Sexual Medicine
Erectile Dysfunction Assessment & Treatment
Treatment is selected according to the underlying cause, medical history and individual priorities — not a single default prescription.
Assessment first
A Diagnosis Before a Prescription
Erectile dysfunction can have vascular, hormonal, metabolic, neurological, medication-related and psychosexual contributors. A consultation and appropriate assessment come before any treatment is recommended.
Assessment vs. treatment
Assessment means understanding the cause: history, relevant examination, and hormonal or vascular investigations where indicated. Treatment is only selected once that picture is clear — not the other way around.
Understanding the mechanism
How an Erection Is Maintained
Four stages, not one mechanism — which is why erectile dysfunction is rarely explained fully by a single phrase like 'not enough blood' or 'the veins leak'.
Arterial inflow
Adequate blood must flow into the penis through the arteries supplying it — the first requirement, and the one most people already associate with erections.
Cavernosal smooth-muscle relaxation
The smooth muscle within the erectile tissue (the corpora cavernosa) must relax, allowing that tissue to expand and fill with blood.
Veno-occlusion
As the corpora cavernosa expand against their surrounding sheath, the veins that normally drain blood out of the penis are compressed against it, reducing outflow — a mechanical consequence of full expansion, not a separate valve switching shut.
Rigidity
Adequate inflow, full expansion and reduced outflow together maintain rigidity. If any one stage is incomplete, the erection can be reduced or difficult to sustain.
Distinguishing the mechanisms
The Vascular Side of Erectile Dysfunction
Reduced arterial inflow, impaired veno-occlusion (often called a 'venous leak'), and non-structural functional patterns are three genuinely different vascular-related mechanisms — Penile Doppler assessment is how they're told apart.
Arterial Insufficiency
Reduced blood flow reaching the penis through the arteries that supply it — the 'inflow' side of the physiology. Often related to cardiovascular risk factors such as high blood pressure, cholesterol or smoking.
Veno-Occlusive Dysfunction
Sometimes called a 'venous leak' — outflow isn't reduced enough once an erection is established, even when inflow is adequate. A mechanical consequence of incomplete cavernosal expansion, not a separate faulty valve.
Functional, Non-Structural Patterns
Not every vascular-looking pattern is structural. Insufficient stimulation, anxiety, heightened sympathetic tone or metabolic factors can produce a similar picture without a fixed anatomical cause.
Penile Doppler assessment is how these mechanisms are distinguished in practice. For a deeper look at one of them specifically, see Venous Leak and Erectile Dysfunction: What Penile Doppler Really Shows.
Understanding the cause
Possible Contributors
Vascular
Reduced blood flow to the penis, often related to cardiovascular risk factors such as high blood pressure, cholesterol or smoking.
Hormonal
Low testosterone or other hormonal imbalances can contribute to reduced erectile function and libido.
Metabolic
Diabetes and metabolic syndrome are common contributors, affecting blood vessels and nerve function over time.
Neurological
Conditions affecting the nerves — including diabetes, spinal injury or pelvic surgery — can disrupt the signals involved in an erection.
Medication-related
Certain medications, including some antidepressants and blood pressure treatments, can affect erectile function as a side effect.
Psychosexual
Stress, anxiety, relationship factors and mood can play a role, independently or alongside physical causes.
Pelvic / structural
Previous pelvic surgery, radiotherapy, or structural conditions such as Peyronie's disease can affect erectile function directly.
Treatment ladder
Matched to the Cause, Step by Step
Not every patient starts at step one, and not every patient needs every step — the ladder reflects the range of options considered, not a fixed sequence every man follows.
Lifestyle / risk-factor management
Addressing cardiovascular risk factors, weight, activity levels, alcohol and smoking where relevant to the underlying cause.
PDE5 inhibitors
Oral medication that can support erectile function in appropriately selected patients, prescribed after assessment.
Hormonal treatment when indicated
Considered only when a hormonal cause, such as testosterone deficiency, has been identified on assessment.
Vacuum / device options
Non-invasive mechanical devices that can support erectile function for selected patients.
Selected shockwave treatment
Low-intensity shockwave therapy may be considered for selected patients where clinically appropriate.
Intracavernosal therapy
Injectable therapy administered directly into the penis, used when oral treatments are not suitable or effective.
Penile implant surgery
A surgical option considered for severe or refractory erectile dysfunction, once other treatments no longer provide reliable results.
Realistic expectations
Risks and Limitations
Every option on the treatment ladder carries its own considerations — from medication interactions and contraindications with PDE5 inhibitors, to the surgical risks associated with penile implant surgery. Response to any treatment, including shockwave therapy, varies between individuals and is not guaranteed. These are discussed in detail at consultation, alongside your medical history, so that any plan reflects your individual circumstances rather than a general assumption.
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