Erectile Dysfunction

Overview

Erectile dysfunction can normally be assessed and managed in primary care see CKS Guidelines (1) . 

Assessment of a man with erectile dysfunction should include:

• A detailed history, including present and past erection quality, lifestyle (including alcohol intake, smoking status, and illicit drug use), and previous treatments tried.
• A focused physical examination to identify any genitourinary, endocrine, vascular, or neurological causes of erectile dysfunction. 
• Appropriate investigations: Initially theses should include HbA1, lipid profile and total testosterone (9am/ early morning) to identify any reversible/modifiable risk factors. If testosterone is low or borderline then also consider checking LH, FSH, prolactin and sex hormone binding globulin (SHBG). There is an ICE profile for ED that includes these investigations.

Medication can be used to successfully treat erectile dysfunction (ED) in at least two-thirds of men. Phosphodiesterase-5 inhibitors (PDE5 inhibitors) are the first line recommended pharmacological treatment, however please see prescribing information below.

Before Referral

Give Lifestyle Advice

Lifestyle changes and risk factor modification must precede or accompany treatment with a PDE-5 inhibitor.

Erectile dysfunction usually responds well to a combination of lifestyle measures (such as weight loss, smoking cessation, and reducing alcohol consumption) and drug treatment.

Assess Cardiovascular Risk

Complete a cardiac risk assessment, such as QRisk, including a blood pressure check and ED blood screen (profile is on ICE).

ED is a marker for cardiovascular disease and is included in QRisk3

Review Medication

Drugs that can cause erectile dysfunction include antihypertensives, antipsychotics, and antidepressants

Address other causes

It is important to note that ED may have organic, psychogenic causes and/or be drug-induced. 

Pharmacological management

Key points

Patients should be advised that PDE-5 inhibitors are not initiators of erection but require sexual stimulation in order to facilitate erection.

There may be many reasons why patients don't respond initially to PDE-5 inhibitors and a sustained trial of treatment at adequate doses may be needed before a response is seen (2,3)

People with ED should receive 6-8 doses of at least 2 recommended PDE-5 inhibitors at maximum doses with sexual stimulation before being considered as a non-responder (2).

Generic Sildenafil and Tadalafil are recommended as first and second line PDE-5 inhibitors in the BNSSG Clinical Guideline: Primary Care Prescribing of PDE5-inhibitors for Erectile Dysfunction. This pathway should be followed before referral is considered.

Possible reasons for poor or non-response to PDE-5 inhibitors (2)

• Comorbidities -  including diabetes, cardiovascular disease, and metabolic syndrome.
• Drugs - e.g. selective serotonin-reuptake inhibitors, thiazides, and β-blockers.
• Lifestyle factors - excessive drinking, smoking, high-fat diet.
• Administration factors - e.g. taking the medication after heavy meals, a lack of sexual stimulation, administration timing, too few attempts.
• Psychological factors

Referral

Most men with ED can be managed in primary care using the guidelines above. Referral for prescribing of PDE5 inhibitors alone is not required as detailed in above prescribing guidance.

See guidance below for advice on when to refer and to what service:

• Urology (via eRS or consider A&G service) — for young men who have always had erectile dysfunction and for all men with a history of trauma to genital area, pelvis or spine; abnormality of the penis or testicles; or no response to maximum dose of at least two PDE-5 inhibitors.
• Endocrinology (via eRS) — if hypogonadism is suspected (abnormal serum testosterone, follicle-stimulating hormone, luteinizing hormone or prolactin levels). Please see the Hypogonadism page for further details.
• Cardiology (via eRS or consider A&G service)  — if the man has CVD that makes sexual activity unsafe or contraindicates PDE-5 inhibitor use.
• Sexual health services for psychosexual therapy (not available via eRS)  — if an underlying psychogenic cause is suspected. See Sexual Health Services (Unity) 

Resources

(1) Erectile dysfunction | Health topics A to Z | CKS | NICE

(2) British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men-2017 (bssm.org.uk)

(3) Practical Approaches to Treat ED in PDE5i Nonresponders - PMC (nih.gov)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.