Dr Jonny Coxon explains how to deliver care for men with ED in general practice and when to refer
Read this article to learn more about:
- creating a comfortable environment to facilitate discussion of symptoms
- how the IIEF-5 questionnaire can help assess the severity of erectile dysfunction symptoms
- what therapies are available to treat erectile dysfunction.
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Erectile dysfunction (ED) can be defined as a consistent or recurrent inability to achieve and/or maintain a penile erection sufficient for sexual activity. It is a common sexual problem that GPs will be familiar with seeing in men of all ages, and which increases with age.1 Men with ED may find that it causes a significant impact on their quality of life, as well as that of their partner’s. Erectile dysfunction may be thought of as a symptom rather than a specific disease, and is associated with many comorbidities.
Reported figures for prevalence of ED vary considerably. This is likely due to several factors, including different patient populations, methodologies, and definitions for ED. That said, there is a clear association between ED and increasing age. A high-quality review of epidemiological ED literature in 2013 confirmed this, and provided some useful figures for prevalence across studies (see Table 1).1
Table 1: Prevalence of ED in different age groups1
|Age (years)||Prevalence (%)|
Comorbidities with erectile dysfunction
Attaining an erection involves a complex interplay between psychological, hormonal, neurological, vascular, and tissue components. Conditions that affect any of these can therefore be associated with ED. Table 2 outlines some important pathophysiological factors.2
Table 2: Pathophysiology of erectile dysfunction2
|Vasculogenic||Cardiovascular disease (hypertension, coronary artery disease, peripheral vasculopathy, etc.)|
|Major pelvic surgery (e.g. radical prostatectomy) or radiotherapy|
|Neurogenic||Central causes||Degenerative disorders (multiple sclerosis, Parkinson’s disease, etc.)|
|Spinal cord trauma or diseases|
|Peripheral causes||Diabetes mellitus|
|Chronic renal failure|
|Surgery (major surgery of pelvis/retroperitoneum)|
|Anatomical or structural
|Hyperthyroidism and hypothyroidism|
|Drug-induced||Antihypertensives (e.g. thiazides, most beta-blockers except nebivolol; ARBs tend to be better for erectile function than ACE inhibitors)|
|Antidepressants (SSRIs, tricyclics)|
|Antipsychotics (neuroleptics, etc.)|
|Recreational drugs (alcohol, heroin, cocaine, marijuana, methadone, anabolic steroids, etc.)|
|Psychogenic||Generalised type (e.g. depression, anxiety, lack of arousability, disorders of sexual intimacy)|
|Situational type (e.g. partner-related, performance-related)|
|ARB=angiotensin receptor blocker; ACE=angiotensin-converting enzyme; SSRI=selective serotonin reuptake inhibitor|
|Adapted from Hatzimouratidis K, Giuliano F, Moncada I et al. Male sexual dysfunction. European Association of Urology 2017. uroweb.org/guideline/male-sexual-dysfunction/
Reproduced with kind permission.
It should be noted that ED may be the first presentation of some medical conditions, including diabetes, hypertension, and cardiovascular disease (CVD). Indeed, it is now well established that ED represents a crucial marker for the onset of CVD, potentially presenting a valuable window of opportunity to focus on primary prevention.3
It is now increasingly recognised that male lower urinary tract symptoms (LUTS) are closely linked to ED—probably sharing some of the same pathophysiology. It seems that most men seeking treatment for either LUTS or ED will in fact have both conditions.4
Role of primary care
The invaluable role of the primary care team starts by creating an environment in which a man feels comfortable discussing his symptoms. Confidence in asking men about sexual matters gets easier with practice. Some healthcare professionals benefit from various courses that are available in taking a sexual history, such as those offered by the STI Foundation.
It is unwise to make assumptions about sex life in older people. A large global study found that approximately one-half of men in their 70s had been sexually active in the last year.5
There are certainly some men for whom targeted questions about possible ED may be considered, such as those with diabetes, CVD, LUTS, or depression. For example, while no longer part of the quality and outcomes framework, a recommendation to offer men the opportunity to discuss ED as part of their annual review is included in the latest NICE guideline on type 2 diabetes in adults.6
Simple questions practitioners can ask may go along the lines of: ‘It is well known that men with “X” are more likely to have problems with their erections: is that something you have noticed to be an issue?’ Giving permission for men to discuss their ED symptoms is often hugely appreciated, and a dedicated appointment can then be arranged to explore any issues further.
