In short
Erectile dysfunction is often the first sign of vascular disease, which is why it is assessed as a cardiovascular problem and not only a sexual one.
- Men with ED are at higher risk of later cardiovascular events, and had twice the rate of undiagnosed diabetes in one national survey.
- How it started matters more than any test. Sudden onset in a man who was previously fine is almost always psychological. Gradual onset points elsewhere.
- Morning erections tell you a great deal. Their presence makes a vascular or nerve cause unlikely.
It affects up to a third of adult men, and most causes are treatable.
Condition Overview
Why is this treated as a cardiovascular issue?
Because erectile dysfunction and cardiovascular disease share their risk factors and their mechanism. Both involve the lining of blood vessels, and the penile arteries are smaller, so they narrow noticeably first.
Men who present with ED are at higher risk of subsequent cardiovascular events. In one national survey, men reporting ED had twice the rate of undiagnosed diabetes.
That is why the assessment includes blood pressure, lipids, glucose and thyroid function rather than jumping straight to a prescription.
How the story tells you the cause
| Sudden, in a man who was fine until one night | Almost always psychological. Performance anxiety, a change in the relationship, or another emotional cause |
| Gradual, failing occasionally then more often | Points to a physical cause: vascular, neurological, hormonal or drug related |
| Sudden after pelvic surgery or trauma | A physical cause of sudden loss, and the main exception to the rule above |
| Loses the erection after penetration | Usually anxiety, or a venous leak |
What do morning erections tell you?
A lot. Most men have spontaneous erections during REM sleep and often wake with one, which shows that the nerve reflexes and the blood flow into the penis are intact.
Their presence points toward a psychological cause. Their complete absence points toward a nerve or blood vessel problem.
How is severity measured?
With a validated five question questionnaire, which classifies ED as severe at 5 to 7, moderate at 8 to 11, mild to moderate at 12 to 16, mild at 17 to 21, and absent at 22 to 25.
That matters because it gives a baseline. A meaningful improvement on treatment is a defined change, not a vague impression.
Are hormones usually the cause?
Less often than the marketing suggests. Estimates of low testosterone in men presenting with ED range from 4 to 35 per cent depending on the population and the cut off used.
In one series of 1022 men, persistently low testosterone was found in 4 per cent under 50 and 9 per cent over 50. But testing only men with low desire or physical signs would have missed 40 per cent of the cases, including 37 per cent of those who responded to treatment. So testosterone is measured in everyone presenting with ED, and it is not assumed to be the answer.
When to See a Doctor
- Erections have become unreliable over months, rather than failing once
- You still get morning erections but cannot maintain an erection with a partner
- You have diabetes, high blood pressure, high cholesterol or you smoke
- You have started a new medication, particularly an antidepressant or a blood pressure drug
- Libido has dropped alongside the erections, which is a different pattern and points elsewhere
- Chest discomfort, breathlessness on exertion or reduced exercise tolerance, which need assessing before any ED treatment is started
- A curve, bend or hard plaque in the penis, which suggests Peyronie's disease
- Loss of body hair, breast enlargement, small testicles, or changes in your visual fields, which point to a hormonal or pituitary cause
How Dr. Felix Assesses This
-
1
How and when it started
Sudden or gradual, whether morning erections persist, whether the erection is lost after penetration, and whether desire has changed too. History and examination identify the cause in about 95 per cent of cases, though they are far less specific, which is why tests follow.
-
2
Medication and risk factor review
Antidepressants and antihypertensives are common contributors. Smoking, obesity, diabetes, hypertension and abnormal lipids are all identified and treated in their own right, because treating them can improve erections.
-
3
Examination and bloods
Femoral and peripheral pulses, penile plaques, testicular size, body hair and gynaecomastia. Bloods include 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.
-
4
Cardiovascular risk stratified before treatment
Sexual activity is exertion. Risk is graded low, intermediate or high. Intermediate risk warrants an exercise test, and high risk needs cardiology review before ED treatment starts.
Treatment Options
ED Consultation
Why so much weight on the history? Because it is that good. History and examination have around 95 per cent…
View Treatment
Erectile Dysfunction Treatment
How well do they work? Well. Across the four drugs, successful intercourse rates are 68 to 69 per cent compared…
View Treatment
Low Libido Treatment
Treatment by cause Low testosterone Replacement, once confirmed. The most reliably treatable hormonal cause Raised prolactin Treated in its own…
View Treatment
Why Early Treatment Can Matter
What is gained by acting early?
