Erectile Dysfunction

Treatment is usually a PDE5 inhibitor such as sildenafil or tadalafil, taken either as needed or as a low daily dose.

Book if

• You have difficulty achieving or maintaining an erection
• It has changed recently, which makes finding the cause more urgent
• Treatment you have tried has not worked, or has worn off

Do not take a PDE5 inhibitor if

You take nitrates — GTN spray, isosorbide — or nicorandil. The combination can cause a catastrophic drop in blood pressure. This is not a caution, it is an absolute contraindication.

Why buying online without assessment is a bad idea

Beyond the nitrate interaction, it means the cardiovascular warning goes unheard. Men who treat ED without investigating it lose the early notice that something else needs attention.

1. Why, before what

Erectile dysfunction is frequently the first sign of cardiovascular disease, appearing years before anything else. It also links to diabetes, high blood pressure, low testosterone, medication side effects and psychological factors.

Treating the symptom without asking why is the part that questionnaire-and-pills services skip, and it is the part that matters most.

2. Medication review

Nitrates are an absolute contraindication. Some blood pressure and antidepressant medicines contribute to the problem in the first place.

3. Treatment

Usually a PDE5 inhibitor, either as needed or as a low daily dose. Which suits you depends on frequency and preference.

4. Review

Including whether a different dose or preparation would work better.

The first review is about dose and technique

The commonest reason a PDE5 inhibitor "does not work" is that it was not given a fair trial, and that is fixable rather than a reason to give up.

• Try each dose four to eight times before concluding it has failed. A single disappointing occasion tells you very little
• It does not cause an erection on its own — arousal is still required. A great many men take a tablet, wait, and conclude it did nothing
• Sildenafil needs 30–60 minutes and is significantly slowed by a heavy or fatty meal. Tadalafil is far less affected and lasts up to 36 hours
• Alcohol reduces the effect, and more than a couple of drinks works against you

Review at four to six weeks

• Whether it worked, and what actually happened when it did not
• Whether the dose needs increasing, which is very often the answer
• Whether a different preparation suits you better — as-needed versus a low daily dose, which suits men in regular relationships and removes the planning
• Side effects, and whether they are settling
• The results of any bloods, and what they mean for the underlying picture

The part that matters more than the tablet

Erectile dysfunction is frequently the first sign of cardiovascular disease, appearing years before anything else. The follow-up is therefore about your arteries as much as your erections:

• Blood pressure and cholesterol
• HbA1c — ED is a recognised early presentation of type 2 diabetes
• Smoking, alcohol, weight and activity, all of which affect erections directly and quickly

A man treated with tablets alone and never assessed has been sold a symptom fix and denied a warning.

Seek urgent help for

• An erection lasting more than four hours — priapism. A&E, not the morning. It causes permanent damage if untreated
• Sudden loss of vision or hearing — stop and seek urgent assessment
• Chest pain during sex — 999, and do not take nitrates if you have taken a PDE5 inhibitor. Tell the paramedics you have

If it still does not work

Roughly a third of men do not respond adequately to tablets, and there are further options — vacuum devices, injectable or urethral alprostadil, and urology referral. Come back rather than concluding nothing can be done.

Treating the cause rather than the symptom

This is where the real gains usually are, and it is what a questionnaire-and-pills service skips.

• Cardiovascular risk. ED often precedes heart disease by years. Blood pressure, cholesterol, blood sugar and smoking all matter more than the tablet
• Diabetes, of which ED is a recognised early presentation
• Medication. Several are common culprits — beta blockers, thiazide diuretics, SSRIs and finasteride. Sometimes an alternative exists, and that conversation is free
• Low testosterone, worth checking where libido has also fallen — see TRT. Note that PDE5 inhibitors often work regardless
• Sleep apnoea, which is strongly associated and badly under-diagnosed
• Alcohol, smoking, weight and inactivity — all reversible, and all with a measurable effect

Psychological causes are real causes

Sudden onset, normal morning erections, or difficulty with a partner but not alone points towards a psychological rather than vascular cause — and that is not a lesser diagnosis.

Anxiety, depression, relationship difficulty and performance anxiety all respond to treatment, and psychosexual therapy has good evidence. Relate and the College of Sexual and Relationship Therapists both list qualified therapists. Tablets can help break the cycle while that is addressed.

Other medical options

• The four PDE5 inhibitors differ. Sildenafil is cheapest and shortest-acting; tadalafil lasts up to 36 hours and is less affected by food, which many men prefer; avanafil acts fastest. If one has not worked, another may
• Vacuum erection devices — no drugs, no interactions, and effective. Under-used, largely because nobody mentions them
• Alprostadil, as an injection or urethral pellet, for men who do not respond to tablets
• Urology referral for implants or vascular assessment where nothing else works

What to avoid

Herbal "natural" ED products are a genuine safety problem — they frequently contain undeclared sildenafil, which is exactly the interaction risk you were trying to avoid by not seeing a doctor.

