Erectile dysfunction: what it means and how it's treated in Australia

What erectile dysfunction is

Erectile dysfunction (ED) is the persistent inability to achieve or maintain an erection firm enough for satisfactory sexual activity, lasting six months or more. It affects roughly half of men aged 40-70 in Australia, with about a quarter describing it as bothersome. Despite how common it is, ED remains under-discussed and under-treated - many men wait years before raising it with a GP.

One of the most important things to understand about ED is that it is rarely just a sexual problem. In most cases, particularly in men over 40, ED is an early warning sign of cardiovascular disease. The arteries supplying the penis are smaller than those supplying the heart, so problems with blood vessel function (endothelial dysfunction) show up in the penis first. Studies tracked by the Heart Foundation consistently show ED can precede a heart attack or stroke by three to five years. This is why Australian guidelines, including the Urological Society of Australia and New Zealand (USANZ) and eTG Genitourinary, treat ED as a prompt for a full cardiovascular workup, not just a script for tablets.

This article explains how ED is assessed and treated in Australian general practice, drawing on USANZ guidance, Therapeutic Guidelines, the Australian Medicines Handbook, Healthy Male (Andrology Australia), and the 2023 Heart Foundation CVD risk guideline.

What causes erectile dysfunction

ED has several distinct causes, and most men with ED have more than one contributing factor.

Vasculogenic (blood-vessel related). The most common cause in men over 40. The same risk factors that cause coronary artery disease and stroke - type 2 diabetes, high blood pressure, raised cholesterol, smoking, obesity, and physical inactivity - also damage the small blood vessels of the penis. Atherosclerosis reduces blood flow during arousal, making it harder to achieve or maintain an erection.

Neurogenic (nerve-related). Conditions that damage the nerves controlling erection produce ED. Common Australian examples include long-standing diabetes (autonomic neuropathy), nerve injury following prostate surgery for cancer or BPH, multiple sclerosis, Parkinson’s disease, and spinal cord injury.

Hormonal. Low testosterone (hypogonadism) reduces libido and contributes to ED. It typically presents alongside low energy, low mood, loss of muscle mass, and reduced morning erections. Less common hormonal causes include raised prolactin (sometimes from a pituitary tumour) and untreated hypothyroidism. Hormonal ED is uncommon as a sole cause but worth screening for.

Drug-induced. Many widely prescribed medications can cause or worsen ED. The most common culprits are beta-blockers (atenolol, metoprolol, propranolol), thiazide diuretics, spironolactone, SSRIs and other antidepressants, antipsychotics, and opioids. Heavy alcohol use, cannabis, and methamphetamine also contribute. Reviewing and where possible switching offending medications is an important first step before reaching for ED-specific treatments.

Psychogenic. Performance anxiety, depression, relationship stress, or past trauma can cause ED. Classic clues are sudden onset, situational triggers (works fine alone, fails with a partner), and preserved nocturnal or early morning erections - which indicate the plumbing is still functional. Younger men with ED are more likely to have a significant psychological component.

Mixed. Most older men have overlapping vascular, hormonal, psychological, and medication-related contributors.

How a GP assesses erectile dysfunction

A standard Australian assessment in general practice covers history, examination, and blood tests, with cardiovascular risk evaluation built in.

History focuses on:

• Onset (sudden versus gradual), duration, and severity
• Erection quality during morning or nocturnal episodes (preserved erections at these times suggest psychogenic cause)
• Libido and energy levels (low across the board points toward hormonal causes)
• Current medications - particularly blood pressure tablets, antidepressants, opioids
• Comorbid conditions - diabetes, hypertension, sleep apnoea, prostate problems
• Smoking, alcohol, and substance use
• Mental health screen - depression, anxiety, suicidality
• Relationship context and partner factors

Examination:

• Blood pressure, weight, waist circumference, BMI
• Cardiovascular examination - peripheral pulses
• Genital examination - testicular size and consistency, penile examination for curvature or plaque (Peyronie’s disease), digital rectal examination of the prostate where indicated
• Check for gynaecomastia or other features of hormonal change

