Guidelines on the management of erectile dysfunction
• British Society for Sexual Medicine •
Epidemiology and risk factors
– other urological symptoms (past or present) • Erectile dysfunction (ED) has been defined as the persistent inability to attain and/or maintain an • A digital rectal examination (DRE) of the erection sufficient for sexual performance prostate is not mandatory in ED but should be conducted in the presence of genito-urinary or • The risk factors for ED (sedentary lifestyle, protracted secondary ejaculatory symptoms obesity, smoking, hypercholesterolaemia and the metabolic syndrome) are very similar to the risk • Blood pressure, heart rate, waist circumference • It is clear that ED may be associated with Laboratory testing
other causes of CVD such as hypertension, dyslipidaemia and endothelial dysfunction. ED • The choice of investigations depends on the may be the first presentation of serious medical individual circumstances of the patient. Serum conditions such as diabetes or hypertension Diagnosis
• Hypogonadism is a treatable cause of ED that may also make men less responsive, or even non- Initial assessment
responsive, to phosphodiesterase type 5 (PDE5) inhibitors; therefore, all men with ED should have • Sexual history—a detailed description of the serum testosterone measured on a blood sample problem, including the duration of symptoms and taken in the morning between 08.00 and 11.00 original precipitants, should be obtained • Serum prostate specific antigen (PSA) should • Concurrent medical, psychiatric and surgical be considered if clinical y indicated. It should history should also be recorded, as should the current relationship status, history of previous testosterone therapy and at regular intervals sexual partners and relationships. Issues of sexual orientation and gender identity should also be noted. Final y, the patient should be asked Cardiovascular system
about alcohol, smoking and il icit drug misuse • Coronary heart disease (CHD) is associated • The use of validated questionnaires, particularly with many of the same risk factors as ED. the International Index of Erectile Function (I EF) Coronary artery disease (CAD) is often just one or the validated shorter version of the SHIM affected site in a generalised arteriopathy that (Sexual Health Inventory for Men) may be helpful is also likely to affect the arterial inflow to the corpora cavernosum of the penis Physical examinations
• ED in an otherwise asymptomatic man may • All patients should have a physical examination. A genital examination is recommended, and this is with unexplained ED should have a thorough evaluation and any risk factors for CHD that are – deviation of the penis during tumescence OBSTETRICS, GYNAECOLOGY & UROLOGY
• A man with ED and no cardiac symptoms is a – identifying and treating any curable causes of ED – initiating lifestyle change and risk factor – providing education and counsel ing to cardiovascular (CV) patient provides an ideal and effective opportunity to address other CV risk factors and improve treatment outcomes Reversible causes of ED
• Men with previously-diagnosed CHD should be asked about ED as part of their routine surveil ance and management; ED treatments • Current NICE guidance recommends that all men • Post-traumatic arteriogenic ED in young patients with type 2 diabetes be asked annual y about ED, assessed, and offered oral treatment with • Drug-induced ED—drugs may affect sexual the medication with the lowest acquisition cost – drugs that cause sedation may affect sexual • There is no evidence that currently licensed treatments for ED add to the overall CV risk in – drugs that affect CV function, such as patients with or without previously-diagnosed CVD antihypertensive agents, may act central y and may also affect penile haemodynamics Specialised investigations
– some drugs affect endocrine parameters— anti-androgens and oestrogens may affect • Most patients do not need further investigations unless specifical y indicated. However, some – drugs that cause hyperprolactinaemia, such patients wish to know the aetiology of their ED as phenothiazines, may also affect sexual and should be investigated appropriately. Other indications for specialist investigations include: – young patients who have always had difficulty • Partner sexual problems in obtaining and/or sustaining an erection – where an abnormality of the testes or penis is – patients unresponsive to medical therapies that may desire surgical treatment for ED Lifestyle management
Penile abnormalities
• Lifestyle modifications can greatly reduce the risk of ED, and should accompany any specific • Surgical problems that cause ED, e.g. phimosis, pharmacotherapy or psychological therapy. tight frenulum and penile curvatures, should be diagnosed clinical y and are usual y simple to treat withheld on the basis that lifestyle changes surgical y, which results in a permanent cure of ED Treatment
– adverse side-effects of non-prescription drugs • The primary goal of management of ED is – influence of any co-morbidities, including those to enable the individual or couple to enjoy a satisfactory sexual experience. This involves: OBSTETRICS, GYNAECOLOGY & UROLOGY
Management algorithm according to graded cardiovascular risk
Sexual inquiry
Risk factors and CHD evaluation, treatment and follow-up for all patients with ED ED management recommendations
Cardiovascular status upon presentation
for the primary care physician
• Controlled hypertension• Asymptomatic ≤3 risk factors for CAD – • Manage within the primary care setting • Review treatment options with patient and his • Post successful revascularisation• CHF (NYHA class I) INTERMEDIATE RISK
• Recent MI or CVA (i.e. within last 6 weeks)• Asymptomatic but >3 risk factors for CAD – • Specialised evaluation recommended (e.g. exercise test for angina, echocardiogram for • Patient to be placed in high or low risk category, depending upon outcome of testing HIGH RISK
• Severe or unstable or refractory angina• Uncontrolled hypertension • Refer for specialised cardiac evaluation and • Treatment for ED to be deferred until cardiac • Recent MI or CVA (i.e. within last 14 days) • Hypertrophic cardiomyopathy• Moderate/severe valve disease ED=erectile dysfunction; CAD=coronary artery disease; NYHA= New York Heart Association; MI=myocardial infarction; CVA=cerebral vascular accident; LVD=left ventricular dysfunction; CHF=congestive heart failure; TIA=transient ischaemic attack; SBP=systolic blood pressure.