Initial assessment and diagnosis
Primary care is well placed to arrange the initial assessment of ED.7 Duration, severity, and any precipitants of symptoms should be explored. Some clinicians and patients will prefer to complete a questionnaire to ‘score’ ED symptoms, which allows a considered assessment of different components. In the author’s experience, the most commonly used scale is the abbreviated version of the International Index of Erectile Function, the IIEF-5.8
In addition to establishing the severity of symptoms, it is important to understand the degree of bother that the ED is causing a man and/or his partner, as this will vary considerably between people. A relationship history is important, and a past medical history may be relevant, focusing on related comorbidities (see Table 2). Practitioners should also ask about:
- any other substance misuse.
Assessing and subsequently addressing mental health issues can be crucial. The aetiology of ED is sometimes divided into psychogenic and organic, and while practitioners may find more of the former in younger men and more of the latter in older men, the picture is often mixed. Nocturnal erections are more commonly maintained in psychogenic cases, but by no means always.
Examination of the genitalia will occasionally reveal abnormalities, such as plaques in Peyronie’s disease, or phimosis; these will often require referral to specialist care, depending on the severity and degree of bother. Blood tests are recommended and should include lipids, glucose/HbA1c, and morning (before 11 am) testosterone levels.7 Clinical suspicion may prompt a full blood count or thyroid function tests.
The 2015 NICE Guideline 12 on Suspected cancer9 recommends that practitioners consider a digital rectal examination (DRE) and prostate specific antigen (PSA) test in men with ED; however, in the author’s opinion, this has caused controversy in urological circles, as it is rare for ED and prostate cancer to be causally linked. Practitioners should assess DRE and PSA if testosterone replacement therapy is considered.7
Among the causes of ED, any that are reversible should, of course, be addressed where possible (e.g. sedentary lifestyle, medications, smoking, adverse lipid profile, poor diabetic control, and hypogonadism). This can range from a simple medication review to a specialist assessment for diagnosed hypogonadism (e.g. a total serum testosterone consistently <12 nmol/l, on a minimum of two morning samples.7,10)
Addressing lifestyle factors has been shown to improve erectile function; these factors include:11
- alcohol consumption
- physical activity.
This will also help treat associated morbidities, such as CVD risk and hypogonadism.11 There may also be a role for regular pelvic floor exercises.12
While access to psychosexual counselling is not always straightforward, it should certainly be considered for cases where a strong psychogenic component of the ED is suspected. For example, younger men with relatively sudden onset of ED that then proves to be longstanding are especially likely to benefit.
For most men with ongoing confirmed ED, first-line treatment will be a phosphodiesterase-5 inhibitor (PDE5I). In the UK, for understandable cost issues, the current favoured initial choice is sildenafil, which at the time of writing (June 2017) is the only PDE5I available for ED to all men on an NHS prescription;13 however, this may change as soon as patents expire for other treatments. NHS prescriptions for other PDE5Is (see Table 3) are limited to those men meeting the Schedule 2 (Selected List Scheme) criteria.
Table 3: Important differences between phosphodiesterase-5 inhibitors
|PDE5I||Maximum concentration (hrs)14||Approximate half-life (hrs)14||Effect of food on absorption of drug15||NHS prescriptions for all13|
|Sildenafil 100 mg||1||3||Reduced absorption||Yes|
|Tadalafil 20 mg||2||17.5||None||No|
|Vardenafil 20 mg||1||4||Reduced absorption||No|
|Avanafil 200 mg||0.5–0.75||6||Reduced absorption||No|
Phosphodiesterase-5 inhibitors are, on the whole, very safe medications. There is no evidence that currently licensed ED treatments add to CVD risk in patients with or without previously-diagnosed CVD.7 In terms of any CVD risk, encouraging sexual activity with ED medications is generally considered safe for men who can comfortably walk 1 mile on flat terrain in 20 minutes, or briskly climb two flights of stairs in 10 seconds.16
Co-administration of PDE5Is with nitrates should be avoided due to risk of hypotension. If a patient is taking nitrate containing-medications, there may be an opportunity to switch these to alternative medications. Alpha-blockers should be co-prescribed with caution.15
Common side-effects of PDE5Is include:15
- nasal congestion
- back pain
Reported rates of these vary with different PDE5Is, so switching to another PDE5I may be helpful if side-effects occur and are problematic to the individual.2
It is essential to emphasise to men that they should not just expect an erection to spontaneously arrive after taking a PDE5I. Inform patients that they need to wait approximately 1 hour, and then will still require adequate sexual stimulation to achieve an erection. Increased physical stimulation becomes more important with age.
