Red flag symptoms - Erectile dysfunction

Dr Tillmann Jacobi examines the the possible red flag symptoms to consider when a patient presents with erectile dysfunction.

Prostate surgery can cause ED (Photograph: SPL)
Prostate surgery can cause ED (Photograph: SPL)

Erectile dysfunction (ED) is the situation when an erection is either entirely absent or does not last to enable sexual intercourse. It is a common condition with about 50% or more of all men in western societies between 40 and 70 years affected to some degree, and also a propotion of younger patients. The physical and emotional impact varies between individuals depending on their social situation and other factors.

Erectile dysfunction should now be firstly regarded as a symptom for another possible underlying problem rather than an isolated condition in itself. Probably 80% of presentations are caused by organic causes, which may not be immediately obvious.

Possible Causes
  • Atherosclerosis
  • Diabetes
  • Obesity
  • Hypertension
  • Depression
  • Trauma
  • Hypogonadism
  • Drug side-effects
  • Sickle cell disease
  • Prostate cancer


There are many possible reversible or progressive medical reasons for ED. However, the main initial focus of attention should immediately be on cardiovascular and lifestyle risks, such as hypertension, systemic atherosclerotic disease, peripheral vascular disease, hyperlipidaemia, diabetes, obesity, excess alcohol consumption, smoking, recreational drugs, poor diet and riding a bicycle for more than three hours a week.

This has been shown to be an independent risk factor and may improve with reduced biking or a better adjustment and cushioning of the saddle. Establish the timeline of the development of ED (sudden or gradual) and other general symptoms, such as fatigue, weakness, weight changes, urinary or bowel symptoms as well as physical and emotional stresses or disturbances.

A current medication review can be important, because antihypertensive treatments and others may cause or worsen ED. Rarer reasons for ED include neurological causes (for example, epilepsy, multiple sclerosis, Parkinson's disease), urological causes (prostate cancer), hormonal causes (abnormal testosterone and cortisol levels, thyroid problems) and mechanical trauma.

Primary ED (complete absence of any conscious erections, ever) is rare and warrants a direct specialist referral.


Consider a questionnaire such as the International Index for Erectile Function (IIEF). Complete a full cardiovascular risk assessment including blood pressure, pulses, current body mass index, a capillary blood sugar measurement, urine dipstick and a review of any recent blood tests including lipids, cholesterol, liver and renal function, thyroid function and possible PSA and testosterone. Particularly if you suspect a possible structural problem, examine the genitalia for signs of hypogonadism or Peyronie's disease; also look for signs of gynaecomastia and check the prostate gland for abnormalities.

Otherwise, a trial of phosphodiesterase-5 inhibitors in eligible patients without contraindications could reveal if the problem is only temporary and reversible, or if further investigation or a specialist opinion may be required. Since last year generic sildenafil no longer needs to be endorsed with "SLS".

In summary, the onset of ED could be regarded as a "red flag" just by itself and should prompt a careful and systematic review of its possible systemic origin.

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  • Dr Jacobi is a GP in York


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