Erectile dysfunction (ED) is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. ED is a common condition, with prevalence increasing steadily with age. However, it affects men across all adult age groups. Market research conducted on behalf of Viatris in Irish men revealed that one in three men experience ED on a regular basis, a figure highlighting both its prevalence and the need for greater awareness and engagement.
Importantly, ED is not a disease but a symptom, with causes that can be physical, psychological, or a combination of both (Figure 1). Medication side effects also contribute significantly (Table 1). ED can serve as an early warning sign for underlying conditions, particularly cardiovascular disease, hypertension, diabetes mellitus, hyperlipidemia, and mental health issues such as anxiety and depression. Early recognition of ED presents an opportunity to screen for, and address, these associated health risks.
Figure 1: Physical and psychological causes of ED I typed it out below, but included also image I was sent for layout purposes
Physical causesÂ
Vascular: Cardiovascular diseases, hypertension, hyperlipidaemia, peripheral arterial disease, diabetes mellitus, smoking and obesity.
Neurological: Multiple sclerosis, Parkinson’s disease, stroke, spinal cord injury and central nervous system disorders.
Neurogenic: Diabetes mellitus, chronic kidney disease, chronic liver disease and pelvic or urological surgery.
Anatomical: Peyronie’s disease, prostate cancer and penile trauma.
Performance anxiety, depression, stress, relationship difficulties, lack of arousal, low self-esteem, major life stressors or reduced libido.
Figure 1. Physical and psychological causes of ED
Table 1: Common iatrogenic causes of erectile dysfunction
| Drug class / therapeutic area | Examples | Potential impact on erectile function |
| Antihypertensives | ACE inhibitors, angiotensin receptor blockers (ARBs), beta blockers | ACE Inhibitors and ARBs interfere with smooth muscle relaxation. Beta blockers can affect testosterone and impair vasodilation of the corpora cavernosa. |
| Antidepressants | Selective serotonin reuptake inhibitors, tricyclics, monoamine oxidase inhibitors | Increased serotonin activity which decreases arousal and desire. |
| Antipsychotics | Phenothiazines (for example, chlorpromazine) | Increased prolactin levels leading to lower levels of testosterone. |
| Hormonal therapies | GnRH agonists (for example, leuprorelin) | Suppressed testosterone production or action, impairing libido and erectile function. |
| 5-Alpha reductase inhibitors | Finasteride, dutasteride | Reduced dihydrotestosterone levels which has a role in erectile function. |
| Opioids | Morphine, codeine, methadone | Reduced testosterone production. |
| Antiseizure medicines | Carbamazepine, phenytoin, barbiturates | Affect circulating sex steroid hormones and gonadotropins concentration including their metabolism. |
| Cytotoxic drugs | Methotrexate, cyclophosphamide | Nausea and malaise caused by these medications often lead to a decrease in libido. |
| Recreational drugs | Alcohol, cocaine, marijuana | Impaired blood flow, disrupting hormone and neurotransmitter levels. |
Community pharmacists in Ireland are ideally placed to support men experiencing ED. As highly accessible healthcare professionals, pharmacists often serve as a first point of contact for men reluctant to engage with other healthcare services. In fact, pharmacists are the most accessed healthcare professionals in Ireland, with 2.1 million weekly visits, and people visit pharmacies up to ten times more often than GPs. Consultations for ED, whether through over-the-counter (OTC) sildenafil or tadalafil requests, or prescription dispensing, provide a unique opportunity to open broader conversations about men’s health.
Pharmacists, through opportunistic engagement during ED consultations, can play a vital role in proactively identifying individuals at risk for cardiovascular and mental health issues. By offering brief interventions and guiding patients to appropriate services, they can make a significant impact. This article aims to highlight the importance of ED consultations as a valuable entry point for broader health discussions, providing community pharmacists with practical strategies to strengthen their role in promoting men’s health and wellbeing.
There is a wealth of educational resources available online about over-the-counter ED products, accessible through the HPRA website. These resources offer comprehensive information on product usage, interactions, contraindications, side effects, and consultation guidelines. Therefore, this article will not provide an exhaustive list of these clinical details. Instead, it will focus on a selection of case studies and suggested management strategies to illustrate practical approaches within community pharmacy settings.
“Consultations for ED, whether through over-thecounter (OTC) sildenafil or tadalafil requests, or prescription dispensing, provide a unique opportunity to open broader conversations about men’s health.”
Rahul is a 45-year-old man who was diagnosed with primary hypertension last year. After several adjustments to his treatment, his blood pressure has remained stable for the past four months with a regimen that includes amlodipine 10mg once daily, losartan 50mg once daily, and bendroflumethiazide 2.5mg in the morning. He is now experiencing difficulties with erectile function and is enquiring about the possibility of purchasing an over-the-counter product.
Suggested approach:
John is a 52-year-old man who has been a regular customer at your pharmacy, frequently purchasing OTC sildenafil. It has been eight months since his initial purchase, and despite your repeated reminders to follow up with his doctor, he has yet to do so. He assures you that he plans to schedule an appointment as soon as possible.
Suggested approach:
Sam is a 59-year-old male who presents to the pharmacy requesting over-the-counter tadalafil for ED. He explains that he has been experiencing difficulty maintaining an erection for the past three months. Sam is a regular patient at the pharmacy, and although he cannot recall the names of his medications, you can verify from his records that his current medication includes atorvastatin (20mg once daily), isosorbide mononitrate MR (60mg once daily), bisoprolol (2.5mg once daily), and lisinopril (20mg once daily).
Suggested approach:
ED is increasingly recognised as an early indicator of cardiovascular risk, with conditions such as hypertension, diabetes, and high cholesterol often contributing to its development. When men present with ED, it’s an important opportunity to discuss heart health and other cardiovascular risk factors. Many men may not initially connect ED with their heart health, so a gentle, open-ended question can help prompt a broader conversation. Questions like:
. . . can help uncover cardiovascular risks and open the door for further evaluation and referral.
Many cases of hypertension, remain undiagnosed because it often has no symptoms, making it a silent condition. You could offer to check their blood pressure in the pharmacy, which can provide immediate insight into their cardiovascular health. Encourage men to discuss these concerns with their GP, particularly if they have multiple risk factors. Creating a supportive, non-judgmental space during the ED consultation can encourage men to take action on their heart health, ultimately helping to prevent more serious conditions like heart attacks or stroke.
ED is strongly associated with psychological factors including performance anxiety, stress, depression, and relationship issues. Men may be reluctant to volunteer mental health concerns unprompted, but a sensitive, open-ended enquiry during an ED consultation can create a safe space.
Simple, questions like:
. . . can help uncover underlying issues and offer an opportunity for brief intervention or referral to appropriate supports such as GP, counselling services, or mental health helplines (Samaritans, Aware, Pieta, MyMind). Create a safe, private space for these conversations where possible, even if brief.
ED is not just a sexual health issue but a potential indicator of broader health concerns, particularly cardiovascular and mental health. Community pharmacists are well-positioned to identify men at risk, initiate conversations, and guide them to appropriate healthcare interventions. Through compassionate, non-judgmental discussions, pharmacists can encourage early detection, prevention, and timely referrals, addressing both cardiovascular risks and mental well-being. By integrating these discussions into routine ED consultations, pharmacists can offer a holistic approach to patient care, improving long-term health outcomes. As trusted healthcare professionals, community pharmacists have the opportunity to turn a simple product request into a life-saving conversation, enhancing their practice and contributing significantly to the well-being of their male patients.
References available on request.
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