Erectile Dysfunction Pathway

Erectile Dysfunction Pathway

Men who develop ED in their 40s are at higher risk of CVD, so it is important that these men have their cardiovascular risk factors assessed

Differentiate physical (gradual onset, loss of nocturnal/morning erections) from psychogenic (sudden onset, maintains nocturnal erections, often associated relationship problems), smoking, drugs including recreational,

alcohol. Additionally, enquire about partner's physical and mental health.

If psychogenic consider psychosexual counselling if appropriate, couple therapy or

psychiatric referral if predominantly psychogenic ED

although physical treatment may be used in selected patients

Treat risk factors where possible and other treatable

causes

Examine for painful conditions: phimosis, balanitis, penile ulceration, a

short penile frenulum & penile induration due to Peyronie's disease.

Assess cardiovascular risk factors (incl. BMI & BP), general body habitus, evidence of normal, male hirsutism

Investigations

Blood lipids Urine dip for DM (+/- blood glucose),

Consider Prolactin (prolactin adenoma) or TSH (hypothyroidism) if suggestive

symptoms

(+/- PSA if lower urinary tract symptoms or abnormal digital rectal

examination)

Try each of the available PDE-5 inhibitors at a variety of doses over a

three month period

If no improvement consider further tests including testosterone, FSH/LH

(pituitary hypogonadism)

Offer lifestyle advice weight loss stop smoking

reduce alcohol intake increase exercise etc.

Consider urological referral if normal investigations and treatment contraindicated or fails

Produced November 2011 by WSCF and WSH. Clinical Leads: Dr John Mcloughlin, West Suffolk Hospital, Dr Jon Ferdinand, WSCF

Erectile Dysfunction notes

ED is increasingly becoming a common presentation to GPs. Prevalence of complete ED: 5% in 40yr-olds, 10% in 60s, 15% in 70s and 30-40%in 80s. It can have a severe effect on psychological and social well-being, and can negatively impact on personal relationships and may be a marker for hypertension, diabetes or depression.

Any painful, penile condition may inhibit erection simply by virtue of the pain it induces.

All patients with lifestyle problems should be offered advice as these are often the cause of ED advice e.g. weight loss, stop smoking, reduce alcohol intake, increase exercise etc

First-line treatment for organic erectile dysfunction is a PDE-5 inhibitor, initiated in general practice (within local guidance or offer a private prescription); this is effective in 65-75% of patients regardless

of the cause of the erectile dysfunction. Other treatments are only indicated if PDE-5 inhibitors are ineffective, associated with severe sideeffects or contraindicated (because of concomitant use of nitrates, either for angina or recreationally),

a suggested alternative treatment in primary care is intra-urethral prostaglandin (MUSE?) Consider referral to urology if ED is causing severe mental distress and unable to afford private PDE-5

Secondary care treatment options include: Self-administered penile prostaglandin injections (Viridal Duo? or Caverject?), Vacuum erection assistance devices or failing that, insertion of penile prostheses.

Produced November 2011 by WSCF and WSH. Clinical Leads: Dr John Mcloughlin, Consultant Urologist, West Suffolk Hospital & Dr Jon Ferdinand, GP, WSCF References: European Association of Urology (2005) Guidelines on erectile dysfunction. Clinical Knowledge Summaries website: Erectile dysfunction

Top tips in two minutes: Erectile dysfunction - Mr Nimesh Shah, Consultant Urologist, Addenbrookes and Hinchingbrooke

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