Ep 114 – Erectile dysfunction

In this episode, Dr Hannah Rosa discusses erectile dysfunction. Using the latest guidelines, this episode takes you through everything to consider when first reviewing a patient with erectile dysfunction, including key points to cover in the history and examination and which investigations to order. A four-step approach to management is discussed, along with guidance on referral and follow up.

Key references

1. NIH Consensus Conference. JAMA. 1993;270(1):83-90.
2. European Association of Urology. https://uroweb.org/guidelines/sexual-and-reproductive-health.
3. Hamilton W, et al. Br J Gen Pract. 2006;56(531):756-762.
4. Baumhäkel M, et al. Int J Clin Pract. 2011;65(3):289-298. doi: 10.1111/j.1742-1241.2010.02563.x.
5. British Association of Urological Surgeons. Erectile dysfunction (impotence). https://www.baus.org.uk/patients/conditions/3/erectile_dysfunction_impotence.
6. British Association of Urological Surgeons. Phosphodiesterase type-5 (PDE-5) inhibitors for erectile dysfunction. https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Viagra.pdf.
7. EROXON® StimGel. https://hcp.eroxon.co.uk/hcpentry/eroxon-unique-mechanism-of-action.
8. Boots. https://www.boots.com/eroxon-erectile-dysfunction-treatment-gel-4-pack-10327183.

Patient resources

• NHS. Erectile dysfunction. https://www.nhs.uk/conditions/erection-problems-erectile-dysfunction/.
• British Association of Urological Surgeons. Erectile dysfunction (impotence). https://www.baus.org.uk/patients/conditions/3/erectile_dysfunction_impotence.
• British Association of Urological Surgeons. Phosphodiesterase type-5 (PDE-5) inhibitors for erectile dysfunction. https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Viagra.pdf.
• NHS Electronic Drug Tariff England. https://www.drugtariff.nhsbsa.nhs.uk/#/00857004-DC/DC00856263/In%20England.
• NHS Electronic Drug Tariff Wales. https://www.drugtariff.nhsbsa.nhs.uk/#/00857004-DC/DC00856435/In%20Wales.

Key take-home points

• Erectile dysfunction may be due to a primary organic or psychogenic cause, but most cases are a mixture of both.
• An organic cause is suggested by a gradual onset of symptoms, lack of tumescence, and low-to-normal libido, whereas a psychogenic cause can result in a sudden onset of symptoms, low libido and good quality spontaneous or self-stimulated erections.
• A population-based case-control study published in 2006 found that the positive predictive value of erectile dysfunction leading to a diagnosis of prostate cancer was 3%. This places it higher than many other symptoms including frequency, nocturia, haematuria and weight loss.
• We should consider doing a digital rectal examination to assess the prostate – especially in men over the age of 50, or in men with a previous history of prostate cancer, obstructive lower urinary tract symptoms or other symptoms such as prolonged ejaculation.
• All men presenting with erectile dysfunction should have blood tests for HbA1c or a fasting blood glucose, lipids and a fasting serum total testosterone. Depending on the likely underlying cause and clinical judgement, testing prostate-specific antigen, liver function, thyroid function, urea and electrolytes and prolactin should also be considered.
• Four steps to management:
  • Provide patient information
  • Advise patients about any lifestyle modifications
  • Optimise the management of any reversible or modifiable risk factors or conditions, such as diabetes, hypertension and dyslipidaemia
  • Consider treatment with a phosphodiesterase-5 (PDE-5) inhibitor, and then arrange follow-up 6–8 weeks later.
• PDE-5 inhibitors should not be prescribed to patients who have a high cardiac risk or who regularly or intermittently use nitrates, such as glyceryl trinitrate spray, nicorandil or recreational drug poppers.
• Generic sildenafil can be prescribed without restriction on the NHS in England. Viagra, tadalafil, vardenafil and avanafil are not prescribable on the NHS for erectile dysfunction unless the man has one of the specific medical conditions, or previous treatments, listed in the selective list scheme.
• Patients may benefit from a referral to urology, endocrinology, cardiology, mental health or for psychosexual or relationship counselling.