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What is erectile dysfunction (ED)?

  • ED is the persistent inability to attain and/or maintain an erection sufficient for satisfactory sexual performance
  • ED is caused by various vascular, neuronal, hormonal and metabolic factors, mediated by endothelial and smooth-muscle dysfunction
  • Although most causes of ED are physical, some are due to psychosexual issues; nevertheless, all patients with ED should have a history, examination and investigations performed, even if a psychological cause is suspected
  • ED is a cardiovascular (CV) risk factor, posing a risk equivalent to that of current, moderate smoking
  • ED is also an important marker for future CV events, with symptoms occurring some 3–5 years before an event
  • The physical and psychosocial effects of ED can significantly affect the quality of life of patients and their partners

Who is at risk?

  • The risk factors for ED are similar to those for cardiovascular disease (CVD):
    • older age 
    • sedentary lifestyle 
    • obesity 
    • dyslipidaemia 
    • metabolic syndrome 
    • diabetes 
    • smoking

What are the other benefits of case-finding ED in practice?

  • Increasing awareness regarding the availability of safe and effective oral drugs for ED, has led to more men seeking help for this condition, which facilitates the early detection of: 
    • diabetes (ED may be the first symptom in up to 20% of men)
    • dyslipidaemia (may not require treatment according to primary prevention guidelines, but may be a major reversible component in ED)
    • occult cardiac disease (in an otherwise asymptomatic man, ED may be a marker for underlying coronary artery disease)
    • testosterone deficiency (TD; a reversible cause of ED that may not require specific ED treatment, and which also has other long-term health implications) 
    • associated lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) (ED and LUTS severity are closely related, and treatments for one condition may beneficially or adversely affect the other)
History taking
  • Obtain a detailed description of the problem, including:
    • symptom duration
    • predisposing, precipitating and maintaining factors (if identified)
    • any subsequent investigations
    • previous/current treatment interventions and response
    • reported tumescence, rigidity and quality of morning, spontaneous, masturbatory and/or partner-related erections
    • sexual desire
    • ejaculatory timing, control and orgasmic dysfunction
    • previous erectile capacity
    • any personal issues regarding sexual aversion or pain
    • any partner issues, such as low sexual desire, menopause or gynaecological pain
  • Record concurrent medical, psychiatric and surgical history, current relationship status, history of sexual partners and relationships, alcohol intake, smoking status and recreational drug use
  • Consider the use of validated questionnaires, (such as the IIEF, shorter version of the SHIM, IPSS or AMS scale) to assess sexual function domains and response to therapy
  • Note any issues regarding sexual orientation and gender identity
Abbreviations: IIEF=International Index of Erectile Function; SHIM=Sexual Health Inventory for Men; IPSS=International Prostate Symptom Score; AMS=Aging Males’ Symptoms
Physical examination 
  • Measure heart rate, blood pressure, abdominal circumference, weight, and height if body mass index required
  • Conduct a DRE of the prostate if there are genitourinary or protracted secondary ejaculatory symptoms
  • Perform a genital examination, particularly with pain of sudden onset, deviation of the penis during tumescence, symptoms of TD, or other urological symptoms (past or present)
Abbreviations: DRE=digital rectal examination; TD=testosterone deficiency
Investigations 
  • Check serum lipids, fasting plasma glucose and/or glycated haemoglobin
  • Measure serum TT in the morning (before 11 am), in the fasting state. If low (TT <8 nmol/l) or borderline (TT 8–⁠12 nmol/l), repeat with serum LH and prolactin. FT has a greater correlation with clinical symptoms of TD (FT and bioavailable testosterone can be calculated from TT, SHBG and albumin; an online FT calculator and downloadable app, sponsored by the Primary Care Testosterone Advisory Group (PCTAG), can be found at http://www.pctag.uk/testosterone-calculator/. If levels are abnormal, consider specialist referral
  • Consider specialist investigations in men who:
    • wish to know the aetiology of their ED
    • have an arterial abnormality on Doppler ultrasound
    • have a history of traumaa
    • are young and:
      • have always had trouble obtaining/maintaining an erection
      • have a primary CV abnormality
      • have suspected primary venous leakage
      • are being considered for surgical intervention
    • have an abnormality of the penis or testes
    • have not responded to medical therapy and may want surgical treatment
  • Consider measuring PSA if clinically indicated, and certainly before commencing testosterone therapy and at 3, 6, and 12 months afterwards
  • Consider thyroid function tests
Abbreviations: TT=total testosterone; LH=luteinising hormone; FT=free testosterone; TD=testosterone deficiency; SHBG=sex hormone-binding globulin; ED=erectile dysfunction; CV=cardiovascular; PSA=prostate-specific antigen

Diagnosing and managing ED in primary care

  • The primary objective in the management of ED is to enable the man or couple to enjoy a satisfactory sexual experience
  • When managing ED, consider not only the efficacy and safety of the different treatments, but also patient and partner preference, and all the factors that may influence this
  • It is of paramount importance to use the opportunity to manage any previously undiagnosed comorbidities that present following the patient assessment, and to treat to target any existing conditions and make lifestyle modifications, where necessary

Diagnosing and managing ED in primary care ONLINE

Algorithm on diagnosing and managing ED in primary care. Download a PDF of this algorithm.

