Erectile Dysfunction

 

Erectile dysfunction is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.  Some experts advise that symptoms lasting at least three months warrant evaluation and consideration of treatment.  Erectile dysfunction is a symptom and not a disease, therefore it is important to identify any underlying disease or condition which may be causing it.  Erectile dysfunction is associated with physical causes such as diabetes mellitus and hypertension; psychological or emotional causes such as relationship problems or mental health problems; and the use of certain drugs such as antihypertensive drugs

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Assessment

History:

  1. Take a detailed account of the man's personal details and his interpretation of the problem, and ascertain whether the nature of dysfunction is physical or psychological
    1. This should include questions about his current and past medical, surgical, and psychiatric history; psychological (or emotional) factors; and medication for comorbidities
  2. Ask about:
    1. Relationship status (current and past) and sexual orientation
    2. Present and previous erection quality (including erections during sexual relations as well as awakening and masturbatory erections), and concomitant ejaculatory and orgasm dysfunction
    3. Issues with sexual aversion or pain, or issues for his partner (including menopause or vaginal pain)
    4. Lifestyle, including use of alcohol, tobacco, and illicit drugs (including cannabis), and treatments already tried
    5. Energy levels, loss of libido, loss of body hair, or spontaneous hot flushes (symptoms of hypogonadism)

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Examination:

In all men, perform a focussed physical examination with measurement of body weight, waist circumference, heart rate, and blood pressure as a minimum

  • Examination of the genitalia may reveal hypogonadism or malformation such as Peyronie's disease (further detailed assessment is required if there is a history of rapid onset of pain or deviation of the erection). Also check for gynaecomastia and reduced body hair
  • A digital rectal examination is recommended if there are symptoms of an enlarged prostate, including obstructive urinary symptoms such as a weak and intermittent urinary stream. Rarely, the enlarged prostate obstructs the flow of ejaculate causing prolonged and intermittent ejaculation

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Investigations:

In all men:

  1. Calculate the 10-year cardiovascular risk by measuring lipid and fasting glucose serum levels
  2. Measure free testosterone in the morning between 9 am and 11 am.  If the free testosterone is low or borderline:
    1. Repeat the testosterone measurement, and measure follicle-stimulating hormone, luteinizing hormone, and prolactin levels
    2. Consider referral to endocrinology if these are abnormal

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Self-care advice

  1. Counsel the man that erectile dysfunction usually responds well to a combination of lifestyle changes and drug treatment. Advise, where applicable, that he should lose weight (important), stop smoking, reduce alcohol consumption, and increase exercise
  2. For men with coronary heart disease (CHD), advise that most men with CHD can safely resume sexual activity and use phosphodiesterase-5 (PDE-5) inhibitors, except those with unstable heart disease, a history of recent myocardial infarction, poorly compensated heart failure, or unstable dysrrhythmia
  3. For men who cycle for more than 3 hours per week, encourage a trial period without cycling (if possible) to see if this improves their erectile function
  4. Advise the man not to take unlicensed herbal remedies for erectile dysfunction

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Treatment

  1. If the man is taking medication that may cause erectile dysfunction, consider substituting it with another drug if a temporal link can be demonstrated
  2. Prescribe a phosphodiesterase-5 (PDE-5) inhibitor regardless of suspected cause (provided there are no contraindications). Sildenafil (Viagra®), tadalafil (Cialis®), and vardenafil (Levitra®) are probably equally effective, so when first prescribed the man should make an informed choice on which to use
  3. Before prescribing, assess whether the man qualifies for an NHS prescription. If he does not, a private prescription can be issued
  4. Prescribe the lower dose of the drug initially, and consider titrating upwards if this is ineffective
  5. Ensure the man is aware that PDE-5 inhibitors are not initiators of erection but require sexual stimulation in order to facilitate erection
  6. A man with erectile dysfunction should receive eight doses of a PDE-5 inhibitor at a maximum dose with sexual stimulation before being classified as a non-responder
  7. Advise the man not to take unlicensed herbal remedies for erectile dysfunction as they may contain prescription-only medicines which may be contraindicated or interact with prescribed medication

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Follow up

NOTE Where possible, involve the man's partner in follow-up appointments (bearing in mind the sensitive nature of the condition)

  1. Ask about the effectiveness of treatment
  2. If treatment has not been satisfactorily effective:
    1. Counsel about the appropriate use of phosphodiesterase-5 (PDE-5) inhibitors. Ensure that the man is aware that PDE-5 inhibitors are not initiators of erection but require sexual stimulation in order to facilitate erection
    2. Reconsider comorbidities and treat where possible. In particular, consider the possibility of hypogonadism (which makes PDE-5 inhibitors ineffective)
    3. Consider increasing to the maximum dose, or switching to an alternative PDE-5 inhibitor. If this fails, consider referral

A person with erectile dysfunction should receive eight doses of a PDE-5 inhibitor at a maximum dose with sexual stimulation before being classified as a non-responder

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When to refer

Admit to hospital if there is priapism (persistent erection). Warn the man to seek advice if he has an erection lasting longer than 4 hours

Refer to urology:

  • Young men who have always had difficulty in obtaining or maintaining an erection
  • Men with a history of trauma (for example to the genital area, pelvis, or spine)
  • If an abnormality of the penis or testicles is found on examination
  • Men who do not respond to the maximum dose of at least two phosphodiesterase-5 (PDE-5) inhibitors (for people with diabetes, consider referral to diabetes clinic)
    • A person with erectile dysfunction should receive eight doses of a PDE-5 inhibitor with sexual stimulation at maximum dose before being classified as a non-responder

Refer to endocrinology men who have hypogonadism (characterized by abnormal testosterone, follicle-stimulating hormone, luteinizing hormone, or prolactin levels)

Refer to cardiology men who have severe cardiovascular disease that would make sexual activity unsafe, or contraindicates PDE-5 inhibitor use

Consider referral for psychological assessment for men with a psychogenic underlying cause of erectile dysfunction

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Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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