Investigations typically include:

• Fasting glucose or HbA1c
• Fasting lipid profile
• Liver and kidney function tests
• Morning (8-10 am) total testosterone with SHBG - if low, repeat with LH, FSH, and prolactin to distinguish primary from secondary hypogonadism
• Thyroid function (TSH)
• Cardiovascular risk calculation via the Australian CVD Check tool
• PSA may be discussed as part of prostate-cancer screening shared decision-making
• Urinalysis if urinary symptoms

Specialist tests like penile Doppler ultrasound or nocturnal penile tumescence monitoring are reserved for refractory cases or where there’s diagnostic uncertainty.

Treatment

Australian guidelines take a stepped approach: address the underlying causes, support the foundations with lifestyle change, and then add medication or device-based treatments as needed.

Address the underlying conditions

Comprehensive cardiovascular risk management - optimising blood pressure, lipids, diabetes control, and smoking cessation - is the foundation of ED care, particularly in men over 40. This is detailed in the Heart Foundation 2023 CVD risk guideline. Where current medications are contributing to ED, your GP may consider switching to alternatives - for example changing from a beta-blocker to a different antihypertensive class, or rotating an antidepressant.

Lifestyle

Robust evidence supports several lifestyle interventions for ED:

• Smoking cessation - smoking causes endothelial dysfunction; quitting improves erectile function over months
• Regular exercise - at least 150 minutes per week of moderate-intensity aerobic activity plus resistance training
• Weight reduction if overweight - particularly central obesity
• Mediterranean-style diet - improves endothelial function and cardiovascular health
• Alcohol moderation - heavy drinking worsens ED
• Sleep optimisation and treatment of obstructive sleep apnoea where present
• Mental health support - treating depression and anxiety improves ED outcomes

PDE5 inhibitor medications (first-line)

Phosphodiesterase type 5 inhibitors are the first-line pharmacotherapy across Australian guidelines, per eTG, AMH, and USANZ. The four agents available in Australia are sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Spedra). They work by enhancing the nitric oxide signalling pathway that produces erections in response to sexual stimulation. They do not cause spontaneous erections - arousal is still required.

Practical points:

• Generic sildenafil is widely available and substantially cheaper than the originator brand. For most men it is an effective starting option.
• Tadalafil has a long duration of action (around 24-36 hours), offering more flexibility around timing. A low-dose daily formulation also helps urinary symptoms from benign prostatic hyperplasia (BPH) - the only PBS Authority listing for tadalafil is for BPH-LUTS, not ED.
• PDE5 inhibitors are not subsidised on the PBS for ED in Australia. They are a private cost. Most men find generic sildenafil affordable.
• Common side effects are usually mild: facial flushing, headache, indigestion, nasal congestion, and occasionally a bluish tinge to vision. Rare but serious effects include a sudden vision loss condition called NAION and priapism.
• Absolute contraindication: nitrate medications. PDE5 inhibitors must never be combined with nitrates used for chest pain (such as glyceryl trinitrate) - the combination causes a dangerous fall in blood pressure. Tell every doctor and emergency team that you are taking a PDE5 inhibitor.
• Caution with alpha-blockers used for blood pressure or BPH - low starting doses and time-separated dosing help prevent postural hypotension.

When PDE5 inhibitors don’t work

A meaningful minority of men don’t respond adequately to PDE5 inhibitors. Second-line options per USANZ include:

• Vacuum erection device - a non-pharmacological pump and tension ring system. Drug-free, can be used long-term, effective for many men.
• Intracavernosal alprostadil injection (Caverject) - a small injection into the side of the penis just before sex. Highly effective. PBS Authority listed. Specialist initiation, with careful counselling about priapism risk.
• Intraurethral alprostadil (MUSE) - a pellet inserted into the urethra; alternative to injection.
• Topical alprostadil (Vitaros) - a cream; modest efficacy.
• Penile prosthesis - a surgical implant for men who don’t respond to other measures. Definitive treatment with high patient satisfaction. Specialist urology referral.