• The potential advantages of lifestyle changes reported adverse events. Vardenafil is also may be particularly pronounced in those with available as a 10 mg oro-dispersable tablet psychogenic ED, but patients with serious medical il nesses such as diabetes may also benefit from these changes, e.g. weight loss – are highly effective in inducing erections Hypogonadism and testosterone
– reported satisfaction rates vary considerably replacement therapy
– long-term usage of vacuum devices also • The cause of hypogonadism should always be varies but is considerably higher than for self- sought before treatment with testosterone is initiated, but this does not mean that treatment – most men who are satisfied with vacuum for ED should be deferred. Prior assessment and safety monitoring should be performed according – adverse effects include bruising, local pain, and failure to ejaculate. Partners sometimes report the penis feels cold • Men with a total serum testosterone that is – serious adverse events are very rare but skin consistently <12 nmol/l might benefit from up to a 6 months trial of testosterone replacement
therapy for ED and should be managed according Second-line treatment
to current guidelines (see algorithm below)
• A range of wel -tolerated testosterone – long-acting (three-monthly) testosterone injection or daily application of a transdermal • Topical alprostadil, taken with a substance that testosterone gel are acceptable to most men enhances skin penetration, can be applied to the tip of the penis First-line treatment
Third-line treatment
• PDE5 inhibitors (e.g. sildenafil, tadalafil, vardenafil): – have proven efficacy and safety both in non- selected populations of men with ED and in – should be offered to all patients who are specific sub-groups of patients (e.g, men with unwil ing to consider, failing to respond to, or diabetes and those who have had a prostatectomy) unable to continue with medical therapy or – sildenafil and vardenafil are relatively external devices. All patients and their partners short-acting drugs, having a half life of should be counsel ed pre-operatively, see and approximately 4 hours, whereas tadalafil has handle al the available devices and, if possible, a significantly longer half life of 17.5 hours speak to other patients who have had surgery – are not initiators of erection but require sexual – particularly suitable for those with severe organic stimulation in order to facilitate an erection. It ED, especial y if the cause is Peyronie’s disease is currently recommended that patients should or post priapism. All patients should be given a receive eight doses of a PDE5 inhibitor with choice of either a malleable or inflatable prosthesis sexual stimulation at maximum dose before classifying a patient as a non-responder – tadalafil is licensed for daily use at 2.5 mg and Patient/partner education—
5 mg for patients who anticipate sexual activity consultation and referrals
more than twice per week. This regimen may
be more cost effective in such cases and
• The primary reason for referral to the clinician clinical trials suggest a marked reduction in should be elicited. The motivating factors and OBSTETRICS, GYNAECOLOGY & UROLOGY
Algorithm for androgen therapy in a man presenting with ED
Male with ED
Male with ED. Failure of PDE5i
First-time presentation
No previous T testing
expectations should be clarified as well as the – radical pelvic surgery – severe pelvic injury intention, or otherwise, of the partner to accept – renal failure treated by dialysis or transplant any specific pharmacological, physical or – NHS drug treatment before 15th September • An understanding by the patient and partner of basic anatomy and physiology and the purpose of – if patient is suffering severe distress on blood and specialist investigations is helpful • An explanation of the principles of the treatment • The GP is recommended to refer if severe distress is suspected. It is the role of the specialist to endorse that judgement. It is • Provision of educational information is valuable recommended that the fol owing should be – significant disruption to normal social and Government guidance on good
– marked effect on mood, behaviour, social practice—HSC/177 (1999)
– marked effect on interpersonal relationships • ED associated with the fol owing medical • After an initial titration period, 1 tablet per week is considered to be appropriate for the majority of patients, but when more is required the GP should prescribe that quantity at NHS cost full guideline available from…British Society for Sexual Medicine, Hol y Cottage, Fisherwick, Near Lichfield, Staffordshire WS14 9JL (% – 01543 432622); British Society for Sexual Medicine. Guidelines on the management of erectile dysfunction.


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