Erectile Dysfunction

This is the partial or complete failure to achieve a satisfactory erection. The inability to ejaculate (ejaculatory erectile dysfunction) is not dealt with here. Erectile dysfunction presents fairly often to GPs and will probably do so increasingly frequently as new treatments are developed and publicised.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Depression/Anxiety
  • Excessive Alcohol Intake
  • Relationship Dysfunction
  • Vascular: Arterial Insufficiency (Arteriopathy) or Excessive Venous Drainage
  • Iatrogenic (e.g. Prostatic Cancer Treatments, Hypotensives, some Antidepressants)

Occasional Diagnoses

  • Testosterone Deficiency (May be Primary or Secondary)
  • Diabetic Autonomic Neuropathy
  • Trauma: Pelvic or Spinal Fracture, Trauma to Penis, Post-TURP
  • Anatomical: Phimosis, Tight Frenulum
  • Excessive Cigarette Smoking
  • Peyronie’s Disease
  • Drug Abuse (e.g. Heroin, Amphetamines)

Rare Diagnoses

  • Fetishism (Erection only Possible with Unusual Stimuli)
  • Spinal Cord Compression: Tumour
  • Thrombosis of a Corpus Cavernosum
  • Neurological: Tabes Dorsalis, Multiple Sclerosis

Ready reckoner

Key distinguishing features of the most common diagnoses

Depression/ AnxietyAlcoholRelationship DysfunctionVascularDrugs
TATT/sleep ProblemYesPossiblePossibleNoNo
Occasional OnlyPossibleNoYesNoNo
Full Morning ErectionYesNoYesNoNo
Reduced Foot PulsesNoNoNoYesNo
Taking MedicationPossibleNoNoNoYes

Possible investigations

Likely: Urinalysis.

Possible: Blood sugar or HbA1c, FBC, LFT, endocrine assays (testosterone, prolactin, FSH/ LH, TSH), cholesterol, PSA.

Small Print: Doppler flow studies, angiography, intracorporeal prostaglandin injection test, MRI scanning – all likely to be specialist initiated.

  • Urinalysis: An essential easy screen for undiagnosed diabetes.
  • Blood sugar or HbA1c: To confirm diabetes.
  • FBC and LFT possibly helpful in alcohol excess (raised MCV and possible LFT abnormalities).
  • Testosterone levels reduced in primary or secondary hypogonadism. Prolactin, FSH/LH and TSH check pituitary function. Erectile dysfunction may be a sign of cardiovascular disease – so in certain patients a cholesterol level would be warranted.
  • The link between prostate cancer and erectile dysfunction is far from clear. Some guidelines recommend PSA in this situation to assess for possible prostate cancer; judge each case on its merits and according to other symptoms and the man’s wishes.
  • Doppler flow studies of superficial and deep penile arterial flow assess arterial sufficiency. Angiography may be necessary if symptoms suggest significant lower limb arterial insufficiency associated with impotence.
  • Intracorporeal prostaglandin injection test: Immediate and prolonged response indicates neurological problems. Good initial response with rapid failure indicates excessive venous drainage.
  • Possible neurological causes will occasionally require further investigation (e.g. MRI scanning for cord lesions or MS).

Top Tips

  • Establish whether the patient can get an erection at any time (e.g. early morning). If he can, then the cause is unlikely to be organic. Take a positive approach – many psychological causes are transient.
  • Don’t be too quick to diagnose anxiety as the underlying problem. This may be the effect, rather than the cause, of the impotence.
  • Erectile dysfunction is often presented as a ‘by the way’ or ‘while I’m here’ symptom. The temptation is to invite the patient to book a further appointment, but bear in mind that this may represent a lost opportunity to help, as he may not return.
  • Demonstrate that you are taking the problem seriously – for example, by performing an appropriate examination or by inviting the patient’s partner to attend a subsequent appointment.

Red Flags

  • Sudden onset of erectile dysfunction with saddle anaesthesia and sphincter disturbance indicates a cauda equina lesion. Refer urgently.
  • An erection which is consistently lost after a predictable period is likely to be organic – probably vascular – in origin.
  • Do not forget that alcohol and drug abuse are possible causes. Look in the notes for clues and make specific enquiry, as these problems are unlikely to be volunteered.
  • Erectile dysfunction may well be a marker for vascular disease elsewhere. Extend your assessment as appropriate.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.