01Principles and purposeThe professional or clinical skill and the decisions it supports.
Sexual dysfunction is an umbrella description rather than one diagnosis. Difficulties may affect interest, arousal, erection, lubrication, orgasm, ejaculation, pain, penetration or satisfaction. Establish the person’s concern, duration and distress before applying a label. Variation in desire or frequency is not itself disease, and a partner’s expectation must not replace the patient’s own goals.
A biopsychosocial history is the core assessment. Ask about onset and precipitating events, function in different contexts, morning or spontaneous erections where relevant, pain and genitourinary symptoms, fertility or pregnancy concerns, chronic disease, pelvic surgery, menopause, disability and fatigue. Review antidepressants, antipsychotics, antihypertensives, opioids, hormones and recreational substances without stopping essential treatment abruptly.
Psychological and relational contributors include performance anxiety, depression, trauma, body-image distress, conflict, grief and cultural or religious pressure. Speak to the patient alone for at least part of the consultation when coercion is possible. Couple work can help only when each person freely consents and the relationship is safe; it is unsuitable as a substitute for domestic-abuse intervention.
Examination and tests follow the clinical question. Blood pressure, body habitus and cardiovascular risk matter in persistent erectile dysfunction. Genital, pelvic, neurological or endocrine examination may be offered with explicit consent and a chaperone. Glucose or HbA1c, lipids, morning testosterone and other endocrine tests are selective rather than a universal panel.
Management combines explanation, treatment of disease, medicine review, smoking and alcohol support, psychological therapy and problem-specific options. Erectile dysfunction may respond to a properly counselled PDE5 inhibitor, vacuum device or specialist therapy. Ejaculatory, desire and orgasm difficulties need diagnosis-specific care; unlicensed drug use should be identified clearly. Agree a measurable outcome meaningful to the patient rather than promising normal performance.
Follow-up checks whether the formulation remains accurate. Ask about benefit, adherence, adverse effects, cardiovascular symptoms, relationship safety and mood. Failure of one intervention is a reason to revisit diagnosis, technique and expectations, not to escalate blindly. Refer to urology, gynaecology, endocrinology, cardiology, pelvic health or a qualified psychosexual service according to the unresolved component.
Key points
- Ask what has changed in desire, arousal, erection, lubrication, orgasm, ejaculation, pain and satisfaction; the patient defines whether the change is distressing.
- Clarify onset, context, solitary versus partnered function, relationship safety, pregnancy intentions, substances, illness and every prescribed or non-prescribed medicine.
- Persistent erectile difficulty merits blood pressure, cardiovascular and diabetes risk assessment as well as a focused genital, neurological and endocrine review.
- Avoid assuming gender, anatomy, partner configuration, sexual practice or the importance of penetration; use the patient’s own terms and goals.
- Treat reversible disease and medicine effects, support communication and behavioural change, and refer for psychosexual therapy when distress persists.
- PDE5 inhibitors help erectile response only with sexual stimulation and are unsafe with nitrates; prescribing needs cardiovascular and interaction assessment.
- Record consent, agreed outcomes and who will review investigations, treatment benefit, adverse effects and any emerging safety concern.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Function that differs by partner, setting or masturbation may point towards context and anxiety, while still allowing physical contributors.
Difficulty across situations, absent spontaneous response or progressive onset increases concern for medicine, vascular, neurological or endocrine causes.
An erection that is painful and persists for about four hours requires emergency urological assessment rather than reassurance.
Fear, inability to refuse sex, contraception sabotage or injury changes the priority to immediate safety and confidential safeguarding.
Persistent erectile dysfunction may precede overt cardiovascular disease and should trigger risk-factor assessment rather than isolated symptom prescribing.
A close temporal relation to antidepressants, antipsychotics, opioids, antihypertensives or hormonal treatment supports a supervised medication review.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Structured sexual and safety history - Why
- Define the affected phase, context, distress, consent and likely biological or psychosocial contributors.
- Interpretation and limitations
- Patterns guide focused testing; a normal response in one context does not make the person’s distress unreal or exclude mixed causation.
- 02
Blood pressure and cardiovascular risk assessment - Why
- Identify vascular disease and judge whether sexual activity or erectile medication requires further review.
