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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

of CVD in particular


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

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



Information from British Association of Urological Surgeons ( printable 7 pages )

Urology Care Foundation – ED patient Guide- a complete patient guide- autodownload 12 pages

Printable 6 pages leaflet from Sexual Advice Association

Weblink for the page

3 page information leaflet from Andrology Australia -very informative

International Index of Erectile Dysfunction – patient questionnaire

The Sexual Health Inventory for Men ( SHIM ) Questionnaire



A very useful article from Australian Family Physician – Much more than prescribing a pill – Assessment and treatment of ED by the GP

Tips on talking about this problem – from AMS Health

European Association of Urology Guidelines on ED , Premature Ejaculation , Penile Curvature and Priapism 2016

American Urological Association Guideline on ED 2018

Canadian Urological Association CUA Practice guidelines on ED 2015

British Society of Sexual Medicine Guidelines on the Management of ED 2017

A comparison of guidelines between the UK and Europe  from Journal of Clinical Urology –

BNF on PDE5 inhibitors

Type 2 diabetes management on A4Medicine ADA -EASD guideline



  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
  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
  4. CKS NHS Erectile dysfunction Dec 2014
  5. Guidelines on Male Sexual Dysfunction: Erectile dysfunction and premature ejaculation
    K. Hatzimouratidis (Chair), I. Eardley, F. Giuliano, I. Moncada, A. Salonia
  6. Pharmacological treatment of erectile dysfunction BMJ 20014 ; 329 : E310
  7. Guideline for the investigation and management of erectile dysfunction . Alberta Medical Association – via
  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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