Synopsis
Assess sexual difficulties without assumption, identify physical, psychological, relational and medicine-related contributors, recognise urgent or safeguarding concerns, and agree a person-centred treatment or referral plan.
- 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.
Key red flags
A painful erection approaching or exceeding four hours is a urological emergency because delay risks permanent erectile damage.
Sudden severe pelvic or testicular pain, bleeding, fever or genital trauma needs acute assessment before dysfunction is attributed to anxiety.
Unexplained erectile difficulty can be a marker of vascular disease, diabetes, endocrine disease, neurological illness or medicine toxicity.
Fear, unwanted sexual activity, reproductive control or inability to negotiate consent should prompt a private safety and safeguarding assessment.
New dysfunction with severe depression, mania, psychosis, intoxication or suicidal thinking requires same-day mental-health risk management.
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.
Reasoning priorities
Define the affected phase, context, distress, consent and likely biological or psychosocial contributors.
Patterns guide focused testing; a normal response in one context does not make the person’s distress unreal or exclude mixed causation.
Worked reasoning
An adult reports six months of erectile difficulty in every setting and wants treatment.
- Ask about onset, spontaneous erections, libido, pain, medicines, alcohol and drugs, cardiovascular symptoms, mood, relationship safety and treatment goals.
- Measure blood pressure and cardiovascular risk, examine only with consent, and request diabetes, lipid and hormonal tests when the history supports them.
- Explain mixed causation and address smoking, alcohol, disease and medicine contributors before agreeing a safe problem-specific treatment.
- Review response, technique, adverse effects and investigation results; escalate cardiovascular or specialist assessment when risk or failure remains.