Erectile dysfunction (ED)
Is a consistent or recurrent inability to attain and/or maintain a penile erection sufficient for satisfactory sexual activity and intercourse Treatment decision-making
Is a common condition affecting 1 in 5 men over the age Cause: organic, psychosocial or combined Is associated with chronic disease including cardiovascular Benefits, risks and costs of treatment options disease and diabetes. Furthermore, ED may be an early warning sign of these chronic diseases Treatment summary
Is a treatable condition that can impact strongly on the well-being of men and their partners The sexual health of older patients is often overlooked. Understanding female partners’ sexual needs as part The gP’s role
GPs are typically the first point of contact for men with erectile The GP’s role in the management of erectile dysfunction includes clinical assessment, treatment including counselling, 3rd line › Consider specialist referral
Intracavernous vasoactive drug injection How do I approach the topic?
4th line › Specialist referral
“Many men (of your age/with your condition) experience sexual difficulties. If you have any difficulties, I am happy to discuss them” For full details of treatment, refer over page
“It is common for men with diabetes/ high blood pressure /heart disease to experience erectile problems. I can help you, if you are having problems” Specialist referral
Indicators for specialist referral

Refer to Endocrinologist
Refer to Urologist
Refer to ED specialist (either Endocrinologist or Urologist)
Complex problems including vascular, neurological Refer to counsellor, psychologist, psychiatrist
or sexual therapist
Physical examination
Complex psychiatric or psychological disorder genito-urinary: penile, testicular and rectal examination
Cardiovascular: BP, HR, waist circumference, abdominal
aortic aneurysm, carotid bruits, foot pulses
Neurological: focused neurological examination
Follow-up is essential to ensure the best patient outcomes. Assess: Refer to Clinical Summary guide 1
Effectiveness of treatment, patient/partner satisfaction Investigations
Partner’s sexual function (e.g. libido), couple’s adaptation For references and other guides in this series visit
Treatment of erectile dysfunction (ED)
1st Line Treatment
alter Modifiable Risk Factors and Causes

Modify medication regime: Change current medications linked to ED (e.g. antidepressants, antihypertensives) when possible
Manage androgen deficiency: When diagnosed and a cause is established, androgen deficiency replacement can improve low libido,
address psychosocial issues: Includes relationship difficulties, anxiety, lifestyle changes or stress
Facilitating sexual health

Lifestyle changes: Smoking cessation, reduced alcohol, improved diet and exercise, weight loss, stress reduction,
illicit drug cessation, compliance with diabetes and cardiovascular medications Discuss sexual misinformation: Includes importance of sufficient arousal and lubrication, and realistic expectations,
2nd Line Treatment
Oral agents: PDE5 inhibitors

On demand dosing:
Tadalafil (Cialis
®): 10 and 20mg; recommended starting dose 20mg
Vardenafil (Levitra®): 5, 10 and 20mg; recommended starting dose 10mg (usually need 20mg)
Sildenafil (Viagra®): 25, 50 and 100mg; recommended starting dose 50mg (usually need 100mg)
Daily dosing:

Tadalafil (Cialis®): 5mg at the same time every day. The dose may be decreased to 2.5mg but not exceed 5mg daily Adapt dose as necessary, according to the response and side-effects Treatment is not considered a failure until full dose is trialed 7-8 times Ensure patient knows that sexual stimulation is required for drug to work Common side-effects: headaches, flushing, dyspepsia, nasal congestion, backache and myalgia Contraindicated in patients who take long and short-acting nitrates, nitrate-containing medications, or recreational nitrates (amyl nitrate)
Exercise caution when considering PDE5 inhibitors for patients with: active coronary ischaemia, congestive heart failure and borderline low blood pressure, borderline low cardiac volume status, a complicated multi-drug antihypertensive program, and drug therapy
that can prolong the half-life of PDE5 inhibitors
Counselling and education

Offer brief counselling and education in-practice to address psychological issues linked with ED, such as relationship difficulties, sexual performance concerns, anxiety and depression Consider concurrent patient/couple counselling with a psychologist, to address more complex issues, and/or to provide support during other treatment trials
Vacuum devices and rings

Suitable for men who are not interested in, or have contraindications for pharmacologic therapies Typically suitable for patients in long-term relationships Adverse effects include penile discomfort, numbness and delayed ejaculation 3rd Line Treatment › consider referral or specialist training
Intracavernous vasoactive drug injection

alprostadil (Caverject Impulse®): 10 and 20mcg is the first choice for its high rate of effectiveness
and low risk of priapism and cavernosal fibrosis. Alprostadil is commonly used in isolation, or combined with other vasoactive drugs (bimix/trimix) to increase efficacy or reduce side-effects Commence with minimum effective dose and titrate upwards if necessary Initial trial dose should be administered under supervision of an experienced GP or specialist Erection usually appears after 5-15mins and lasts according to dose injected. Aim for hard erection not to last longer than 60mins Recommended maximum usage is 3 times a week, with at least 24hrs between uses Contraindicated in men with history of hypersensitivity to drug or risk of priapism
Patient comfort and education are essential. Inform patient of side-effects (priapism, pain, fibrosis and bruising- particularly if on Aspirin or Warfarin). Provide a plan for urgent treatment of side-effects if necessary 4th Line Treatment › Refer to Urologist
Surgical treatments

Penile prosthesis: A highly successful option for patients who prefer a permanent solution or have not had success with pharmacologic
therapy. Surgery is irreversible and eliminates the normal function of the corpus cavernosa. Cost may be a limiting factor for some patients Vascular surgery: Microvascular arterial bypass and venous ligation surgery can increase arterial inflow and decrease venous outflow.
Uncommon procedure and requires specialist evaluation Acknowledgement: this guide is based on our original ED guide supported by Eli Lilly Australia


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