Erectile Dysfunction

At a glance

What it is: Erectile dysfunction (ED) is the persistent inability to obtain or maintain an erection sufficient for satisfactory sexual activity.^2,11
How common: Approximately 40% of men in their 40s and up to 70% of men in their 70s will have some degree of ED at some stage. Despite this, many men do not seek treatment.^1,5
Why it matters beyond the bedroom: ED is a recognised sentinel marker for cardiovascular disease, diabetes and hormonal disturbance. The first ED consultation is also an opportunity to detect and treat those conditions.^2,12,13
What can be done: A clear treatment ladder from lifestyle change and PDE5 inhibitor tablets, through vacuum erection devices, intracavernosal injections and intraurethral alprostadil, to penile prosthesis implant surgery. The great majority of men can achieve satisfactory erections with one or more of these options.^5,6,9,11,14
Where Urology NSW sits: Dr Raji Kooner offers the full ED treatment pathway, including assessment for an underlying cause, conservative and oral therapy, intracavernosal injection programmes through the practice's pharmacist service, and penile prosthesis implant surgery. Detailed implant information is on the surgical management of ED page.

What is erectile dysfunction?

Erectile dysfunction is the inability to obtain or maintain an erection that is firm enough for satisfactory sexual activity. To meet a clinical definition, the difficulty needs to be persistent (commonly defined as present for at least 3 months) rather than an isolated event.^2,11

ED is a very common condition - approximately 40% of men in their 40s, and up to 70% of men in their 70s, will have some degree of ED at some stage.^1,5 Despite being so common, a substantial proportion of men do not seek help. That is unfortunate, because the modern treatment ladder allows the great majority of men to achieve a satisfactory result with one or more options, and because ED is often a sign of an underlying treatable condition that benefits from being picked up early.

Why ED matters beyond the bedroom (the sentinel-event point)

ED shares its physiology with the wider arterial circulation. The penile arteries are smaller than the coronary arteries, and so changes in the lining of the blood vessels (endothelial dysfunction) often show up first as ED, sometimes years before any cardiovascular symptom.^2,12,13

For this reason, ED should be treated as a sentinel marker for:

Cardiovascular disease and undiagnosed coronary artery disease.^12,13
Type 2 diabetes and impaired glucose tolerance.¹³
High blood pressure and dyslipidaemia.¹²
Low testosterone (hypogonadism) and other hormonal disturbance.^3,11
Obstructive sleep apnoea, depression, and chronic kidney disease.^11,13

Picking these conditions up at the ED consultation, and treating them, is one of the most useful things that can come out of a first visit - independent of what is then done about the erections themselves.

What causes ED?

The mechanism of an erection requires an intact arterial inflow, an intact venous "trapping" mechanism, intact nerve input from the pelvis, and adequate hormonal drive. Difficulty can arise at any of these levels, and most men have more than one contributing factor.^2,11

Vascular. The most common single mechanism in men over 40. Atherosclerosis, hypertension, dyslipidaemia, smoking and diabetes all reduce arterial inflow.^2,12,13
Neurological. Pelvic, prostatic or rectal surgery, spinal cord disease, multiple sclerosis, advanced diabetes, and pelvic radiotherapy.^2,11 ED after radical prostatectomy or radiotherapy is a specific situation discussed in sexual rehabilitation after prostate cancer treatment.
Hormonal. Low testosterone (hypogonadism), high prolactin, untreated thyroid disease, and the late effects of androgen deprivation therapy for prostate cancer.^3,11
Drug-related. Many common medications can contribute, including some antihypertensives (older beta-blockers, thiazide diuretics), some antidepressants (particularly SSRIs), 5-alpha reductase inhibitors (finasteride, dutasteride), opioids, and recreational substances.^2,11 A medication review is part of the ED workup.
Psychological. Stress, performance anxiety, depression, relationship and intimacy issues. A useful clue is preserved early-morning erections and intact erections in different contexts.^4,11
Lifestyle. Smoking, excess alcohol, obesity, physical inactivity, untreated obstructive sleep apnoea, and chronic poor sleep are all modifiable contributors.^11,13

