This site is intended for health professionals only

At the heart of general practice since 1960

Erectile dysfunction

GP Dr Geoff Hackett on firm erections, the risk of patient complaints and the link with cardiovascular disease

GP Dr Geoff Hackett on firm erections, the risk of patient complaints and the link with cardiovascular disease


Always do the tests – even if the cause seems obvious. Erectile dysfunction is closely associated with cardiovascular disease and all patients should have a fasting blood glucose, lipids and morning testosterone checked, and re-measured at follow-up visits – particularly if the patient does not respond to therapy. Over 40% of diabetic patients will suffer from hypogonadism.


Check and re-check for diabetes. Erectile dysfunction is the presenting symptom of diabetes in 20% of cases. Diabetics qualify for free NHS treatment for erectile dysfunction and a GP faces the risk of a complaint if he inflicts private costs of over £300 per year by failing to do the tests that are clearly recommended in all of the published guidelines.


Treat raised cholesterol. Raised cholesterol, especially LDL, is a significant risk factor for erectile dysfunction even if a Framingham risk score does not reach significance in terms of CHD. Treatment with a statin in the early stages is extremely cost-effective and can reverse erectile dysfunction as early as six months.


Seek information on erectile dysfunction in all cases of hypertension. Erectile dysfunction is present in 65% of newly diagnosed hypertensive patients and angiotensin receptor blockers have been shown to improve erectile dysfunction, potentially avoiding much more expensive therapy. ACE inhibitors are probably neutral but ß-blockers and thiazides should be avoided.


Avoid over-diagnosing psychogenic causes. Men with persistent erectile dysfunction (as opposed to situational) should be considered to have an organic cause until otherwise is proved. Over 80% of men with erectile dysfunction have a significant vascular component and should be fully assessed for CV risk factors.


Involve the partner at an early stage. Ask the patient ‘what does your wife feel about the situation'? A reluctant partner will usually defeat all the best efforts of doctor and patient. Recognising this at an early stage will save a lot of time and money.


Give adequate supplies of medication and repeat prescriptions. Men find it very difficult to discuss sex with doctors and many doctors feel equally uncomfortable. Restricting quantities is associated with high failure rates. Once per week is guidance and not a rule.

The schedule 2 guidelines are not evidence based. Severe distress is the norm for men with erectile dysfunction. Patients should be told to take at least eight tablets of the highest dose. Twice weekly tadalafil at 20mg on Friday and Tuesday is most likely to relieve the pressure of pre-planned sex.


Start all but mild cases on the higher dose. PDE5 inhibitors are safe and well tolerated. Early success is vital and doses can easily be reduced once the patient has seen that they work. I have never seen a patient complain that their erections were too firm.


Arrange a definite follow-up. Always fix a formal follow-up within six weeks of the initial conversation and explain to the patient the important links with other diseases as this motivates them to continue. Arrange for the patient to get repeats before seeing you again rather than having to face a grilling from the receptionist.


Treat testosterone deficiency before starting PDE5 inhibitors. Low testosterone is the commonest reason for failure of PDE5 inhibitors and around 30% of men with erectile dysfunction and low testosterone (below 12nmol/l) will respond to testosterone alone (transdermal or as three-monthly depot Nebido). Introducing the PDE5 inhibitor after the correction of a low testosterone level is associated with a far greater chance of success. This is particularly important for patients with type 2 diabetes.

Dr Geoff Hackett is a GP in the West Midlands and consultant in sexual dysfunction at the Good Hope Hospital, Sutton Coldfield

Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say