In short
One appointment that ends with a cause, a cardiac risk category, and a prescription only if it is safe to give one.
- History. Sudden or gradual onset, morning erections, whether desire changed too. This identifies the cause in about 95 per cent of cases.
- Bloods. Glucose, lipids, thyroid, blood count, liver and kidney function, and testosterone.
- Cardiac risk graded low, intermediate or high. Sex is exertion, and the medications interact with nitrates.
Nobody leaves with a prescription before the heart question has been settled.
Treatment Overview
Why so much weight on the history?
Because it is that good. History and examination have around 95 per cent sensitivity for determining the cause of erectile dysfunction, though only about 50 per cent specificity, which is exactly why tests follow rather than lead.
Three questions do most of the work.
| How did it start? | Sudden in a previously unaffected man means psychological, apart from after pelvic surgery or trauma. Gradual means physical |
| Do you still wake with erections? | Their presence shows the nerves and blood flow are intact and points away from a vascular cause |
| Has desire changed too? | Low desire and erectile dysfunction are separate problems with different causes |
What is examined?
- Femoral and peripheral pulses, as a clue to vascular disease, and femoral bruits if pulses are normal
- Penile plaques, indicating Peyronie’s disease
- Body and facial hair, breast tissue and testicular size, indicating a hormonal cause
- The cremasteric reflex, an index of the nerve pathway
- Visual fields, since a pituitary tumour can present this way
Which blood tests, and why?
Fasting glucose or HbA1c, full blood count, liver and kidney function, thyroid function, a lipid profile and total testosterone.
Glucose is not a formality. In one national survey, men reporting erectile dysfunction had twice the rate of undiagnosed diabetes. If testosterone is low, it is repeated with LH and prolactin before any decision.
Why the cardiac question comes before the prescription
Two reasons. Sexual activity is physical exertion, and PDE5 inhibitors are absolutely contraindicated with nitrates in any form, because the combination can cause severe low blood pressure.
- Low cardiac risk: treatment can proceed
- Intermediate risk: an exercise stress test first. A positive test means further cardiac assessment before treatment
- High risk: cardiology review before any ED treatment is started
Is a scan needed?
Usually not. Penile ultrasound is used where the cause is unclear, where there has been trauma or priapism, in Peyronie’s disease, or where medication has failed.
Overnight erection testing in a sleep laboratory is no longer routinely done. Home monitoring devices can quantify erections during sleep where that question genuinely matters.
Who Is a Good Candidate?
- Erections have become unreliable and you want the cause identified rather than just a prescription
- You have been given tablets elsewhere without any assessment
- You have diabetes, high blood pressure or high cholesterol, or you smoke
- You take nitrates, or are not sure whether one of your medicines counts as one
- You want the cardiovascular side taken seriously as well as the sexual side
- Chest discomfort or breathlessness on exertion, which needs cardiac assessment before any treatment
- You take nitrates in any form, regularly or occasionally, which rules out the standard tablets entirely
- Visual field changes with headaches, which can indicate a pituitary cause
What Happens During the Consultation
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1
The sexual history
Onset, morning erections, whether the erection is lost after penetration, whether desire has changed, and whether it happens in every situation. Ejaculatory problems and any penile curvature are asked about at the same time.
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2
Medication, risk factors and the relationship
Antidepressants and antihypertensives are common contributors. Smoking, weight, diabetes, blood pressure and lipids are recorded. Interpersonal conflict is asked about, because it is common and rarely volunteered.
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3
Examination and bloods
Pulses, penile examination, testicular size, breast tissue, hair pattern and visual fields. Bloods cover glucose or HbA1c, blood count, liver and kidney function, thyroid, lipids and testosterone.
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4
Cardiac risk graded, then the plan
Low, intermediate or high. Intermediate means an exercise test first, high means cardiology review first. Only then is treatment discussed, with a baseline score recorded so improvement can be measured.
