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Erectile Dysfunction

 

  • Incidence of ED is approximately proportional to age, ie. 60% of 60y olds, with half that number severely affected. ED aetiology is usually a combination of organic and psychological causes.  
  • ED itself is a cardiovascular risk factor conferring a risk equivalent to a current moderate level of smoking (HR 1.46) 
  • The pro-active management of ED in the cardiovascular patient provides an ideal and effective opportunity to address other cardiovascular risk factors  
  • Mainstay of contemporary treatment is with PDE5i that can be instigated in primary care. 

Initial assessment  

  • Medical & psychosexual hx. Examination to include penile deformity?, BP and gross neuro exam, peripheral vascular exam.
  • Baseline tests: fasting glucose, lipids, Free Androgen Index (test profile- testosterone, SHBG & Free Androgen index) between 9-11am.” “If Free Androgen Index is low or borderline then repeat it (between 9am-11am) and also test for FSH, LH and Prolactin. If considering testosterone replacement then also test PSA.
     

Management prior to referral:

  • Modifiable lifestyle changes
  • Consider changing drugs associated with ED
  • Psychosexual counselling where relevant (RELATE)
  • PDE5i therapy:
    • Beware CI, concomitant nitrate use
    • All PDE5i similar efficacy overall, individual responses vary
    • Try Viagra & Cialis & Levitra at maximum dose x8 each drug taken 1-2x/week before declaring failure
    • Where PDEi successful subsequently titrate down dose

Who to refer: (Mr Willis does not see ED referrals) 

  • PDE5 failures and CIs only
  • Those with penile deformity (ask patient to bring photos of errect penis to OPA) 
  • For those with ED and hypogonadism (Testosterone below normal range) refer to endocrine dept. for consideration of supplementation 
  • Caverject/Muse therapy undertaken in Urology OPA in the absence of a specialist ED clinic currently.
  • Insertion of penile prosthesis is not routinely commissioned by NHS Kernow 
  • Vacuum pumps can be purchased from reputable medial suppliers, see www.sexualadviceassociation.co.uk/pump