Two separate things. The erections usually improve, and the cardiovascular risk that produced them gets found while it is still silent.
Lifestyle change and treatment of cardiovascular risk factors both improve sexual function in some men. Exercise of 18 MET hours a week or more was associated with better sexual function, and a meta analysis of 11 trials found aerobic exercise improved erectile function against placebo.
What else improves it?
- Stopping smoking
- Weight loss, including after bariatric surgery, which also raises testosterone
- Treating sleep apnoea. CPAP improved erectile function in some studies though not all
- Reviewing medication, particularly antidepressants and some blood pressure drugs
Why is the cardiac check done before treatment?
Because sex is physical exertion, and the drugs used for ED interact with nitrates. A man on nitrates in any form cannot take a PDE5 inhibitor, because the combination can cause a severe drop in blood pressure.
Where cardiac risk is intermediate, an exercise test comes first. Where it is high, cardiology review comes first. This is a sequence, not a formality.
What if a partner is involved in the assessment?
It usually helps. A partner can give a perspective on the relationship and on other sexual issues, and men whose partners have no sexual difficulty of their own are more likely to recover erectile function.
Interpersonal conflict is one of the more common and least often acknowledged causes.
Why Early Treatment Can Matter
What is gained by acting early?
Two separate things. The erections usually improve, and the cardiovascular risk that produced them gets found while it is still silent.
Lifestyle change and treatment of cardiovascular risk factors both improve sexual function in some men. Exercise of 18 MET hours a week or more was associated with better sexual function, and a meta analysis of 11 trials found aerobic exercise improved erectile function against placebo.
What else improves it?
- Stopping smoking
- Weight loss, including after bariatric surgery, which also raises testosterone
- Treating sleep apnoea. CPAP improved erectile function in some studies though not all
- Reviewing medication, particularly antidepressants and some blood pressure drugs
Why is the cardiac check done before treatment?
Because sex is physical exertion, and the drugs used for ED interact with nitrates. A man on nitrates in any form cannot take a PDE5 inhibitor, because the combination can cause a severe drop in blood pressure.
Where cardiac risk is intermediate, an exercise test comes first. Where it is high, cardiology review comes first. This is a sequence, not a formality.
What if a partner is involved in the assessment?
It usually helps. A partner can give a perspective on the relationship and on other sexual issues, and men whose partners have no sexual difficulty of their own are more likely to recover erectile function.
Interpersonal conflict is one of the more common and least often acknowledged causes.
Treatable in most men
PDE5 inhibitors achieve successful intercourse in 68 to 69 per cent of men against 33 to 35 per cent on placebo, and lifestyle change adds to that.
What it can be warning you about
Undiagnosed diabetes at twice the background rate, and a higher risk of later cardiovascular events. ED often arrives before the cardiac diagnosis.
The history does most of the work
Sudden or gradual onset, and whether morning erections persist, narrow the cause before any test is ordered.
Cost & Consultation Investment
The consultation and the blood panel are quoted before anything is ordered. The panel is a standard one covering glucose, lipids, thyroid, blood count, liver and kidney function and testosterone, not a specialist hormone screen. Where cardiac risk means an exercise test or cardiology review is needed first, that is explained and arranged rather than skipped to get to a prescription.
Frequently Asked Questions
Sometimes, and the history usually tells you. ED that appeared suddenly in a man who was previously fine is almost always psychological. ED that failed occasionally and then more consistently points to a physical cause.
It means the nerve reflexes and the blood flow into the penis are working, which makes a vascular or neurological cause unlikely and points toward a psychological one.
Yes. Testosterone is measured in all men presenting with ED. But it is the cause less often than people expect, and low levels are confirmed on a repeat sample with LH and prolactin before anything is prescribed.
You need your cardiac risk stratified. Sexual activity is exertion, and the medications interact with nitrates. Intermediate risk means an exercise test first, and high risk means cardiology review first.
Very possibly. Antidepressants and several blood pressure medicines are common contributors, and reviewing them is one of the first steps rather than one of the last.
It can improve it substantially in some men. Aerobic exercise improved erectile function against placebo in a meta analysis of 11 trials, and weight loss, stopping smoking and treating sleep apnoea all help.
If you want them to, it often helps. A partner adds perspective, and men whose partners have no sexual difficulty of their own recover erectile function more often.
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.