Men should be encouraged to try at least eight doses of the maximally tolerated dose of a PDE5I before being classed as ‘non-responders’.7 Identifying men who do not respond to PDE5I therapy is made much easier by arranging a follow-up appointment, for example, 2 months after the start of treatment. At the follow up, confirm with the patient that the medication is being used correctly, and if so, try switching the dosage from ‘as-needed’ to ‘daily use’—this will resolve the situation for a good proportion of people who have not previously responded to treatment. Local referral pathways are likely to exist to help guide when to refer on. As an illustration, the BNF states: ‘Patients who fail to respond to the maximum dose of at least two different phosphodiesterase type-5 inhibitors should be referred to a specialist.’
Tadalafil 2.5–5 mg is a licensed once-daily option (the 5 mg dose is also licensed for benign prostatic hyperplasia).17 Sildenafil has a shorter half-life compared with tadalafil; however, its licence states one dose in 24 hours (with a maximum single dose of 100 mg),18 so (similarly to tadalafil) it can be taken daily rather than as required. It has been noted that taking sildenafil every night can increase nocturnal erections and successful sexual activity, with the current advantage of being much cheaper compared with tadalafil.19
It is of interest that the use of daily sildenafil is recommended as an early option in published UK recommendations for treatment of ED that is either post-surgical20 or resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer.21
There are several other options that can be prescribed for ED; however, confidence in prescribing these therapies in primary care may vary, and help from community or secondary-care clinics may be sought.
Vacuum erection devices can be very effective, but counselling in proper use is important. These devices are listed as a first-line treatment in the British Society for Sexual Medicine erectile dysfunction guideline; however, in real-life practice, accessing counselling on appropriate use is much more difficult than prescribing PDE5Is in primary care. Long-term use varies, but there is good uptake in men who find these devices helpful.7
Alprostadil can be introduced into the penis in various ways: via intracavernosal injection, intra-urethral pellets, or topically to the urethral meatus, in the form of a cream. Another type of licensed intracavernosal injection uses an aviptadil/phentolamine mix.7
It can sometimes be helpful to try various combinations of PDE5Is with these second-line medications.
There is increasing interest in the use of low-intensity extracorporeal shockwave therapy to treat ED,22 but evidence is inconsistent, and it is not widely available in the UK.
When all other therapies have failed, it is important that primary care clinicians are aware of the option of penile implants, which may be funded on the NHS for some patients (often men who have experienced ED after surgery, radiotherapy, or trauma).
When to refer
While most men with ED can be managed in primary care, some will need referring for further investigation (see Box 1).7
Box 1: Indications for specialist investigations7
The following are indications for specialist referral:
- young men who have always had difficulty in obtaining and/or sustaining an erection
- men with a history of trauma
- where an abnormality of the testes or penis is found on examination
- men who are unresponsive to medical therapies and may desire surgical treatment.
- British Society for Sexual Medicine: Guidelines on the management of erectile dysfunction7
- European Association of Urology guidelines on male sexual dysfunction: pocket guidelines.23
Erectile dysfunction is a condition that presents very commonly in primary care, particularly in older men with certain co-morbidities. There are many possible co-morbidities associated with ED, and ED in itself may represent a risk factor for developing established cardiovascular disease.
Previous advice on restricting prescribing PDE5Is has perhaps created an impression that effective treatment options are limited; however, these restrictions have now been lifted for generic sildenafil, with other PDE5Is likely to follow soon. Beyond these medications, practitioners and patients alike should be assured that many other effective management strategies exist, and can usually be accessed by specialist referral when appropriate.
- The prevalence of ED rises steeply with age
- Numerous comorbidities should be considered in patients with ED, especially diabetes, CVD, and depression
- ED may represent a crucial marker for CVD
- Several drugs (prescribed and recreational) can contribute to ED
- Taking a confident sexual history is important
- Use the IIEF-5 questionnaire to help grade severity
- Blood tests should include lipids, glucose/HbA1c, and morning (before 11 am) testosterone levels
- PDE5Is must be taken properly and given time to work, with adequate sexual stimulation
- Once-daily sildenafil may be helpful for some men, and can be cost effective
- Men with ED should be advised that there are several second- and third-line options.
GP commissioning take home messages for England
written by Dr David Jenner, GP, Cullompton, Devon
- Erectile dysfunction is a common disorder and GPs should be aware that it can be a possible symptom of other important pathologies, and not just a problem in its own right
- NHS commissioners should liaise with public health commissioners to ensure that ED services are jointly commissioned and available through sexual health clinics
- Commissioners could (with support from specialist sexual health providers) construct a care pathway for the management of ED, this should include all the necessary tests and examinations that primary care should consider
- the pathway should clearly identify referral criteria to specialist care and commissioners should ensure that these specialist care services are available locally
- Local formularies should identify the licensed indications and doses of available ED medications, and identify what medications are available on the NHS and for which indication.