Assessment

The aim of the first consultation is to confirm the diagnosis, identify reversible contributing factors, screen for the cardiovascular and metabolic conditions ED can flag, and agree on a treatment plan. A standard workup includes:^2,3,11

History. The pattern and duration of the difficulty (sudden vs gradual, situational vs constant), early-morning erections, libido, ejaculation, sexual relationship context, full medication and recreational substance review, and prior pelvic surgery or radiotherapy.
Validated questionnaires. The Sexual Health Inventory for Men (SHIM) and the International Index of Erectile Function (IIEF) are standard tools used to grade severity and to track response to treatment over time. Scoring forms are available on this site as PDFs in the resources block below.¹¹
Cardiovascular and general examination. Blood pressure, peripheral pulses, body habitus.
Genitourinary examination. Examination of the penis (Peyronie plaques, phimosis), the testicles, and a digital rectal examination of the prostate where appropriate.
Baseline blood tests. Full blood count, urea, electrolytes, liver function, fasting blood sugar (HbA1c where indicated), fasting lipid profile, thyroid function, and PSA where appropriate for age.³
Hormone panel. Morning testosterone, sex hormone binding globulin (SHBG), prolactin, FSH and LH to confirm whether the hormonal axis is intact.^3,11

A targeted scan (penile Doppler ultrasound) or specialist neurological tests are reserved for selected cases - they are not part of the standard ED workup for most men.¹¹

The treatment ladder

ED treatment is best thought of as a stepwise ladder. Most men start at the top of the ladder; if a step does not give a satisfactory result, the next step is added (or substituted). Lifestyle change underpins the whole ladder and is not a step that gets skipped.^11,13,14

1. Lifestyle, risk factor modification, and psychological factors

Smoking cessation, weight loss, regular aerobic exercise, treatment of high blood pressure / cholesterol / diabetes, reduction of excess alcohol, and treatment of any obstructive sleep apnoea all measurably improve erectile function in men with vascular ED.^11,13 A careful look at current medications can sometimes find a substitutable contributor.

Where psychological factors are clearly contributing - stress, anxiety, relationship issues, depression - a discussion of the partnership and, where appropriate, a referral for counselling or sex therapy is part of the plan. For some men, treating the psychological cause is enough to restore function and the medication is no longer needed.^4,11

2. Oral PDE5 inhibitors

Phosphodiesterase type 5 (PDE5) inhibitors are usually the first medication tried. The four agents available in Australia are sildenafil, tadalafil, vardenafil and avanafil; they work by amplifying the natural nitric oxide signal that opens the penile arteries.^5,6

How to take them. Most are taken on demand, half an hour to an hour before sexual activity, and remain effective for several hours. Sexual stimulation is still required for the medication to work - they do not produce erections in the absence of arousal.^5,6
Daily low-dose option. Tadalafil can also be taken at a low daily dose for men who prefer not to plan around the timing of intercourse, or who also have lower urinary tract symptoms.⁷
Side effects. Most are mild and uncommon: indigestion, nasal stuffiness, facial flushing, occasional headache. Studies have not shown an increase in cardiovascular events with PDE5 inhibitors when used appropriately.⁶
Important warning. PDE5 inhibitors must not be combined with nitrate medications used for angina (glyceryl trinitrate spray, isosorbide mono- or dinitrate) - the combination can cause a dangerous fall in blood pressure. Always tell your doctor and pharmacist about every medication you take.^5,6
If they do not work first time. Many men think they have not responded when in fact the dose, the timing, or the level of sexual stimulation was not optimal. A second consultation to review technique and dose, or to switch to a different PDE5 inhibitor, often resolves this before declaring "PDE5 failure".^1,11

3. Vacuum erection device (penis pump)

A vacuum erection device (VED) is a simple mechanical option with no medications. A clear plastic cylinder is placed over the penis, a vacuum is created (manually or with a small battery pump), blood is drawn into the penis, and a soft constriction band is then slid onto the base of the penis to maintain the erection for intercourse.⁸

Reproducible result every time, no medication interactions, one-off cost.
The trade-off is a slight "hinge" effect at the base, because the device only engages the outer part of the erectile tissue.⁸
The constriction band must be removed within 30 minutes to avoid prolonged compression of the penile tissues.
VEDs are also used as part of penile rehabilitation after radical prostatectomy to maintain blood flow and length of the erectile tissue while the cavernous nerves recover.