ED therapies  

PDE5I

  • ~25–50% of men fail to respond within 12 months
    • rates are higher in men with T2DM or post-RP
  • inadequate prescribing/ instruction is the main cause of treatment failure
  • daily/frequent dosing regimens may salvage men who’ve failed with on-demand therapy
  • correction of testosterone levels <10.4 nmol/l may salvage non‑responders
  • nitrates may be safely discontinued (with a cardiologist’s approval), to aid therapy
  • co-administration with antihypertensives may increase the drop in blood pressure

Contraindications include:[A]

  • use of nitrates in any form, guanylate cyclase stimulators, potent CYP3A4 inhibitors
  • loss of vision in one eye due to NAION
  • severe renal/hepatic impairment
  • hypotension

Dose adjustments may be required in:[A]

  • renal or hepatic impairment
  • concomitant use of CYP3A4 inhibitors

Apply caution in:[A]

  • patients receiving alpha‑blockers and those with anatomical penile deformities or a predisposition to priapism

Possible adverse effects include:[A]

  • headache
  • dizziness
  • flushing
  • dyspepsia
  • nasal congestion

Intra-urethral alprostadil

  • less invasive than injection therapy but works for only ~30–⁠60% of patients
  • higher doses of MUSE (500/1000 mcg) are usually required

Contraindications include:

  • anatomical deformity of the penis
  • predisposition to priapism

Apply caution in:

  • men whose partners could be pregnant (a condom must be used)

Possible adverse effects include:

  • penile pain
  • haematoma
  • headache
  • dizziness
  • hypotension
  • muscle spasm

Intracavernous injections

  • include alprostadil and aviptadil+phentolamine (A/P)
  • alprostadil is effective in >70% of men, but compliance rates may be low
  • A/P has similar efficacy to alprostadil, with less painful injections
  • unlike alprostadil, A/P injections need to be accompanied by some form of sexual stimulation for an optimal erection

Apply caution in:[A]

  • men at increased risk of bleeding (anticoagulants are contraindicated with A/P)

Contraindications include:[A]

  • predisposition to priapism
  • penile implants

Possible adverse effects include:[A]

  • bruising and haematoma at injection site
  • penile pain (alprostadil)
  • flushing of face/trunk (A/P)

Vacuum erection devices

  • highly effective, regardless of ED aetiology
  • reported satisfaction rates vary between 35% to 84%
  • can be a useful adjunct to PDE5I/injection therapy post-RP, and to salvage treatment failures
  • work best if the man and his partner receive sufficient instruction, and have positive attitudes towards their use

Contraindications include:

  • bleeding disorders
  • concurrent anticoagulant therapy

Possible adverse effects include:

  • bruising
  • local pain
  • failure to ejaculate
  • coldness of the penis

Alprostadil cream

  • store alprostadil cream (Vitaros) in the refrigerator
  • apply 300 mcg in 100 mg (3 mg/g) into the urethral meatus at room temperature
  • improved tumescence of the glans may be useful in men post-penile prosthesis
  • has been shown to produce a 2.5‑point increase in IIEF and a 15% relative increase in successful intercourse attempts

Contraindications include:

  • anatomical deformity of the penis
  • predisposition to priapism

Apply caution in:

  • men whose partners could be pregnant (a condom must be used)

Possible adverse effects include:

  • penile/genital pain/erythema
  • urethral pain
[A] See the individual Summary of Product Characteristics for full details, because these vary between products. Abbreviations: T2DM=type 2 diabetes mellitus; RP=radical prostatectomy; CYP3A4=cytochrome P450 3A4; NAION=non-arteritic anterior ischaemic optic neuropathy; MUSE=Medicated Urethral System for Erections; ED=erectile dysfunction; PDE5I=phosphodiesterase type 5 inhibitor; IIEF=International Index of Erectile Function

British Society for Sexual Medicine. A practical guide on managing erectile dysfunction. BSSM, 2018. Available at: www.bssm.org.uk/wp-content/uploads/2018/09/ED-Practical-Guide-v3-for-BSSM-review.pdf.