Erectile dysfunction (ED) is a common male sexual dysfunction with an estimated incidence of 20–40% of men in their 60s, increasing to 50–100% of men in their 70s (Lewis, et al, 2010). ED is defined as the inability of a man to get and maintain an erection that is sufficient for sexual intercourse. ED commonly has a profound negative impact on quality of life in the patient and his partner, which can result in changes to sexual self-confidence (Steggall, 2007). It may also impact compliance with other prescribed medications where it is known that side effects can cause ED. Men who identify with traditional masculine ideals may take risks concerning their health. For these men sexual functioning is a vital part of their identity and manhood, and sexual competency validates their masculinity (Helgeson and Lepore, 2004). In other words, some men find ED difficult to cope with due to either fear or embarrassment. Therefore, they may seek to self-manage the condition by stopping anti-hypertensive or other medications if they know side effects can cause erection difficulties.
Epidemiology and aetiology
Epidemiological evidence suggests that 8% of men in their 40s report moderate or complete ED and this increases to 40% of men in their 60s (McKinlay, 2000). Risk factors for developing ED are shown in Table 1, indicating that a large proportion of men attending primary care may have undiagnosed ED as this condition is closely associated with changes to the cardiovascular system. Incorporating ways of adding questions about ED to a clinical consultation may prevent or delay deterioration of the cardiovascular system, thus saving ‘costs’ – human and financial – to the patient, his partner and to the NHS.
Table 1. Organic and psychogenic risk factors for erectile dysfunction
| Examples of organic factors | Examples of psychogenic factors |
|---|---|
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Acknowledging that it can be difficult to know what words to use, or how to broach the subject, Table 2 provides examples of how conversations can be facilitated in the clinical environment. In all consultations these need to be culturally sensitive, as terms such as ED can be easily misunderstood and imagery can be inadvertently stereotypical (eg heterosexual couples).
Table 2. Creating the opportunity to discuss erectile dysfunction
| Option | Examples |
|---|---|
| Make aware | Posters on the waiting room wall serve as a medium for raising awareness |
| Inform | Men need to know that ED is common, with both physical and psychological causes, but can often be treated. Diet and exercise, ie ‘good’ cardiovascular health, are important in preventing or limiting ED |
| Ask | When undertaking a medication or cardiovascular review, ask the patient if he has experienced any side effects (eg to antihypertensives). Patients can find it difficult to say no to clinicians so use language carefully. ED is failure to have an erection of sufficient strength for penetration/maintenance of an erection; premature ejaculation is when the sperm comes out too soon. After ejaculation, the penis will lose tumescence. Is the ED before or after the sperm comes out? If after, then it is more likely to be an ejaculation problem |
Pathophysiology
Common causes of ED have been classified into ‘organic’ or ‘psychogenic’, although rarely, if ever, does one not affect the other. Organic causes include, but are not limited to, anti-hypertensive medication, diabetes mellitus and prostate surgery. Psychogenic causes include, but are not limited to, change in body image, perhaps following surgery or illness, relationship difficulties or pressure to meet norms and expectations in a relationship. The evidence linking ED and cardiovascular disease is incontrovertible, with risk factors for both problems including hypertension, dyslipidaemia, physical inactivity, obesity and tobacco consumption (Kloner, 2007; Sarma et al, 2019).
ED can certainly be considered the harbinger of cardiovascular disease (Kloner, 2008), with the mean time onset between ED and a cardiovascular event being 3–5 years (Montorsi et al, 2006). Risks are reduced with lifestyle interventions, hence the recommendation to make every clinical encounter count by raising awareness of this common condition.
Investigations and diagnosis
Diagnosis of ED is often determined by the patient himself although careful questioning is needed to differentiate between premature ejaculation (PE) and ED or other forms of sexual dysfunction. For example, a man who ejaculates very early may describe loss of erection rather than premature ejaculation. Although treatment for premature ejaculation can include phosphodiesterase type 5 inhibitors (PDE5Is), these tend to shorten post ejaculatory recovery time (PERT) rather than manage the underlying problem. The inability to penetrate is frequently the main precipitating factor, but it needs to be elicited whether this is because the penis is not firm or because the man has already ejaculated. If the former then it is likely to be ED, if the latter, it is likely to be PE. Some practitioners may find that completing one of the erectile function assessment scores – for example the 5-item International Index of Erectile Function (IIEF) (Rosen et al, 1999) – can help in establishing the severity of ED, and this is a recommendation in both the British Society of Sexual Medicine (BSSM) (Hackett et al, 2018) and European Urology Association (EAU) guidelines (Rai and Terry, 2018). Table 3 provides a guide that may assist in assessing the likely cause of ED that may also inform subsequent treatment choices.