4. Intracavernosal injection therapy

A small amount of medication (most commonly alprostadil as Caverject Impulse, or a compounded "triple-mix" of alprostadil, papaverine and phentolamine) is injected with a tiny insulin-style needle into the side of the penis. An effective erection follows in 5 to 10 minutes and lasts approximately 30 to 60 minutes depending on dose.⁹

It feels daunting at first but is very straightforward in practice - similar to the way someone with diabetes self-administers insulin.⁹
The first injection is usually given at the rooms with formal teaching by the practice's men's health pharmacist; subsequent doses are self-administered at home.
Practical detail on the most commonly used product is on the Caverject Impulse information page.
Side effects to know: occasional small areas of penile scarring or fibrosis (reduced by rotating the injection site each time), penile ache, and rarely a prolonged erection (priapism).^9,10
Priapism warning. Any erection lasting longer than approximately 4 hours is a medical emergency. Go to your nearest emergency department immediately, as untreated priapism can permanently damage the erectile tissue.¹⁰
Starting low and titrating up under supervision keeps the priapism risk very low.¹⁰

5. Intraurethral alprostadil

A small alprostadil pellet (MUSE, Medicated Urethral System for Erection) inserted into the urethra is an option for men who cannot tolerate self-injection. The product is not currently subsidised in Australia and may need to be obtained on a special-access basis; suitability and availability are discussed at consultation.¹¹

6. Penile prosthesis (implant)

For men in whom the steps above have been tried and have not given a satisfactory result, a penile prosthesis implant is an excellent option. A three-piece inflatable device (two cylinders inside the penis, a small pump in the scrotum, and a saline reservoir in the abdomen) is implanted through a small skin incision; once healed, the device is invisible to the patient and to a partner, and an erection of any duration can be produced on demand by squeezing the pump.^2,15

Detailed information on the procedure, recovery and outcomes is on the surgical management of erectile dysfunction page; the same page links to the AMS 700 patient brochure used at the practice. In Dr Kooner's view, penile prosthesis surgery remains an underutilised option in Australia in men for whom the earlier steps have not worked.^2,15

Special situations

ED after prostate cancer treatment

Radical prostatectomy, external beam radiotherapy and brachytherapy can all affect erectile function. Recovery depends on baseline function, the extent of nerve sparing achievable for the individual cancer, and the type of treatment delivered. Early penile rehabilitation with PDE5 inhibitors and, where appropriate, a vacuum device or low-dose injections, is started in the first weeks after treatment to maintain the health of the erectile tissue while the nerves recover.^11,16 Detail is on the sexual rehabilitation after prostate cancer treatment page.

ED in men with diabetes

Diabetes contributes to ED via a combination of small-vessel disease, autonomic nerve damage, and the effects of co-existing cardiovascular disease and medications. Tight glycaemic control, blood pressure and lipid management, and a structured assessment for cardiovascular risk are all part of the plan, alongside the same treatment ladder above. The ED and diabetes page covers this in more detail.¹³

Mainly psychological ED

Where the picture suggests a primarily psychogenic cause - sudden onset, situational difficulty, preserved early-morning erections, intact erections with masturbation - a short course of an oral PDE5 inhibitor in combination with counselling or sex therapy often re-establishes confidence and the medication can then be stopped.^4,11

Who is suitable for which option?

There is no single "best" treatment for ED. The right choice depends on the underlying cause, the man's general health and medications, partner factors, and personal preference. A general guide:

Most men start with PDE5 inhibitors (sildenafil, tadalafil, vardenafil or avanafil), provided there is no contraindication (chiefly nitrate medications).^5,6
A vacuum device suits men who prefer to avoid medication, who want a one-off cost, and who are happy with a slightly different feel of erection.⁸
Intracavernosal injections are an excellent option for men who do not respond to oral therapy, who have nerve injury after pelvic surgery, or who want a stronger and more reliable response than tablets can provide.^9,16
A penile prosthesis is the right step when oral, vacuum and injection options have all been tried and have not given a satisfactory result. It is not a last resort; for the right man it is the most reliable long-term solution.^2,15

