Bssm.org.uk

Obstetrics, GynaecOlOGy & UrOlOGy
Guidelines on the management of erectile dysfunction
• British Society for Sexual Medicine •
Epidemiology and risk factors
– the symptoms of hypogonadism– other urological symptoms (past or present) • Erectile dysfunction (ED) has been defined as the persistent inability to attain and/or maintain • A digital rectal examination (DRE) of the an erection sufficient for sexual performance prostate is not mandatory in ED but should be conducted in the presence of genito-urinary or • The risk factors for ED (sedentary lifestyle, protracted secondary ejaculatory symptoms obesity, smoking, hypercholesterolaemia and the metabolic syndrome) are very similar to the risk factors for cardiovascular disease (CVD) circumference and weight should be measured • It is clear ED may be associated with other Laboratory testing
causes of CVD such as hypertension, dyslipidaemia and endothelial dysfunction. ED • The choice of investigations depends on may be the first presentation of serious medical the individual circumstances of the patient. conditions such as diabetes or hypertension Serum lipids and fasting plasma glucose should be measured in al patients Diagnosis
• Hypogonadism is a treatable cause of ED that may also make men less responsive, or even non- Initial assessment
responsive, to phosphodiesterase type 5 (PDE5) inhibitors; therefore, al men with ED should have • Sexual history – a detailed description of the serum testosterone measured on a blood sample problem, including the duration of symptoms taken in the morning between 08.00 and 11.00 and original precipitants, should be obtained • Serum prostate specific antigen (PSA) • Concurrent medical, psychiatric and surgical should be considered if clinical y indicated. history should also be recorded, as should the current relationship status, history of previous sexual partners and relationships. Issues of regular intervals during testosterone therapy sexual orientation and gender identity should also be noted. Final y, the patient should be asked Cardiovascular system
about alcohol, smoking and il icit drug misuse • Coronary heart disease (CHD) is associated • The use of validated questionnaires, particularly with many of the same risk factors as ED. the International Index of Erectile Function (I EF) Coronary artery disease (CAD) is often just or the validated shorter version of the SHIM one affected site in a generalised arteriopathy (Sexual Health Inventory for Men) may be helpful that is also likely to affect the arterial inflow to the corpora cavernosum of the penis Physical examinations
• Al patients should have a physical examination. A genital examination is recommended, and this is essential if there is a history of: thorough evaluation and any risk factors for CHD that are identified should be addressed – deviation of the penis during tumescence Obstetrics, GynaecOlOGy & UrOlOGy
• A man with ED and no cardiac symptoms is a cardiac patient until proven otherwise cardiovascular (CV) patient provides an ideal and effective opportunity to address other CV risk factors and improve treatment outcomes Reversible causes of ED
• Men with previously-diagnosed CHD should be asked about ED as part of their routine surveil ance and management; ED treatments • Current NICE guidance recommends that al men with type 2 diabetes be asked annual y about • Post-traumatic arteriogenic ED in young patients ED, assessed, and offered oral treatment with the medication with the lowest acquisition cost • Drug-induced ED – drugs may affect • There is no evidence that currently licensed – drugs that cause sedation may affect treatments for ED add to the overal CV risk in sexual motivation and, indirectly, cause ED patients with or without previously-diagnosed CVD – drugs that affect CV function, such as antihypertensive agents, may act central y Specialised investigations
– some drugs affect endocrine parameters • Most patients do not need further investigations unless specifical y indicated. However, some patients wish to know the aetiology of their ED – drugs that cause hyperprolactinaemia, and should be investigated appropriately. Other indications for specialist investigations include: – young patients who have always had difficulty in obtaining and/or sustaining an erection – patients unresponsive to medical therapies that may desire surgical treatment for ED Lifestyle management
Penile abnormalities
• Lifestyle modifications can greatly reduce • Surgical problems that cause ED, e.g. phimosis, the risk of ED, and should accompany any tight frenulum and penile curvatures, should be specific pharmacotherapy or psychological diagnosed clinical y and are usual y simple to treat surgical y, which results in a permanent cure of ED should not be withheld on the basis that lifestyle changes have not been made Treatment
• The primary goal of management of ED is – adverse side-effects of non-prescription drugs to enable the individual or couple to enjoy a satisfactory sexual experience. This involves: Obstetrics, GynaecOlOGy & UrOlOGy
Management algorithm according to graded cardiovascular risk
Sexual inquiry
Risk factors and CHD evaluation, treatment and follow-up for all patients with ED ED management recommendations
Cardiovascular status upon presentation
for the primary care physician
• Controlled hypertension• Asymptomatic ≤3 risk factors for • Manage within the primary care setting • Review treatment options with patient • Post successful revascularisation• CHF (NYHA class I) interMediate riSk
• Recent MI or CVA (i.e. within last 6 weeks)• Asymptomatic but >3 risk factors for • Patient to be placed in high or low risk category, depending upon outcome of testing high riSk
• Severe or unstable or refractory angina• Uncontrolled hypertension • Treatment for ED to be deferred until • Recent MI or CVA (i.e. within last 14 days) • Hypertrophic cardiomyopathy• Moderate/severe valve disease ED=erectile dysfunction; CAD=coronary artery disease; NYHA= New York Heart Association; MI=myocardial infarction; CVA=cerebral vascular accident; LVD=left ventricular dysfunction; CHF=congestive heart failure; TIA=transient ischaemic attack; SBP=systolic blood pressure.