Program Structure & Follow-Up
What happens after the consultation
Results are explained with what each one means, including the cardiovascular findings, which usually matter more in the long run than the sexual ones.
The first review
- Whether the treatment is working, measured against the baseline score rather than an impression
- Whether it was taken correctly, since instruction rescues about 25 to 30 per cent of apparent non responders
- Side effects, and whether a different drug in the same class would suit better
What a meaningful improvement is
A defined change on a validated score: two points for mild, five for moderate and seven for severe erectile dysfunction. That is why a baseline is recorded before anything is started.
Alongside the sexual treatment
| Cardiovascular risk | Managed in its own right, because ED often arrives before the cardiac diagnosis |
| Newly found diabetes | Treated as diabetes, which is a more consequential diagnosis than the ED |
| Low testosterone | Confirmed on a repeat sample with LH and prolactin, then treated with its own monitoring schedule |
If the first treatment does not work
Second line options exist and are discussed rather than the case being closed. A vacuum device is usually tried first, being non invasive and less expensive than injections or intraurethral treatment.
Benefits, Limits & Safety
What the consultation delivers
A cause rather than a guess, a cardiac risk category, a baseline score, and a treatment that is safe to take given everything else you are on.
It also delivers a cardiovascular assessment that many men would not otherwise have had, at an age where it is worth having.
What the consultation cannot do
- It cannot make a treatment safe if you take nitrates. That is an absolute contraindication
- It cannot fix a relationship problem, and where that is the driver it will be named rather than prescribed around
- It cannot short circuit the cardiac assessment where risk is intermediate or high
The honest note about testosterone
Testosterone is measured in all men presenting with erectile dysfunction. But it is the cause less often than expected: persistently low levels were found in 4 per cent of men under 50 and 9 per cent over 50 in one series of 1022 men.
Testing only men with low desire or physical signs of deficiency would have missed 40 per cent of the cases found, which is why it is measured in everyone rather than in the obvious cases.
What is not offered
Prescriptions without assessment, treatment before the cardiac question is settled, and shockwave or platelet based therapies marketed as regenerative, which do not have the evidence base to justify them.
A cause, not a guess
History and examination identify the cause in about 95 per cent of cases, and the tests confirm it rather than starting the search.
A baseline before treatment
A validated score recorded first, so improvement is a defined change rather than an impression. Two points for mild, five for moderate, seven for severe.
Absolute stop
Nitrates in any form, regular or occasional. High cardiac risk needs cardiology review, and intermediate risk needs an exercise test, before treatment starts.
Cost & Program Investment
The consultation and the blood panel are quoted before anything is ordered. The panel is a standard one rather than a specialist hormone screen. Where cardiac risk means an exercise test or cardiology review is needed first, that is arranged and quoted rather than skipped to reach a prescription faster. Medication itself is an ordinary prescription bought at pharmacy prices.
Frequently Asked Questions
Not without the cardiac question being settled. Sexual activity is exertion, and these drugs are absolutely contraindicated with nitrates in any form. Intermediate cardiac risk needs an exercise test first.
Long enough for a proper history and examination, because those identify the cause in about 95 per cent of cases. The tests confirm what the history suggested rather than starting the search.
Glucose or HbA1c, full blood count, liver and kidney function, thyroid function, lipids and total testosterone. If testosterone is low it is repeated, with LH and prolactin.
Because erectile dysfunction and cardiovascular disease share the same mechanism, and ED usually arrives first. In one survey, men with ED had twice the rate of undiagnosed diabetes.
Usually not. Penile ultrasound is reserved for unclear causes, trauma, priapism, Peyronie's disease, or failure to respond to medication. Overnight testing in a sleep laboratory is no longer routine.
It is often the instruction rather than the drug, and retrying properly rescues about 25 to 30 per cent of apparent non responders. Beyond that there are second line options, usually starting with a vacuum device.
Entirely. Nothing goes to an employer, insurer or anyone else without your explicit instruction, and consultations are in English or German.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.