- Eardley I. The incidence, prevalence, and natural history of erectile dysfunction. Sex Med Rev 2013; 1 (1): 3–16.
- Hatzimouratidis K, Giuliano F, Moncada I et al. Male sexual dysfunction. European Association of Urology, 2017. uroweb.org/guideline/male-sexual-dysfunction/ (accessed 14 June 2017).
- Gandaglia G, Briganti A, Jackson G et al. A systematic review of the association between erectile dysfunction and cardiovascular disease. Eur Urol 2014; 65 (5): 968–978.
- Seftel A, de la Rosette J, Birt J et al. Coexisting lower urinary tract symptoms and erectile dysfunction: a systematic review of epidemiological data. Int J Clin Pract 2013; 67 (1): 32–45.
- Nicolosi A, Laumann E, Glasser D et al. Sexual behavior and sexual dysfunctions after age 40: the global study of sexual attitudes and behaviors. Urology 2004; 64 (5): 991–997.
- National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. NICE Guideline 28. NICE, 2015 (updated May 2017). Available at: www.nice.org.uk/ng28
- British Society for Sexual Medicine. Guidelines on the management of erectile dysfunction. In: Hayeem N, editor. Guidelines—summarising clinical guidelines for primary care. 62nd ed. Chesham: MGP Ltd; March 2017. pp 216–221.
- Rosen R, Cappelleri J, Smith M et al. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Dysfunction (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res 1999; 11 (6): 319–326.
- National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. NICE Guideline 12. NICE, 2015. Available at: www.nice.org.uk/ng12
- Hackett G, Kirby M, Edwards D et al. UK policy statements on testosterone deficiency. Int J Clin pract 2017; 1–10.
- Kirby M. The circle of lifestyle and erectile dysfunction. Sex Med Rev 2015; 3 (3): 169–182.
- Siegel A. Pelvic floor muscle training in males: practical applications. Urology 2014; 84 (1): 1–7.
- NHS Choices. Can I get medication for erectile dysfunction (ED) on the NHS? www.nhs.uk/chq/pages/882.aspx (accessed 14 June 2017).
- Datapharm Ltd. Electronic medicines compendium. www.medicines.org.uk/emc/ (accessed 14 June 2017).
- British National Formulary. Phosphodiesterase type-5 inhibitors. NICE, 2017. www.evidence.nhs.uk/formulary/bnf/current/7-obstetrics-gynaecology-and-urinary-tract-disorders/74-drugs-for-genito-urinary-disorders/745-drugs-for-erectile-dysfunction/phosphodiesterase-type-5-inhibitors (accessed 14 June 2017).
- Nehra A, Jackson G, Miner M et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease.Mayo Clin Proc 2012; 87 (8): 766–778.
- British National Formulary. Tadalafil. NICE, 2017. www.evidence.nhs.uk/formulary/bnf/current/7-obstetrics-gynaecology-and-urinary-tract-disorders/74-drugs-for-genito-urinary-disorders/745-drugs-for-erectile-dysfunction/phosphodiesterase-type-5-inhibitors/tadalafil (accessed 14 June 2017).
- British National Formulary. Sildenafil. NICE, 2017. www.evidence.nhs.uk/formulary/bnf/current/7-obstetrics-gynaecology-and-urinary-tract-disorders/74-drugs-for-genito-urinary-disorders/745-drugs-for-erectile-dysfunction/phosphodiesterase-type-5-inhibitors/sildenafil (accessed 14 June 2017).
- Hackett G. Stinting on sildenafil supply can prove costly. Trends in Urology & Men’s Health 2016; 7 (3): 32–33.
- Kirby M, White I, Butcher J et al. Development of UK recommendations on treatment for post-surgical erectile dysfunction. Int J Clin Pract 2014; 68 (5): 590–608.
- White I, Wilson J, Aslet P et al. Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer. Int J Clin Pract 2015; 69 (1): 106–123.
- Clavijo R, Kohn T, Kohn J, Ramasamy R. Effects of low-intensity extracorporeal shockwave therapy on erectile dysfunction: a systematic review and meta-analysis. J Sex Med 2017; 14 (1): 27–35.
- Hatzimouratidis K, Giuliano F, Moncada I et al. EAU guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. European Association of Urology, 2017. uroweb.org/guideline/male-sexual-dysfunction/?type=pocket-guidelines (accessed 11 May 2017).
- Sexual Advice Association. For men factsheets. March, 2016. sexualadviceassociation.co.uk/factsheets/for-men/for-men-factsheets/ (accessed 14 June 2017).
- NHS Choices. Erectile dysfunction (impotence). www.nhs.uk/conditions/Erectile-dysfunction/Pages/Introduction.aspx (accessed 14 June 2017). G