Erectile Dysfunction

Dr S Vas 2015

Learning Outcomes

• Understand what ED is

• Describe the causes of ED

• List relevant investigations

• Describe treatment in Primary Care

• Identify those patients requiring refarral to Secondary Care

Definition

• Erectile dysfunction is defined as – the persistent inability to attain and maintain an

erection sufficient to permit satisfactory sexual performance

Symptoms lasting 3 months should warrant further investigations/treatment

Prevalence

• 52% of men aged 40 to 70 reported some degree of ED

• On average a GP will see between 1 and 4 cases per month

Causes - Physical• Vascular

– cardiovascular disease, hypertension, hyperlipidaemia, diabetes mellitus, smoking

• Neurological– Multiple sclerosis, multiple atrophy, Parkinson's disease, tumours,

stroke, spinal disorders, diabetes mellitus, alcoholism, uraemia, polyneuropathy, surgery (of the pelvis or retroperitoneum)

• Anatomical or structural– Peyronie's disease, penile fracture, congenital curvature of the

penis, micropenis, hypospadias, epispadias

• Hormonal– Hypogonadism, hyperprolactinaemia, hyperthyroidism,

hypothyroidism, Cushing's disease, hypopituitarism following traumatic brain injury

Causes - Medication• Diuretics

– Thiazides (for example bendroflumethiazide), spironolactone

• Antihypertensives– Methyldopa, clonidine, beta-blockers (for example propranolol), verapamil

• Fibrates– Clofibrate, gemfibrozil

• Antipsychotics– Phenothiazines (for example chlorpromazine), butyrophenones (for example

haloperidol)

• Antidepressants– Tricyclics (for example amitriptyline), monoamine oxidase inhibitors (for example

phenelzine), selective serotonin reuptake inhibitors (for example fluoxetine), lithium

• Histamine (H2)-antagonists– Cimetidine, ranitidine

• Hormones and hormone-modifying drugs– Oestrogens (for example estradiol), progesterone, corticosteroids (for example

prednisolone), cyproterone acetate, 5-alpha reductase inhibitors (for example finasteride)

• Cytotoxics– Cyclophosphamide, methotrexate

• Anti-arrhythmics and anticonvulsants– Disopyramide, carbamazepine

Causes - Psychological

• Various factors– Lack of sexual knowledge

– Past sexual problems

– Relationship problems

– Restrictive upbringing

– Previous sexual abuse

– Unclear sexual or gender preference

– Family or social issues

– Mental health issues

History

• Relationship status (current and past) and sexual orientation

• Present and previous erection quality (including erections during sexual relations as well as awakening and masturbatory erections), and concomitant ejaculatory and orgasm dysfunction.

• Issues with sexual aversion or pain, or issues for his partner (including menopause or vaginal pain).

• Lifestyle, including use of alcohol, tobacco, and illicit drugs (including cannabis), and treatments already tried.

• Energy levels, loss of libido, loss of body hair, or spontaneous hot flushes (symptoms of hypogonadism).

Examination

• Body weight, waist circumference, blood pressure and pulse

• Genitalia

• +/- DRE (if symps of enlarged prostate)

Investigations

• Fasting Lipids/Glucose for CVD risk

• Testosterone (between 9 and 11 am)

• If Testosterone low or borderline check:– Repeat Testosterone– LH/FSH/Prolactin

Self Care Advice• Lifestyle changes

– Weight loss,smoking cessation, reduced alcohol and exercise

• Changes to medication– Only consider changing if appropriate substitute

• PDE-5 inhibitors

• If cycle > 3 hrs week consider “abstaining”

• Do not advise “unlicensed” herbal remedies

Questions?

Medical Treatment• PDE-5 inhibitors

– Sildenafil (Viagra) – effects last 4 hrs– Tadalafil (Cialis) – effects last 4 hrs– Vardenafil (Levitra) – effects last 17 hrs (“weekend-

warrior”)

• Contra-indications– Absolute in men receiving Nitrates in any form– Unstable heart disease, recent MI (within last 6

months), poorly controlled heart failure, unstable arrythmia

– + other more specific risk factors

SLS Criteria• Diabetes• MS• Parkinson’s Disease• Poliomyelitis• Prostate Cancer• Severe Pelvic Injury• Spina Bifida• Spinal Cord Injury• Single Gene Neuro Disease i.e. Huntingdon’s Disease• Renal dialysis for renal failure• Radical Pelvic Surgery, Prostatectomy or Renal transplant

Referral Criteria• Endocrine Referral

– Men with hypogonadism (i.e. low testosterone levels)

• Urology Referral

– Abnormality to the penis or testicles

– Young men who have always had difficulty in obtaining or maintaining an erection

– Men with a history of trauma (for example to the genital area, pelvis, or spine)

– Men who do not respond to the maximum dose of at least two phosphodiesterase-5 (PDE-5) inhibitors (person with erectile dysfunction should receive eight doses of a PDE-5 inhibitor with sexual stimulation at maximum dose before being classified as a non-responder)