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Erectile dysfunction is a common issue, and the cause can be cardiovascular, hormonal, or psychological. The online consultation starts by ruling out anything serious before proposing a treatment.

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What the consultation evaluates

The doctor reviews your symptoms, cardiovascular history, current medication and allergies to distinguish between physical and psychological causes. Worry about sexual performance is sometimes the primary driver rather than a physical cause — see performance anxiety for how a doctor tells the two apart. Certain answers, such as nitrate medication, rule out some treatments entirely because of a dangerous interaction.

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Your path to treatment

A licensed doctor reviews your answers about your health, medical history and current medication as part of a sexual-health consultation, to work out the likely cause before considering treatment.
1

Start your online visit

Answer a questionnaire about your health and goal. No in-person appointment, no travel — you’ll know within 24 hours if you’re a candidate.
2

A doctor reviews your case

A licensed doctor reviews your answers personally. If they need clarifications, they message you in the private chat on your account. If treatment is appropriate, they sign an electronic prescription.
3

Review and payment

If the doctor does not approve treatment, the consultation fee is refunded in full within 48 hours.
4

Ongoing support

Private chat with your doctor for questions, a 4-week check-in, and renewal before your prescription expires.

Licensed EU doctors

Prescription in under 24 hours

Full refund if not approved

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Treatments a doctor considers

PDE5-inhibitor tablets are one option a doctor may consider once the cause has been assessed — see avanafil for one such medicine, its EU authorisation, and its trial evidence, and the Spedra (avanafil) usage guide for day-to-day dosing.
Worry about sexual performance is sometimes the primary driver rather than a physical cause. See performance anxiety for how a doctor tells the two apart.

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Common questions

The doctor reviews a questionnaire about your symptoms, medical history and current medication. They assess cardiovascular health, hormonal factors and psychological causes. If they need clarifications, they message you in the private chat on your account.
PDE5-inhibitor tablets such as avanafil are one option. The doctor may also consider Vitaros (alprostadil cream) when tablets are unsuitable. The decision depends on the cause identified during the consultation.
Response varies by treatment and individual. With on-demand tablets such as avanafil, the effect can begin within 15 to 30 minutes. The doctor reviews your response and adjusts the plan if needed.
Yes. A licensed EU doctor reviews your case remotely and, if appropriate, issues an electronic prescription valid at any EU pharmacy under Directive 2011/24/EU.
Yes. Your answers and the doctor’s decision stay in your private account. The doctor messages you through the secure chat on your account.
If the doctor does not approve treatment, the consultation fee is refunded in full within 48 hours. Declining is a normal outcome and does not mean the issue cannot be addressed through another route.

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How Hi-Doctor handles it

One consultation, one doctor, one decision. See pricing for the consultation fee, how it works for the full process, and safety for how eligibility checks and doctor review work. Medication, if prescribed, is paid separately, at a pharmacy of your choice.

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Mechanism of PDE5 inhibitors

Penile erection depends on the L-arginine–nitric oxide (NO)–cyclic guanosine monophosphate (cGMP) signalling cascade (PMID 15224127). Sexual stimulation triggers release of NO from non-adrenergic, non-cholinergic (NANC) neurones and from cavernosal endothelial cells. NO diffuses into adjacent vascular smooth muscle cells of the corpus cavernosum, where it activates soluble guanylyl cyclase to convert guanosine triphosphate (GTP) to cGMP. cGMP activates protein kinase G (PKG), which phosphorylates targets that lower intracellular calcium concentration — by inhibiting calcium influx through L-type channels and by promoting calcium sequestration in the sarcoplasmic reticulum — resulting in relaxation of the trabecular smooth muscle. This relaxation allows arterial blood to fill the sinusoidal spaces, compressing subtunical venules and trapping blood within the corpora. Phosphodiesterase type 5 (PDE5) is the predominant phosphodiesterase in the corpus cavernosum. Its catalytic domain hydrolyses cGMP to GMP, thereby terminating the NO signal. PDE5 inhibitors (avanafil, sildenafil, tadalafil, vardenafil) are competitive, reversible inhibitors that bind the catalytic domain of PDE5 with high affinity, preventing cGMP breakdown and potentiating the endogenous NO signal. The drugs differ in their onset of action, duration, and selectivity against other PDE isoenzymes. Avanafil reaches peak plasma concentration in approximately 30–45 minutes, enabling on-demand dosing shortly before sexual activity, and has a half-life of roughly 5 hours. PDE5 inhibitors require sexual stimulation to work — they do not initiate the cascade, only amplify the endogenous response.

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Contraindication by mechanism: nitrates

The most important contraindication to PDE5 inhibitors is concomitant use of organic nitrates (glyceryl trinitrate, isosorbide mononitrate, isosorbide dinitrate). Both drug classes raise intracellular cGMP: nitrates by donating NO directly, PDE5 inhibitors by blocking cGMP breakdown in vascular smooth muscle. The combined effect produces a synergistic — not merely additive — reduction in blood pressure, which can cause severe symptomatic hypotension (PMID 10078539). This interaction persists as long as the PDE5 inhibitor is present in the circulation. For short-acting PDE5 inhibitors, nitrate administration should be avoided for at least 24 hours after the last dose; for longer-acting agents such as tadalafil, a 48-hour interval is recommended. The consultation questionnaire screens for nitrate use, and a positive answer rules out PDE5 inhibitor prescribing.

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Diagnostic assessment: the IIEF-5

The International Index of Erectile Function (IIEF-5) is a five-item validated questionnaire that scores erectile function over the preceding 6 months on a 5-point ordinal scale. The total score distinguishes severity categories: severe (5–7), moderate (8–11), mild to moderate (12–16), mild (17–21), and no erectile dysfunction (22–25). The reviewing doctor uses the questionnaire responses together with the medical history — cardiovascular risk factors, diabetes, smoking, pelvic surgery or radiotherapy — to determine whether the dysfunction is primarily organic, psychogenic, or mixed. The presence of morning erections suggests a preserved neurovascular axis and points toward a psychogenic component, whereas their absence suggests an organic cause.

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Start a consultation

Sexual health consultation

Answer the sexual health questionnaire and a registered doctor reviews it. They decide whether treatment is appropriate, which one, and at what dose — and declining is a normal outcome. See what it costs and how the review works.
This page is reference information, not medical advice and not a prescription. Whether a medicine is appropriate for you is decided by a registered doctor after reviewing your consultation.