When should I consider referring a patient with erectile dysfunction to a specialist?

Consider referring a patient with erectile dysfunction (ED) to a specialist in the following situations:

• If the patient is young or has a lifelong history of difficulty obtaining or maintaining an erection, suggesting possible primary ED, refer to a urology specialist.
• If there is a history of pelvic, perineal, or genital trauma, refer to urology.
• If there is a penile structural abnormality or abnormal testicular examination, arrange urology referral.
• If hypogonadism is suspected (low serum testosterone or other hormonal abnormalities) or testosterone replacement therapy is being considered, refer to an endocrinologist.
• If the patient is at high or intermediate cardiac risk where sexual activity or PDE-5 inhibitor use may be unsafe, refer to cardiology for specialist assessment before resuming sexual activity.
• If psychological or relationship issues are suspected to contribute to ED, or if there is a complex or severe mental health condition not manageable in primary care, refer to mental health services or psychosexual counselling.
• If initial PDE-5 inhibitor treatment is ineffective, not tolerated, or contraindicated despite correct use and dose optimization, consider referral to urology for specialist treatment options such as vacuum devices, intracavernosal injections, or surgery.
• If there is evidence of priapism (painful erection lasting more than 4 hours), arrange emergency hospital admission.

These referral recommendations are based on the British Society for Sexual Medicine (BSSM) guidelines, European Association of Urology (EAU) guidelines, and expert opinion NICE CKS.