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Erectile Dysfunction

Erectile dysfunction ( ED )  Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance

Very common disorder Massachusetts Male Aging Study ( MMAS ) 1987-97 an important study revealed that 52 % men ( aged 40-70 yrs ) reported erectile dysfunction Prevalence and severity ↑es with age ED is a strong

 predictor
 
of CVD in particular

 CAD

Risk factors Shares both unmodifiable and modifiable risk factors with CVD
○ diabetes
○ obesity
○ dyslipidemia
○ metabolic syndrome
○ lack of exercise
○ smoking , alcohol Age Poor physical and psychological health Lower urinary tract symptoms and BPH

Causes – vasculogenic Generalised CV disease Hypertension Hyperlipidemia Diabetes Smoking Major pelvic surgery or Radiotherapy ( pelvis or retroperitoneum ) Neurogenic -Degenerative disorders -eg multiple sclerosis , Parkinson’s , multiple atrophy etc Spinal cord trauma or diseases Stroke CNS tumours Hormonal-Hypogonadism Hyperprolactinaemia Hyperthyroidism , Hypothyroidism Cushing’s disease Hypopituitarism following traumatic brain injury Anatomical-Eg cavernous fibrosis , Peyronie’s disease and penile fracture , micropenis , hypospadias , epispadias Psychological-Can be predisposing ( risk factors ) precipitating 
( present ) or maintaining ( ongoing ) causes

History –Detailed medical and sexual history
 Comorbid conditions eg hypertension , peripheral vascular disease , diabetes , obesity , renal disease
 Sexual history should include
○ sexual orientation
○ previous and current sexual relationships
○ current emotional status
○ onset and duration of erectile problem
○ previous consultations and treatments

Validated psychometric questionnaires such as
○ International Index for Erectile Function ( IIEF ) or
○ Sexual health Inventory for Men ( SHIM ) – shorter version of IIEF can be used
 Two question scale for depression ( if depression suspected)
○ during the past month have you often been bothered by feeling down , depressed or hopeless ?
○ during the past month have you often been bothered by little interest or pleasure in doing things ?
 Lifestyle including alcohol , tobacco , illicit drugs 
 Symptoms of hypogonadism – loss of libido , loss of body hair , spontaneous hot flushes
 Pelvic surgery , radiation , trauma
 Medications

Examination-Focused physical examination
○ body weight
○ waist circumference
○ heart rate
○ blood pressure
○ pulses and sensation
 Examine genitalia 
○ may reveal hypogonadism ( small testes )
○ Peyronie’s disease
 Check for gynaecomastia and reduced body hair
 DRE- if symptoms of enlarged prostate
○ obstructive urinary symptoms in ED erection loss happens before orgasm whereas in premature ejaculation it happens afterwards 

Calculate the 10 year CV risk ( eg using QRisk2 calculator )

○ If not tested recently consider fasting blood glucose or Hba1c and lipid profile
○ ECG can be considered in younger men (< 60 )
 Controversy exists on the ideal endocrine workup


Free testosterone in 
the morning
( between 9-11 AM )



 Repeat testosterone SHBG Check FSH LH Prolactin levels 

Lifestyle –Usually responds well to combination of lifestyle changes and drugs Lifestyle advice ( where applicable )
○ weight loss
○ smoking cessation
○ ↓ alcohol intake
○ ↑ exercise

All PDE5-Inhibitors slow the degradation of cGMP Inhibition leads to prolonged activity of cGMP Decreases the intracellular Calcium conc , maintains smooth muscle relaxation Rigid penile erections Men with Coronary Heart Disease- Most men can safely resume sexual activity and use PDE-5Is. 
Exception being Unstable heart disease H/O recent MI ( CKS NHS – within 6 months ) Poorly compensated heart failure Unstable dysarrythmia

Contraindications- If on nitrates in any form 
( risk of severe hypotension ) Who have lost sight in one eye due to non-arteritic anterior ischaemic optic neuropathy Hypotension ( systolic < 90 ) Recent stroke Unstable angina
 Vardenefil is CI in 
○ severe hepatic impairment
○ end stage renal disease patients on dialysis
○ known hereditary retinal degenerative disorders as retinitis pigmentosa
 Sildenefil is CI in
○ severe hepatic impairment
○ hereditary degenerative disorders as PRetinosa
 Tadalafil is CI in men with
○ NYHA class2 or greater heart failure in the last 6 months
○ uncontrolled arryhtmias
○ uncontrolled hypertension
 Caution-CV disease LV outflow obstruction Anatomical deformation of penis ( eg angulation , cavernosal fibrosis or Peyronie’s disease ) Predisposition to priapism eg
○ sickle cell disease
○ Multiple-myeloma
○ Leukaemia

35 % patients may
 fail to repond- common causes Diabetes , severe neurological or vascular diseases Start low and
 titrate upwards if ineffective

LINKS AND RESOURCES

PATIENT INFORMATION

Information from British Association of Urological Surgeons ( printable 7 pages ) https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Erectile%20dysfunction.pdf

