sudden onset with perineal/back pain — exclude cauda equina or spinal pathology
- • Associated peripheral vascular symptoms (Leriche syndrome)
- • Priapism on PDE5 inhibitor or injection — emergency
When to seek care
- • Persistent (≥3 months) ED — investigate underlying cause
- • Sudden onset, especially with other neurological symptoms
- • Symptoms suggesting low testosterone (low libido, fatigue, loss of body hair)
Diagnosis
- • History: onset, situational vs global, morning erections, medications, lifestyle, psychosocial
- • Examination: BP, BMI, secondary sexual characteristics, genital and DRE
- • Bloods: HbA1c/fasting glucose, lipids, morning total testosterone (repeat if low), TFTs, prolactin
- • Validated tool: IIEF-5
- • Cardiovascular risk assessment (QRISK3)
Treatment
- • Lifestyle: stop smoking, weight loss, regular exercise (improves erectile function comparable to PDE5i), Mediterranean diet, reduce alcohol
- • Optimise cardiovascular risk factors — BP, lipids, glucose
- • First-line: PDE5 inhibitors (sildenafil, tadalafil, vardenafil) — daily low-dose tadalafil for regular activity
- • Second-line: vacuum erection devices, intracavernosal alprostadil injection, intraurethral alprostadil
- • Third-line: penile prosthesis (highly effective in suitable patients)
- • Treat underlying: testosterone replacement if hypogonadism confirmed; switch culprit drugs where possible
- • Psychosexual therapy ± CBT, with or alongside medical treatment
Prevention
- • Mediterranean diet, regular aerobic + resistance exercise
- • Healthy weight, stop smoking, moderate alcohol
- • Tight control of diabetes, hypertension and cholesterol
- • Pelvic floor exercises
Complications
- • Relationship and psychological distress
- • Untreated cardiovascular disease (ED is a marker)
- • Priapism (rare with oral PDE5i; commoner with injections)
- • Penile fibrosis from injection therapy
Prognosis
Most men respond well to first- or second-line therapy. Treating cardiovascular risk often improves erectile function and protects against future events.
Education & self-care
ED is a common, treatable condition — and often a window into wider heart and metabolic health. Discussing it openly with a clinician is the first step.
Frequently asked questions
Is ED my fault?
No — it is almost always a medical issue with effective treatments. Most cases have a vascular or hormonal contribution.
Are PDE5 inhibitors safe with heart medication?
They must NEVER be combined with nitrates or nicorandil. Most other heart medications are compatible.
Will I need them forever?
Many men improve with lifestyle change and reducing cardiovascular risk; some need long-term treatment.