What to expect at consultation

Initial consultation with history, examination, completion of the SHIM and / or IIEF questionnaires, and request of baseline bloods including the hormone panel.
Review of the results, identification of any reversible contributing factors (medications, lifestyle, untreated cardiovascular or metabolic conditions), and agreement on a starting point on the treatment ladder.
If oral therapy is the starting point, a trial of a PDE5 inhibitor at an appropriate dose, with a follow-up review to confirm response, adjust the dose, or escalate.
If injection therapy is the next step, an in-rooms teaching session with the men's health pharmacist, including the first dose given under supervision and titration to the right dose.
If implant surgery is being considered, a dedicated consultation reviewing the device options, the procedure, risks, recovery and the published outcomes - with full reference to the resources on the surgical management of ED page.

Risks and things to be aware of

Nitrates. PDE5 inhibitors must not be combined with nitrate medications used for angina; the combination can cause a dangerous fall in blood pressure.^5,6
Alpha-blockers. PDE5 inhibitors and alpha-blockers (commonly prescribed for benign prostatic enlargement) can be combined under medical guidance, with attention to dose and timing to avoid postural hypotension.¹¹
Priapism. Any erection lasting longer than approximately 4 hours is a medical emergency. Go to your nearest emergency department.¹⁰
Penile injection scarring. Small areas of fibrosis at injection sites can develop with long-term use; rotating the injection site each time substantially reduces this risk.⁹
Vacuum device band. The constriction band must be removed within 30 minutes to avoid prolonged compression of the penile tissue.
Implant surgery. Carries the usual risks of any operation, plus a small specific risk of device infection and a small late risk of mechanical failure. Detail is on the surgical management of ED page.
"Internet" PDE5 inhibitors. Counterfeit and unregulated products purchased online may contain incorrect doses or contaminants. Use only PBS-registered prescriptions filled by an Australian pharmacy.¹¹
Testosterone therapy. Testosterone replacement is appropriate only when low testosterone has been clearly demonstrated on morning bloods and an underlying treatable cause has been excluded; it is not a treatment for ED in men with normal testosterone levels and carries its own monitoring requirements.^3,11

Frequently asked questions

How common is erectile dysfunction?

Approximately 40% of men in their 40s, and up to 70% of men in their 70s, will have some degree of ED at some stage. It is one of the most common conditions men present to a urologist with, and the great majority can be helped.^1,5

Should ED be a reason to see a GP, even if I am embarrassed?

Yes. Beyond the effect on intimacy, new ED is a recognised early marker for cardiovascular disease, diabetes and hormonal disturbance, all of which benefit from being detected early. The ED consultation is also the opportunity to look for those things.^2,12,13

Can ED come back after it has been treated successfully?

ED is often a chronic condition because the underlying contributors (vascular ageing, diabetes, blood pressure) are themselves chronic. Treatment is usually ongoing, although some men whose ED is mainly psychological can come off medication once confidence is restored.^4,11

Will Medicare or my private fund pay?

Most consultations attract a Medicare rebate. PDE5 inhibitor tablets are PBS-listed for some indications and private-script for others; ask your GP and pharmacist. Implant surgery may attract a private health fund benefit depending on your level of cover and the proposed item numbers - the rooms can provide an estimate of fees and out-of-pocket costs.

Will my partner be able to tell I have an implant?

No - the entire device is internal. Detail is on the surgical management of ED page.

What about testosterone replacement?

Testosterone replacement is appropriate only when low testosterone has been demonstrated on bloods and a treatable cause has been excluded. It is not a treatment for ED in men with normal testosterone levels, and it is not a substitute for the standard ED treatment ladder.^3,11

What about herbal and "natural" ED products?

Most over-the-counter herbal ED products have either no published evidence of effect or, more concerningly, have been found to contain undeclared PDE5 inhibitor in unknown amounts. Use only prescription medications dispensed by an Australian pharmacy.¹¹

Where can I read more?

The short version of this page is a plain-English summary. The surgical management of ED page covers penile prosthesis surgery in detail. The intracavernosal injections hub covers the injection programme. The sexual rehabilitation after prostate cancer treatment page covers ED specifically in the post-prostate-cancer setting.