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REMEDY : BNSSG referral pathways

Erectile Dysfunction

Checked: 07-12-2018 by vicky.ryan Next Review: 13-12-2019

Principles of Management

Erectile dysfunction can normally be managed in primary care see CKS Guidelines

Assessment of a man with erectile dysfunction should include:

  • A detailed history, including present and past erection quality, lifestyle (including alcohol intake, smoking status, and illicit drug use), and previous treatments tried.
  • A focused physical examination to identify any genitourinary, endocrine, vascular, or neurological causes of erectile dysfunction. 
  • Appropriate investigations, including glucose-lipid profile and total testosterone, to identify any reversible/modifiable risk factors.

Drugs that can cause erectile dysfunction include antihypertensives, antipsychotics, and antidepressants

Erectile dysfunction usually responds well to a combination of lifestyle measures (such as weight loss, smoking cessation, and reducing alcohol consumption) and drug treatment.

Medication can be used to successfully treat erectile dysfunction (ED) in at least two-thirds of men. Phosphodiesterase-5 inhibitors (PDE5 inhibitors) are the first line recommended pharmacological treatment, however please see prescribing information below.

Clinical Guidance - Prescribing

See BNSSG formulary chapter on Erectile and ejaculatory conditions for local decisions on prescribing.

In summary:

Offer generic sildenafil when required (PRN) on the NHS for all patients as the first line treatment for ED where clinically appropriate. BNSSG CCG supports Department of Health (DoH) recommendations on quantity i.e. (One treatment per week) four tablets. Private prescriptions are not necessary or appropriate as Viagra Connect is available over the counter (OTC). Prices will vary depending on where patient purchases the product.

Other drug treatments (including branded sildenafil - Viagra) may only be prescribed if generic sildenafil is ineffective. Consider alternative PDE5 inhibitors e.g. generic Tadalafil  or Vardenafil PRN. Only prescribe on the NHS if the patient meets SLS criteria - see local guidance on Changes to legislation on drugs for erectile dysfunction Referral to secondary care does not bypass need to adhere to NHS prescribing restrictions for PDE5 inhibitors (other than sildenafil).  If patient does not meet NHS SLS criteria then refer patient to a doctor who can prescribe this privately.

NHS SLS criteria


Multiple sclerosis

Parkinson’s disease


Prostate cancer

Severe pelvic injury

Single gene neurological disorder

Spina bifida

Spinal cord injury

Are receiving renal dialysis for renal failure


Radical pelvic surgery

Have had a kidney transplant

Referral Guidance


To urology (via eRS or consider A and G service) — for young men who have always had erectile dysfunction and for all men with a history of trauma to genital area, pelvis or spine; abnormality of the penis or testicles; or no response to maximum dose of at least two PDE-5 inhibitors.

To endocrinology (via eRS) — if hypogonadism is suspected (abnormal serum testosterone, follicle-stimulating hormone, luteinizing hormone or prolactin levels).).

To cardiology (via eRS or consider A and G service)  — if the man has CVD that makes sexual activity unsafe or contraindicates PDE-5 inhibitor use.

To sexual health services for psychosexual therapy (not available via eRS)  — if an underlying psychogenic cause is suspected. See Bristol Sexual Health Services