Erectile dysfunction

ED is a persistent or recurrent inability to attain and/or maintain a penile erection sufficient for satisfactory sexual activity and intercourse

ED is a separate (but occasionally related) clinical condition to premature ejaculation, which has its own distinct management

ED is a common condition, with an average prevalence of 30%. Prevalence increases with age, from around 6% of men in their 40s to more than 60% of men aged over 70 years

ED is associated with chronic disease including cardiovascular disease and diabetes. Furthermore, ED may be an early warning sign of these chronic diseases

ED is a treatable condition that can impact strongly on the well-being of men and their partners

The sexual health of older patients is often overlooked

Understanding partners’ sexual needs is part of management

Genito-urinary: penis (plaques), testes (size)

Cardiovascular: BP, HR, waist circumference, cardiac examination, carotid bruits

Neurological: focused neurological examination (e.g. peripheral neuropathy)

Diabetes mellitus

Hyperlipidemia

Hypogonadism

Cardiovascular disease

Others as indicated

Cause: organic, psychosocial or combined

Determine patient and partner goals

Benefits, risks and costs of treatment options

Alter modifiable risk factors and causes

Counselling and education

Oral agents (PDE5 inhibitors)

Vacuum devices/rings

Consider specialist referral

Intracavernous vasoactive drug injection

Specialist referral

Surgical treatment (penile implants)

Modify medication regime: change current medications linked to ED (e.g. antidepressants, antihypertensives) when possible

Manage androgen deficiency: when diagnosed and a cause is established, androgen replacement therapy

Address psychosocial issues: includes relationship difficulties, anxiety, lifestyle changes or stress

Lifestyle changes: Smoking cessation, reduced alcohol, improved diet and exercise, weight loss, stress reduction, illicit drug cessation, compliance with diabetes and cardiovascular medications

Adapt dose as necessary, according to the response and side-effects

Treatment is not considered a failure until full dose is trialled 7-8 times

Ensure patient knows that sexual stimulation is required for drug to work

Common side-effects: headaches, flushing, dyspepsia, nasal congestion, backache and myalgia

Contraindicated in patients who take long and short-acting nitrates, nitrate-containing medications, or recreational nitrates (amyl nitrate or methamphetamines)

Exercise caution when considering PDE5 inhibitors for patients with active coronary ischaemia, congestive heart failure and borderline low blood pressure, borderline low cardiac volume status, a complicated multi-drug antihypertensive program, and drug therapy that can prolong the half-life of PDE5 inhibitors (consult patient’s cardiologist if in doubt)

Sildenafil: 25, 50 and 100 mg; recommended starting dose 50 mg (usually need 100 mg); should be taken on an empty stomach

Tadalafil: 10 and 20 mg; recommended starting dose 20 mg

Vardenafil: 5, 10 and 20 mg; recommended starting dose 10 mg (usually need 20 mg)

Tadalafil: 5 mg at the same time every day. The dose may be decreased to 2.5 mg but not exceed 5 mg daily

As of September 2020 sildenafil and taladafil are off-patent and have generics available, making these more affordable

Offer brief counselling and education to address psychological issues linked with ED, such as relationship difficulties, sexual performance concerns, anxiety and depression

Discuss sexual misinformation: Includes importance of sufficient arousal and lubrication, and realistic expectations, such as normal age-related changes

Consider concurrent patient/couple counselling with a psychologist, to address more complex issues, and/or to provide support during other treatment trials

Suitable for men who are not interested in or have contraindications for oral or injectable pharmacologic therapies

Typically suitable for patients in long-term relationships

Adverse effects include penile discomfort, numbness and painful ejaculation

Consider referral or specialist training/supervision

Alprostadil: 10 and 20 mg is the first choice for its high rate of effectiveness and low risk of priapism and cavernosal fibrosis. If erection is not adequate with alprostadil alone, it may be combined with other vasoactive drugs (bimix/trimix) to increase efficacy or reduce side-effects

Commence with minimum effective dose and titrate upwards if necessary

Initial trial dose should be administered under supervision of an experienced GP or specialist

Erection usually appears after 5 to 15 minutes and lasts according to dose injected. Aim for hard erection not to last longer than 30 minutes

Recommended maximum usage is 3 times a week, with at least 24 hours between uses

Contraindicated in men with history of hypersensitivity to drug or risk of priapism

Refer to urologist (surgical treatments).

Penile prosthesis (penile implant): A highly successful option for patients who prefer a permanent solution or have not had success with pharmacologic therapy. Surgery is irreversible and eliminates the normal function of the corpus cavernosa. Cost may be a limiting factor for some patients.

Topical nitrates and new oral agents are being evaluated and may play a role in treatment of ED in the future.

Level of GP training/experience

Counselling and education

Patient request

Complex endocrine disorders

Penile deformities

Patients for penile implants

Pelvic or perineal trauma

Treatment failure (e.g. poor or non-responders to medication)

Complex problems including vascular, neurological and treatment failures

Follow-up is essential to ensure the best patient outcomes

Effectiveness of treatment and patient/partner satisfaction

Any adverse effects of treatment

Overall physical and mental health

Partner’s sexual function (e.g., libido) and couple’s adaptation to changes to sex life