Key points

• ED prevalence increases with age but is not an inevitable part of ageing.
• Always screen for reversible causes—cardiovascular disease, diabetes, hypogonadism, medications and psychological factors.
• Treatment should be individualised: address medical comorbidity, lifestyle factors, psychosexual counselling and pharmacologic or device options as appropriate.

Causes & classification

• Vascular: atherosclerosis, endothelial dysfunction (common).
• Neurogenic: pelvic surgery, spinal cord injury, neuropathy.
• Endocrine: low testosterone, thyroid disease, hyperprolactinaemia.
• Medication/substance: antihypertensives, antidepressants, antipsychotics, alcohol, tobacco.
• Psychogenic: performance anxiety, depression, relationship problems—often mixed with organic causes.

Clinical assessment

1. Sexual history: onset (sudden vs gradual), situational vs global ED, morning erections, libido, ejaculation and orgasm concerns, partner factors.
2. Medical history: cardiovascular risk factors, diabetes, neurological disease, pelvic surgery, medication review and substance use.
3. Examine: genital exam, secondary sexual characteristics, blood pressure, peripheral pulses and focused neurological exam.
4. Investigations: fasting glucose/HbA1c, lipid profile, total testosterone (morning sample), prolactin as indicated; consider penile Doppler or nocturnal penile tumescence testing in complex cases.

Management — stepwise approach

1. Address reversible/lifestyle factors: smoking cessation, weight reduction, exercise, optimise diabetes and cardiovascular risk, reduce alcohol.
2. Treat underlying medical conditions: adjust causative medications where feasible in consultation with prescribing clinician.
3. First‑line pharmacotherapy: phosphodiesterase‑5 inhibitors (sildenafil, tadalafil, vardenafil) — counsel on contraindications (nitrates) and side effects.
4. When PDE5i ineffective or contraindicated: vacuum erection devices, intraurethral alprostadil, intracavernosal injections (alprostadil, tri‑mix) under supervision.
5. Refractory cases: penile prosthesis surgery (inflatable or malleable) after thorough counselling and trial of less invasive options.
6. Psychosexual interventions: CBT for performance anxiety, couples therapy and sexual therapy enhance outcomes, particularly for psychogenic or mixed ED.

Special considerations

• Cardiac disease: assess cardiovascular risk before sexual activity; follow guidance on sexual activity after cardiac events.
• Diabetes: more likely to have mixed vascular/neurogenic ED—earlier and multimodal interventions often needed.
• Post‑radical prostatectomy: early penile rehabilitation (PDE5i, vacuum device) may improve long‑term outcomes.

Key takeaways

• ED is common and often multifactorial—screen for cardiovascular risk and treat reversible causes.
• PDE5 inhibitors are first‑line pharmacotherapy; device, injection and surgical options exist for refractory cases.
• Integrate psychosexual therapy and partner involvement for best outcomes and refer to specialists when needed.