Counselling · Intermediate · Urology

Difficulty with Erections

Practise this PLAB 2 counselling station on Erectile Dysfunction. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the GP surgery. Mr Gerald Popovic, a 56-year-old man, has attended with erectile dysfunction. He is embarrassed to discuss it. Please conduct a sensitive consultation, explore possible causes, discuss PDE5 inhibitors, and consider referral options.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Non-specific back pain (occasional)

What this station tests

  • Distinguishing organic from psychogenic ED: gradual onset with reduced morning erections suggests organic; sudden onset with preserved morning erections suggests psychological
  • ED as a cardiovascular risk marker: often precedes cardiovascular events by 3 to 5 years in men with vascular risk factors
  • Medication review: beta-blockers and thiazides as common causes, checking current antihypertensive regimen
  • PDE5 inhibitor counselling: not automatic erection, requires stimulation, take on empty stomach, contraindicated with nitrates
  • Sensitive consultation skills: normalising, establishing confidentiality, acknowledging embarrassment without dwelling on it

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

Erectile dysfunction stations test the candidate's ability to conduct a sensitive consultation about a topic the patient finds deeply embarrassing. The clinical content is straightforward but the interpersonal skills are the differentiator. Mr Popovic is 56, attending reluctantly with 10 months of ED. His wife persuaded him to come. Open with: 'Mr Popovic, I know this can be difficult to discuss. I want to assure you that this is very common, very treatable, and everything we discuss is confidential. Tell me what has been happening.'

Core approach

Characterise the ED. Gradual onset over 10 months (gradual suggests vascular or organic cause; sudden suggests psychological). He can achieve an erection but cannot maintain it. He loses firmness during intercourse. Most attempts are affected. Morning erections are reduced (preserved morning erections suggest psychological cause; reduced suggests organic). This pattern points to organic, likely vascular ED.

Assess cardiovascular risk. ED in a man with hypertension and hypercholesterolaemia is a marker of generalised vascular disease. ED often precedes cardiovascular events by 3 to 5 years. Check: is he on a statin? Is his BP controlled? Does he smoke? Does he exercise? This is not just a sexual health issue: it is a cardiovascular risk assessment.

Check medications. Antihypertensives (beta-blockers and thiazides are common causes of ED), statins, any antidepressants, any other medications. His amlodipine is less likely to cause ED than beta-blockers.

Screen for psychological factors. Relationship stress? Depression? Anxiety about performance? Work stress? Alcohol? He is withdrawn and his wife is concerned about his mood. The ED may be contributing to low mood, or low mood may be contributing to ED.

Closing and safety netting

Explain the likely cause: 'The gradual onset and the fact that morning erections are also reduced suggests this is a physical cause, most likely related to blood flow. Your blood pressure and cholesterol are risk factors for this.' Frame ED as a cardiovascular marker: 'This is actually useful information because it tells us we should check your heart health more thoroughly.'

Treatment: PDE5 inhibitor (sildenafil 50mg) is first-line. Explain how it works: 'It does not cause an erection automatically. It helps you achieve and maintain an erection when you are sexually stimulated.' Take on an empty stomach, allow 30 to 60 minutes to work. Contraindicated with nitrates. Cardiovascular risk assessment: fasting glucose, lipid profile, HbA1c if not recently checked.

Address the relationship impact. Offer to involve his wife in a follow-up consultation if he would like. Normalise: 'ED affects about half of men over 50 at some point. You are not alone in this.' Safety net: 'If you develop chest pain, prolonged erection lasting more than 4 hours, or sudden vision changes, seek urgent medical attention.' Follow-up in 4 weeks.

How examiners mark this station

Examiners will assess your ability to explain erectile dysfunction and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: ED characterised (onset, severity, morning erections, relationship pattern). Cardiovascular risk factors assessed. Medication review. Psychological factors screened. Alcohol and lifestyle assessed.

Costs marks: Not characterising ED type. Missing cardiovascular link. Not reviewing medications. Not screening mood.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: PDE5 inhibitor prescribed with correct counselling (timing, food, nitrate contraindication). Cardiovascular risk assessment arranged. Priapism safety netting. Lifestyle advice. Follow-up planned.

Costs marks: Prescribing without counselling. Not checking nitrate use. No cardiovascular assessment. No follow-up.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Establishing confidentiality and normalising at the outset. Comfortable, professional manner. Acknowledging relationship impact. Offering to involve his wife. Not dwelling on embarrassment.

Costs marks: Appearing uncomfortable. Not normalising. Not offering partner involvement. Being clinical without empathy.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Not distinguishing organic from psychogenic. The management differs and the cardiovascular implications differ. Candidates who prescribe sildenafil without characterising the ED type miss the diagnostic step.
  2. Not recognising ED as a cardiovascular risk marker. A 56-year-old with hypertension, hypercholesterolaemia, and ED needs cardiovascular risk assessment. Candidates who treat the ED without assessing CV risk miss the bigger clinical picture.
  3. Being visibly uncomfortable. The patient is already embarrassed. If the candidate appears awkward, the patient will provide less information. Confidence and normalisation are essential interpersonal skills.

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

What is the best way to structure this erectile dysfunction counselling consultation?

Erectile dysfunction stations test the candidate's ability to conduct a sensitive consultation about a topic the patient finds deeply embarrassing. The clinical content is straightforward but the interpersonal skills are the differentiator. Mr Popovic is 56, attending reluctantly with 10 months of ED.

Where are marks won and lost in this erectile dysfunction station?

Examiners reward: ED characterised (onset, severity, morning erections, relationship pattern). Cardiovascular risk factors assessed. Medication review. Psychological factors screened. Alcohol and lifestyle assessed. Candidates are penalised for: Not characterising ED type. Missing cardiovascular link. Not reviewing medications. Not screening mood.

Where do candidates most often go wrong in this station?

Not distinguishing organic from psychogenic. The management differs and the cardiovascular implications differ. Candidates who prescribe sildenafil without characterising the ED type miss the diagnostic step.

Can I do well in this station without real-world experience of erectile dysfunction?

This station rewards process over personal experience. The skill being assessed: ED as a cardiovascular risk marker: often precedes cardiovascular events by 3 to 5 years in men with vascular risk factors. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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