Erectile dysfunction (ED) is observed in up to 81% of men with systemic sclerosis (SSc) and therefore should be counselled as a common complaint in this disorder. Whereas ED is frequently associated with atherosclerosis in the general population in which it is also a harbinger of cardiovascular events, ED has a different aetiology in SSc. In SSc the penile blood flow is impaired due to both myointimal proliferation of small arteries and corporal fibrosis. Data on the prevention of ED in SSc are not available. On-demand phosphodiesterase type 5 (PDE-5) inhibitors are not effective in improving erectile function, but fixed daily or alternate day regimens of long acting PDE-5 inhibitors provide a measurable, although often limited, clinical benefit. When intracavernous injections of prostaglandin E1 (alprostadil) are ineffective, the implantation of a penile prosthesis may be considered. Complex treatment options may require the involvement of urology.