What is erectile dysfunction? It means you keep having trouble getting or keeping an erection firm enough for sex. It affects more than 1 in 10 males and can have physical causes, psychological ones or both. A GP looks for the cause and treats that first, because erectile dysfunction is often the first sign of heart disease or another condition that needs treatment.

What counts as erectile dysfunction?

A persistent problem, not a single bad night. Healthy Male defines it as "a persistent difficulty getting or keeping an erection firm enough for satisfactory sexual activity" (Healthy Male), and healthdirect says it "is also known as ED or impotence", that it "can come and go", and that occasional problems may not need medical help (healthdirect). Problems with ejaculation, fertility or sex drive are not erectile dysfunction (healthdirect), though premature ejaculation is often confused with it and the two can occur together (Australian Prescriber).

What are the symptoms, and what should you ask yourself?

Difficulty getting an erection, difficulty keeping one, sex that fails because the penis is not hard enough, or erections that are not as hard as they used to be (healthdirect; Healthy Male). Before you see a GP, think through the questions Australian Prescriber lists:

  • Does it happen every time, now and then, or only in some situations?
  • Did it start recently, or has it been there a long time?
  • Are morning erections, and erections when you masturbate, still normal? These are "critical" to finding the cause.
  • Did it begin after you started a new medicine?
  • Is there an unusual curve, or was the erect penis ever injured?
  • Have you had mental health problems?

A short questionnaire such as the IIEF-5 can help, but "should not be used alone for diagnosing erectile dysfunction" (Australian Prescriber). More in what does morning wood say about ED? and can you test for erectile dysfunction at home?

What causes it?

Something physical, something psychological, or both. healthdirect's physical causes include reduced blood flow from clogged arteries, nerve and hormone problems, alcohol, smoking and some medicines. Diabetes, high blood pressure, high cholesterol, cardiovascular disease, obesity and sleep disorders contribute. The psychological causes of ED it lists are relationship problems, performance anxiety, stress, depression and anxiety (healthdirect). Each cause in depth: our guide to erectile dysfunction and causes, symptoms and treatment of ED.

How does a GP assess erectile dysfunction?

With questions, an examination and, where needed, blood tests. Your GP asks about your sexual history, general health, relationships and how you feel about sex, examines you, and may order blood tests or a scan such as an ultrasound, or refer you to a urologist (healthdirect). The relationship is part of the history, so open communication with a partner helps: the doctor may offer to talk to your partner to consider other causes (healthdirect). Australian Prescriber adds sleep, snoring, weight, exercise, alcohol, smoking and every medicine you take. Its minimum examination is weight, waist, body mass index, blood pressure and the genitals; its minimum blood tests are blood fats and blood sugar (fasting glucose or, ideally, HbA1c), with testosterone on a sample taken before 11 am if a hormone problem is suspected. Each test explained: tests for erectile dysfunction.

When is erectile dysfunction a warning sign of heart disease?

Often, and years ahead. healthdirect says erectile dysfunction is often the first sign of:

  • Cardiovascular disease
  • Diabetes
  • High blood pressure
  • High cholesterol

The Heart Foundation calls it the "canary in the coal mine": the arteries of the penis are much smaller than the heart's, so damage can show there first (Heart Foundation). Healthy Male says it usually occurs three to five years before coronary heart disease (Healthy Male — cardiovascular disease). In 300 men with chest pain and coronary artery disease, 49% had ED; two-thirds of them said it had started first, and the average gap between the two was 38.8 months (Montorsi et al., 2003). Across 14 studies of 92,757 men, ED meant a 44% higher risk of cardiovascular events and 62% higher risk of heart attack, and the extra risk was greater in younger men (Vlachopoulos et al., 2013). Ask your GP about a Heart Health Check: a Medicare-covered check of your heart attack and stroke risk, for adults without heart disease from 45, or younger in some groups (Heart Foundation — Heart Health Checks). See also can heart problems cause erectile dysfunction?

How is erectile dysfunction treated?

Cause first: your doctor treats any underlying condition, and may suggest diet and exercise, or sex therapy or cognitive behavioural therapy for a psychological cause (healthdirect). The tablets are sildenafil (for example Viagra), tadalafil (for example Cialis), vardenafil and avanafil; they need a prescription in Australia, and must not be taken with nitrates for chest pain (healthdirect — ED medicines). Injections, vacuum devices and a penile implant come next; PRP injections and shockwave therapy are unproven (Healthy Male). More in how erectile dysfunction is treated and lifestyle and erectile dysfunction.

The short answer

Erectile dysfunction is repeated trouble getting or keeping an erection firm enough for sex. Note the pattern, your morning erections and any new medicine, then see your GP, who checks your heart risk as well as the erection. The other questions before a diagnosis: what erectile dysfunction is.