The GP Guide: Managing erectile dysfunction

Erectile dysfunction (ED) is a common condition affecting 6-64% of men aged 45-79¹. While treatable, ED can have a considerable impact on the wellbeing of men and their partners. 

This article outlines the GP’s role in managing ED – from clinical assessment to treatment, referral and follow-up.

What is erectile dysfunction?

ED is a persistent or recurrent inability to attain or maintain a penile erection for satisfactory sexual activity. It becomes more likely with age.

ED is associated with chronic disease including cardiovascular disease and diabetes, and may be an early warning sign of these conditions2.

Premature ejaculation is occasionally related to ED, but it is a separate clinical condition that has its own distinct management. See our clinical guide to ejaculatory disorders for further information.

How to talk to patients about erectile dysfunction

GPs are typically the first point of contact for men with erectile dysfunction. However, patients may be reluctant to bring it up. 

GPs can approach the topic with patients by normalising the condition and giving them space to talk about it. For example:

• “Many men (of your age/with your condition) experience sexual difficulties. If you have any difficulties, I am happy to discuss them.”
• “It is common for men with diabetes/heart disease/high blood pressure to have erectile problems. Also, erectile problems can indicate you are at higher risk for future health problems such as heart disease. So it’s an important issue for us to discuss if it is a problem for you.”

It’s especially important to discuss erectile issues with older patients as their sexual health is often overlooked. 

Diagnosing erectile dysfunction

History

When taking a patient’s history, review medical, sexual and psychosocial factors.

Medical

Check the following: 

• Lifestyle
• General health
• Chronic disease
• Genital disease 
• Medications
• Pelvic surgery or radiation. 

Sexual

Determine the nature of the sexual dysfunction:

• When ED started
• Whether there are spontaneous morning erections
• Whether penetration is possible
• If the patient can maintain an erection.

Psychosocial

Establish if the patient has:

• Depression
• Anxiety
• Relationship difficulties
• A history of sexual abuse.

Physical examination

Perform the following examinations: 

• Genito-urinary: penis (plaques), testes (size). Refer to our guide to male genital examinations 
• Cardiovascular: blood pressure, heart rate, waist circumference, cardiac examination, carotid bruits
• Neurological: focused neurological examination e.g. peripheral neuropathy.

Investigations

Assess for the following conditions:

• Diabetes mellitus
• Hyperlipidemia
• Hypogonadism
• Cardiovascular disease.

Treating erectile dysfunction

When treating ED, GPs should consider:

• Cause — organic, psychosocial or combined
• Patient and partner goals
• Benefits, risks and costs of treatment options.

Their partners’ sexual needs should also be considered as part of managing ED. 

Treatment summary

First line treatment:

• Alter modifiable risk factors and causes 
• Counselling and education.

Second line:

• Oral agents (PDE5 inhibitors)
• Vacuum devices or rings.

Third line

• Consider specialist referral
• Intracavernous vasoactive drug injection.

Fourth line

• Specialist referral
• Surgical treatment (penile implants).

For further detail about treatment options, see our clinical summary guide. 

There are also emerging treatments that may play a role in the management of ED in the future. These include low dose shock wave therapy, topical nitrates and new oral agents.

When to refer the patient to a specialist

GPs may choose to refer patients to a specialist if they do not have training or experience in managing ED. Referral can also be at the patient’s request.

Referral options:

• Refer to an endocrinologist for complex endocrine disorders
• Refer to a urologist if there is pelvic or perineal trauma, penile deformities, the need for penile implants, or treatment failure e.g. poor or non-response to medication
• Refer to an ED specialist (either endocrinologist or urologist) for complex problems including vascular, neurological and treatment failures.

Following up with the patient

Follow-up is essential to ensure the best patient outcomes.

In follow-up appointments, GPs should review and assess:

• Effectiveness of treatment
• Patient and partner satisfaction 
• Whether there are any adverse effects of treatment
• Overall physical and mental health
• Partner’s sexual function e.g. libido, and the couple’s adaptation to changes in their sex life.

Free clinical resource

Download the clinical summary guide as a print-ready PDF:

Erectile Dysfunction