- Interpretation and limitations
- Abnormal findings need primary-care or cardiovascular management; absence of symptoms alone does not establish low vascular risk.
- 03
Focused examination with consent - Why
- Look for genital, pelvic, neurological, vascular or endocrine signs relevant to the stated problem.
- Interpretation and limitations
- Offer only indicated components, explain each step and stop on request; normal examination does not exclude psychological or functional difficulty.
- 04
Glucose or HbA1c and lipid profile - Why
- Detect diabetes and modifiable vascular risk in persistent erectile or arousal difficulty.
- Interpretation and limitations
- Results contribute to overall risk and disease care; they do not by themselves prove the cause of dysfunction.
- 05
Morning testosterone with directed endocrine tests - Why
- Investigate compatible reduced desire, erectile difficulty or hypogonadal features.
- Interpretation and limitations
- Confirm a low result under the appropriate endocrine pathway and interpret it with symptoms, timing and binding-protein context.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked caseFormulate persistent erectile difficultyAn adult reports six months of erectile difficulty in every setting and wants treatment.+
- 1Ask about onset, spontaneous erections, libido, pain, medicines, alcohol and drugs, cardiovascular symptoms, mood, relationship safety and treatment goals.
- 2Measure blood pressure and cardiovascular risk, examine only with consent, and request diabetes, lipid and hormonal tests when the history supports them.
- 3Explain mixed causation and address smoking, alcohol, disease and medicine contributors before agreeing a safe problem-specific treatment.
- 4Review response, technique, adverse effects and investigation results; escalate cardiovascular or specialist assessment when risk or failure remains.
02Psychosexual routeAddress a distressing situational problemFunction is preserved alone but anxiety and avoidance occur with a consenting partner.+
- 1Validate the difficulty and check privately that sex and relationship participation are voluntary and safe.
- 2Offer education, anxiety-focused or psychosexual therapy and communication work matched to the person’s goals.
- 3Reassess for physical disease, pain or medicine effects if symptoms change or therapy does not help.
03Urgent branchTreat prolonged painful erectionA painful rigid erection continues for approximately four hours after medicine or substance use.+
- 1Stop sexual medicines or substances and arrange immediate emergency urological assessment.
- 2Document onset, pain, rigidity, medicines, haematological disease and recreational drug exposure without delaying transfer.
- 3Do not advise waiting at home or repeatedly exercising because time to detumescence affects tissue outcome.
05Relevant medicines and safetySpecific regimens and precautions when the skill involves prescribing.
Sildenafil for erectile dysfunction
Use the current licensed product dose before anticipated sexual activity, with individual adjustment by the prescriber.Contraindicated with nitrates; assess cardiovascular fitness, hypotension, alpha-blockers, interacting medicines, visual symptoms and priapism risk before prescribing.
06Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Review the patient-defined goal, distress and effect on consensual sexual activity rather than frequency alone.
- Check blood pressure, vascular-risk actions and completion of diabetes, lipid or endocrine follow-up.
- Ask about adverse effects, dose timing, stimulation and adherence before declaring a medicine ineffective.
- Revisit mood, substance use, trauma and relationship safety because these may emerge after trust develops.
- Refer when pain, deformity, neurological signs, hormonal abnormality or treatment-resistant dysfunction remains unexplained.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Distress defines the clinical problem
Low frequency or desire is not automatically dysfunction when the person is comfortable and no coercion is present.
Mixed causes are common
Vascular disease can coexist with performance anxiety, so one clue should not close the formulation.
Technique changes apparent failure
PDE5 medicines require correct timing, sexual stimulation and repeated supported attempts before response is judged.
Safety precedes couple work
Joint therapy can increase danger when coercive control or violence is present, so assess the patient privately first.
08Common pitfallsFrequent interpretation and management errors.
- 01
Treating a partner’s preferred frequency as the patient’s diagnosis.
- 02
Prescribing erectile medication without nitrate, cardiovascular and interaction checks.
- 03
Ordering a broad hormone panel without symptoms or a plan for interpretation.
- 04
Calling a normal examination proof that the difficulty is purely psychological.
- 05
Stopping an effective psychiatric medicine suddenly rather than arranging a supervised review.