Shockwave therapy is marketed heavily and privately; the evidence remains limited and it is not NICE-recommended. Be sceptical of anywhere selling expensive courses of it.

What you pay us

• £40 for the consultation, including the medication review and a blood pressure discussion
• Blood tests where indicated — HbA1c, cholesterol, testosterone — quoted before they are arranged
• £40 for review

What you pay the pharmacy

Sildenafil is very cheap. The patent expired years ago, generic sildenafil is one of the least expensive prescriptions in general practice, and you should not be paying a great deal for it. Tadalafil is also generic and inexpensive.

We earn nothing from what is prescribed. Ring a couple of pharmacies — the price differences on these are substantial in percentage terms.

The cheaper route we would rather you knew

Sildenafil 50mg is available from pharmacies without a prescription, after a consultation with the pharmacist. If that is all you need, it is faster and cheaper than seeing us.

The reason to see a doctor instead is the assessment, not the tablet — the cardiovascular picture, the diabetes check, the medication review, and the question of why this is happening now. That is what the £40 buys.

NHS availability

Sildenafil is available on the NHS, and free of charge for men with diabetes, treated prostate cancer, and certain other conditions. Worth asking your own GP, and we will say so if you are likely to qualify.

Where not to spend money

• "Natural" or herbal ED products — no evidence, and frequently found to contain undeclared sildenafil
• Unbranded websites selling without any consultation — counterfeit rates are high, and the nitrate interaction can kill
• Expensive courses of shockwave therapy, where the evidence remains limited
• Subscription "men's health" packages, which create a financial interest in your continued prescription

Why do I need an appointment when I can buy it online?

Two reasons, and the first can kill you.

Nitrates — GTN spray, isosorbide — and nicorandil are an absolute contraindication. Combined with a PDE5 inhibitor they can cause a catastrophic drop in blood pressure. A website does not check this properly.

The second is that ED is frequently the first sign of cardiovascular disease, often years ahead of anything else. Treating the symptom without asking why means losing that warning — which is the single most valuable thing about this appointment.

Is erectile dysfunction really a heart warning?

Yes, and it is worth taking seriously rather than being alarmed by. The arteries supplying the penis are smaller than the coronary arteries, so they narrow detectably earlier.

ED can precede a cardiac event by three to five years — which makes it an opportunity rather than only a problem. It is also a recognised early presentation of type 2 diabetes.

It did not work. Is that it?

Almost certainly not. Most "failures" are one of these:

• Not enough attempts. Try each dose four to eight times before judging it
• Expecting it to work alone. It does not cause an erection — arousal is still needed
• Timing and food. Sildenafil needs 30–60 minutes and a fatty meal delays it considerably
• The dose was too low, which is very common
• Alcohol

Come back before concluding nothing works. A different dose or a different drug succeeds for a great many men.

Sildenafil or tadalafil?

Sildenafil — cheapest, works in 30–60 minutes, lasts around 4–5 hours, affected by food.

Tadalafil — lasts up to 36 hours, much less affected by food, and available as a low daily dose that removes planning altogether. Many men in regular relationships strongly prefer it.

If one has not worked, the other may.

Can I take it with my blood pressure tablets?

Usually yes, with two exceptions that matter. Nitrates and nicorandil are absolute contraindications. Alpha blockers such as tamsulosin need care and timing.

Bring every medicine to the appointment, including anything bought over the counter or online.

Could my other medication be causing it?

Quite possibly, and it is one of the first things we look at. Beta blockers, thiazide diuretics, SSRIs and finasteride are the usual culprits.

Do not stop anything yourself — but an alternative can often be found, and that costs nothing.

Is it psychological?

Often partly, and that is a real cause rather than a dismissal.

Sudden onset, intact morning erections, or difficulty with a partner but not alone all point that way. Anxiety, depression, relationship strain and performance anxiety all respond to treatment, and psychosexual therapy has good evidence.

Tablets can help break the cycle while that is worked on.

Do I need my testosterone checked?

Worth checking if libido has fallen too, or with fatigue and loss of muscle. But most ED is not caused by low testosterone, and PDE5 inhibitors usually work regardless of the level.

See TRT — and be cautious of any service that reaches for testosterone first.

What about "natural" alternatives?

Avoid them. Herbal ED products regularly turn out to contain undeclared sildenafil — so you get the drug and the interaction risk, with none of the safety checks.

What is the emergency I should know about?

An erection lasting more than four hours. Go to A&E — it causes permanent damage if untreated, and waiting until morning is too late.

Also sudden loss of vision or hearing, and chest pain during sex, which is 999. Tell the paramedics you have taken a PDE5 inhibitor, because it changes what they can give you.

Can I get it on the NHS?

Yes, and free of charge for men with diabetes, treated prostate cancer and certain other conditions. Sildenafil 50mg is also available from pharmacies without any prescription, after a pharmacist consultation.

We would rather tell you that than sell you an appointment for a tablet you could get today.