Obstetrics, GynaecOlOGy & UrOlOGy
• The potential advantages of lifestyle changes may be particularly pronounced in those with in such cases and clinical trials suggest a psychogenic ED, but patients with serious marked reduction in reported adverse events medical il nesses such as diabetes may also benefit from these changes, e.g. weight loss – are highly effective in inducing erections Hypogonadism and testosterone
replacement therapy
• The cause of hypogonadism should always be sought before treatment with testosterone is initiated, but this does not mean that treatment for ED should be deferred. Prior assessment and – most men who are satisfied with vacuum safety monitoring should be performed according – adverse effects include bruising, local pain, and failure to ejaculate. Partners • Men with a total serum testosterone that is consistently <12 nmol/l might benefit from up – serious adverse events are very rare to a 6 months trial of testosterone replacement therapy for ED and should be managed according to current guidelines (see algorithm below) Second-line treatment
• A range of wel -tolerated testosterone – long-acting (three-monthly) testosterone injection or daily application of a transdermal testosterone gel are acceptable to most men Third-line treatment
First-line treatment
– should be offered to al patients who are unwil ing to consider, failing to respond to, or unable to continue with medical therapy or – have proven efficacy and safety both external devices. Al patients and their partners should be counsel ed pre-operatively, see and handle al the available devices and, if possible, speak to other patients who have had surgery – particularly suitable for those with severe – sildenafil and vardenafil are relatively short-acting drugs, having a half life of Peyronie’s disease or post priapism. Al approximately 4 hours, whereas tadalafil has patients should be given a choice of either a significantly longer half life of 17.5 hours – are not initiators of erection but require sexual stimulation in order to facilitate an erection. It
is currently recommended that patients should Patient/partner education –
receive eight doses of a PDE5 inhibitor with
consultation and referrals
sexual stimulation at maximum dose before classifying a patient as a non-responder • The primary reason for referral to the clinician – tadalafil is licensed for daily use at 2.5 mg and should be elicited. The motivating factors and expectations should be clarified as wel sexual activity more than twice per week. as the intention, or otherwise, of the partner Obstetrics, GynaecOlOGy & UrOlOGy
algorithm for androgen therapy in a man presenting with ed
Male with ED
Male with ED. Failure of PDE5i
First-time presentation
No previous T testing
– radical pelvic surgery severe pelvic injury – renal failure treated by dialysis or transplant • An understanding by the patient and partner of basic anatomy and physiology and the purpose of blood and specialist investigations is helpful – if patient is suffering severe distress • An explanation of the principles of the • The GP is recommended to refer if severe distress • Provision of educational information is is suspected. It is the role of the specialist to endorse that judgement. It is recommended that the fol owing should be taken into account: Government guidance on good
practice – hSC/177 (1999)
• ED associated with the fol owing medical – marked effect on interpersonal relationships conditions are deemed to qualify for prescription at NHS expense: • After an initial titration period, 1 tablet per week is considered to be appropriate for the majority of patients, but when more is required the GP should prescribe that quantity at NHS cost British Society for Sexual Medicine, Hol y Cottage, Fisherwick, Near Lichfield, Staffordshire WS14 9JL (% – 01543 432622) British Society for Sexual Medicine. Guidelines on the management of erectile dysfunction

Source: http://www.bssm.org.uk/downloads/BSSM_ED_Management_Guidelines_2009.pdf