Urology Care Foundation – ED patient Guide- a complete patient guide- autodownload 12 pages https://www.urologyhealth.org/Documents/Product%20Store/Erectile-Dysfunction-Brochure.pdf

Printable 6 pages leaflet from Sexual Advice Association https://sexualadviceassociation.co.uk/wp-content/uploads/2016/02/Men-9.-Erectile-dysfunction-V4.pdf

Weblink for the page https://sexualadviceassociation.co.uk/erectile-dysfunction/

3 page information leaflet from Andrology Australia -very informative https://www.healthymale.org.au/files/resources/erectile_dysfunction_fact_sheet_healthy_male_2019.pdf

International Index of Erectile Dysfunction – patient questionnaire https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/iief.pdf#

The Sexual Health Inventory for Men ( SHIM ) Questionnaire https://www.pcf.org/c/the-sexual-health-inventory-for-men-shim-questionnaire/

 

INFORMATION FOR CLINICIANS

A very useful article from Australian Family Physician – Much more than prescribing a pill – Assessment and treatment of ED by the GP https://www.racgp.org.au/afp/2017/september/much-more-than-prescribing-a-pill/

Tips on talking about this problem – from AMS Health https://www.amsmenshealth.com/content/dam/American-Medical-Systems/diabeticEducators/tips/MH-397502-AA_Tips%20for%20the%20ED%20Talk-ED_FINAL.pdf

European Association of Urology Guidelines on ED , Premature Ejaculation , Penile Curvature and Priapism 2016 https://uroweb.org/wp-content/uploads/EAU-Guidelines-Male-Sexual-Dysfunction-2016-3.pdf

American Urological Association Guideline on ED 2018 https://www.auanet.org/guidelines/erectile-dysfunction-(ed)-guideline

Canadian Urological Association CUA Practice guidelines on ED 2015 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4336024/

British Society of Sexual Medicine Guidelines on the Management of ED 2017 http://www.bssm.org.uk/wp-content/uploads/2018/09/BSSM-ED-guidelines-2018-1.pdf

A comparison of guidelines between the UK and Europe  from Journal of Clinical Urology –https://www.baus.org.uk/_userfiles/pages/files/professionals/sections/ED.pdf

BNF on PDE5 inhibitors https://bnf.nice.org.uk/treatment-summary/erectile-dysfunction.html

Type 2 diabetes management on A4Medicine ADA -EASD guideline https://a4medicine.co.uk/ada-easd-guideline-management-type-2-diabetes/

 

References

  1. Clinical Review – Erectile dysfunction BMJ 2014 ; 348; g129
  2. Shamloul R, Ghanem H. Erectile dysfunction. Lancet. 2013;381(9861):153‐165. doi:10.1016/S0140-6736(12)60520-0 https://pubmed.ncbi.nlm.nih.gov/23040455/
  3. Bella, Anthony J et al. “2015 CUA Practice guidelines for erectile dysfunction.” Canadian Urological Association journal = Journal de l’Association des urologues du Canada vol. 9,1-2 (2015): 23-9. doi:10.5489/cuaj.2699 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4336024/
  4. CKS NHS Erectile dysfunction Dec 2014 https://cks.nice.org.uk/erectile-dysfunction
  5. Guidelines on Male Sexual Dysfunction: Erectile dysfunction and premature ejaculation
    K. Hatzimouratidis (Chair), I. Eardley, F. Giuliano, I. Moncada, A. Salonia https://uroweb.org/wp-content/uploads/EAU-Guidelines-Male-Sexual-Dysfunction-2015-v2.pdf
  6. Pharmacological treatment of erectile dysfunction BMJ 20014 ; 329 : E310
  7. Guideline for the investigation and management of erectile dysfunction . Alberta Medical Association – via https://actt.albertadoctors.org/CPGs/Lists/CPGDocumentList/ED-Summary.pdf
  8. Erectile Dysfunction Am Fam Physician . 2016 Nov 15;94 (10 ): 820-827 (Abstract )
  9. Guidance for prescribing phosphodiesterase type-5 ( PDE5) inhibitors for erectile dysfunction in primary care North West Commissioning Support unit 2015
  10. Ludwig W, Phillips M. Organic causes of erectile dysfunction in men under 40. Urol Int. 2014;92(1):1-6. doi: 10.1159/000354931. Epub 2013 Nov 21. PMID: 24281298. ( Abstract )
  11. Kubin M, Wagner G, Fugl-Meyer AR. Epidemiology of erectile dysfunction. Int J Impot Res. 2003 Feb;15(1):63-71. doi: 10.1038/sj.ijir.3900949. PMID: 12605242. ( Abstract )
  12. Patel, D V et al. “Investigation of erectile dysfunction.” The British journal of radiology vol. 85 Spec No 1,Spec Iss 1 (2012): S69-78. doi:10.1259/bjr/20361140
  13. Mobley DFKhera MBaum N
    Recent advances in the treatment of erectile dysfunction

 

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