Testosterone replacement (for confirmed hypogonadism only)

Testosterone replacement is reserved for men with confirmed clinical and biochemical hypogonadism, not as a general ED treatment. Diagnosis requires consistently low morning testosterone on two separate samples (usually total testosterone below 6 nmol/L, or 6-12 nmol/L with clear symptoms) alongside features such as low libido, fatigue, and reduced muscle mass. Testosterone is PBS Authority Required for confirmed hypogonadism, typically with specialist endocrinology or sexual-health input.

Reassuring cardiovascular safety data emerged from the TRAVERSE trial published in NEJM 2023, which showed no increase in major adverse cardiovascular events in hypogonadal men with high cardiovascular risk treated with testosterone gel versus placebo. Important caveats: testosterone suppresses sperm production, so men planning fertility need alternative strategies; testosterone is avoided in active prostate cancer, severe untreated BPH, polycythaemia, severe sleep apnoea, and breast cancer. Monitoring of PSA, haematocrit, lipids, and blood pressure is required.

Psychological treatment

Sex therapy, CBT for performance anxiety, and couples counselling have a well-established role - particularly in psychogenic ED, mixed ED with significant psychological overlay, and after physical contributors have been addressed. The Better Access initiative provides Medicare-subsidised psychology sessions via a GP Mental Health Care Plan.

When to see a GP

Book a GP appointment if:

• You’ve had persistent erection difficulties for more than a few weeks
• You’re over 40, particularly if you have diabetes, high blood pressure, raised cholesterol, or are a current or former smoker
• You notice low energy, reduced libido, or low mood alongside ED
• ED is causing significant distress or relationship difficulty
• You’re a younger man with sudden severe ED
• You’ve noticed penile curvature, pain with erection, or a palpable lump (possible Peyronie’s disease)

Red flags - seek urgent care

Some presentations need same-day or emergency review:

• Priapism - an erection lasting more than four hours is a urological emergency. Go to your nearest emergency department immediately. Delayed treatment risks permanent erectile tissue damage.
• Sudden ED with chest pain, breathlessness on exertion, or symptoms on exertion during sex - this can indicate underlying coronary artery disease and requires urgent cardiac assessment.
• Sudden vision loss while taking a PDE5 inhibitor - rare but warrants emergency review for NAION.
• Active suicidality or severe depression linked to ED - urgent mental-health support via your GP, Lifeline 13 11 14, or Beyond Blue 1300 22 4636.

Always tell paramedics and emergency teams about any PDE5 inhibitor you’ve recently taken - this affects which medications they can safely give for chest pain.

What this article is and is not

This article provides general health information drawn from current Australian clinical guidelines - including USANZ, Therapeutic Guidelines (eTG Genitourinary), the Australian Medicines Handbook, Healthy Male (Andrology Australia), and the 2023 Heart Foundation CVD risk guideline. It is not personal medical advice and does not create a doctor-patient relationship. Treatment decisions, including which investigations to pursue, which medications are appropriate for you, and how to manage any underlying cardiovascular or hormonal contributors, are made collaboratively with your own GP and specialist clinicians.

For Australian consumer-friendly information: HealthDirect - Erectile dysfunction · Better Health Channel · Healthy Male · Heart Foundation CVD Check.

For mental-health crisis: Lifeline 13 11 14 · Beyond Blue 1300 22 4636.

Sources cited

1. USANZ - Urological Society of Australia and New Zealand
2. Therapeutic Guidelines - eTG complete (Genitourinary)
3. Australian Medicines Handbook
4. Heart Foundation - Australian CVD Risk Guideline 2023
5. Healthy Male (Andrology Australia)
6. HealthDirect - Erectile dysfunction
7. Better Health Channel - Erectile dysfunction
8. Lincoff AH et al. Cardiovascular safety of testosterone-replacement therapy (TRAVERSE). NEJM 2023
9. PBS Online - Pharmaceutical Benefits Scheme