Table 3. Assessment of erectile dysfunction
| Assessment | Rationale | Implication for treatment |
|---|---|---|
| Surgical history | Clues to organic causes of ED, ie damage to nerves or blood supply, or altered body image | Changes to blood supply or nerve damage |
| Changes to blood supply or nerve damage | Clues to organic causes of ED, ie specifically assessing whether there is known physiological dysfunction | Changes to blood or nerve damage |
| Current medication | Clues to organic causes of ED, ie anti-hypertensives commonly worsen the quality of an erection | Check for contraindications to any treatment for ED |
| Allergies | Interaction with treatment | Interaction with treatment |
| Tobacco | Assess vascular damage | Give lifestyle advice as needed |
| Alcohol (and/or illicit drugs) | Desensitises the individual to stimulation | Potential to effect success of treatment |
| Specific history | ||
| Description of the problem | Is it erection failure, loss of desire, or premature ejaculation? What is the duration of problem? | Guides management and treatment |
| Gradual or sudden onset? | Organic or psychogenic causes? | Gradual suggests organic causes whereas sudden onset suggests psychogenic causes |
| Early morning or nocturnal tumescence | Is the blood supply intact? | If tumescence is present, this suggests that the blood flow/nerve supply are intact, and point to potential psychology causation |
| Libido | Assess desire | Often absent in long-term ED; can be endocrine-related |
| Is penetration possible? | Assess strength of erection | Assesses blood flow; may indicate ‘strength’ of medication required |
| Current sexual relationship | Need to know if there is some sexual activity | Absence of intimacy is important – for the medication to work some type of sexual stimulation is required |
| Psychological factors | ||
| Social problems (particularly prior to onset of problem) | Anxieties inhibit function | Feelings of ‘impotence’ in other areas will be reflected in sexuality – need to resolve underlying problem |
| Performance anxiety | Maintains problem | Break cycle of failure/restore confidence |
| Does the partner know of their visit? | Status of relationship | Address unresolved issues with both partners |
Both the BSSM (2017) and EAU (Hatzimouratidis et al, 2016) guidelines recommend laboratory testing of serum lipids, fasting plasma glucose and HbA1c, unless there is already a clinical diagnosis of cardiovascular disease and/or diabetes mellitus, as well as a focused clinical examination (Hackett, et al, 2018). Serum testosterone, taken between 08:00 and 11:00 (because this is when testosterone ‘peaks’) and prostate-specific antigen (PSA) (if clinically indicated) also form part of the guidance notes. Depending on results, treatment can be commenced. If low testosterone is detected, referral to secondary care (endocrinology or urology) for further investigation or commencement of testosterone supplementation should be considered.
Treatment
The introduction of PDE5Is in 1998 (sildenafil citrate/Viagra) encouraged men to seek help for ED, and since then various PDE5Is have become available (Table 4). Although these share a common mode of action, there are variations between them. Patients should be encouraged to choose the medication that they think fits ‘best’ with their sex lives. Not all men will be eligible for NHS treatment and therefore cost can become a factor. Sildenafil (Viagra) is now available over-the-counter, which may result in a poor or absent diagnostic work up, and therefore, risks missing organic causes for ED or lifestyle modifications that may improve overall cardiovascular health, as the man simply manages the erection failure himself. Furthermore, incorrect use of medication may lead to a belief that the medication is ineffective.
Table 4. Summary of treatments available for erectile dysfunction
| Treatment | Dosage guide | Time to onset (hours) | Contraindications | Mode of action |
|---|---|---|---|---|
| Avanafil (Spedra) | 100 mg initially, then dose adjust depending on response. Range is 50–200 mg as needed | 1/4 | Concurrent use of nitrates; recent myocardial infarction, unstable angina or stroke; ischaemic optic neuropathy, hypotension; do not use with nicorandil (lowers blood pressure), some antibiotics, and grapefruit juice | Phosphodiesterase type-5 inhibitor, increases blood flow to penis |
| Sildenafil citrate (Viagra)/sildenafil | 25–100 mg, need 6–10 doses before benefits seen; regular dosing helps to reduce performance anxiety | 1 | As above | As above |
| Tadalafil (Cialis) | 10–20 mg, need 6–10 doses before benefits seen; regular dosing helps to reduce performance anxiety; Tadalafil 2.5–5 mg daily dosing (takes around seven days to build up a therapeutic level) | 1/2 to 2 | As above | As above |
| Vardenafil (Levitra®) | 5–20 mg, need 6–10 doses before benefits seen; regular dosing helps to reduce performance anxiety | 1/3 | As above | As above |
| Medicated Urethral System for Erections (MUSE®): intraurethral alprostadil (prostaglandin E1) | 250–1000 μg, essential to massage the intra-urethral medication for up to 10 minutes | 1/3 | Sickle cell disease or bleeding disorders | Increases blood flow to penis |
| Vitaros (contains alprostadil) | 3 mg/g applied to the tip of the penis | Takes 5–30 mins to work | As above | As above |
| Intracavernosal injection of alprostadil (prostaglandin E1) – Caverject®, Caverject® dual chamber or Viridal Duo® | 2.5–60 μg essential to provide full teaching of injection technique and support/discuss patient anxieties | 1/4 | Warfarin, bleeding disorders | Increases blood flow to penis |
| Vacuum devices | Important to teach correct technique and reinforce that the vacuum needs to be created slowly | 1/3 | None, but must be competent to remember to remove the constriction ring within 30 minutes | Non-pharmacological, drawing blood into the corpus cavernosum under pressure. Blood held in place by constriction band |
| Surgery (prostheses) | Various prostheses available | 1/4 | Depends on fitness for surgery | Prosthesis – artificial implants replace the corpus cavernosum. Erection then possible ‘on demand’ |
| Psychosexual therapy (behavioural programme with counselling of underlying issues) | Weekly or regular attendance with ‘homework’ | n/a | Lack of acceptance, culturally unacceptable | Breaks pattern of failure, removes anxiety and restores confidence |
The common treatment options are summarised in Table 4. The efficacy can be variable and dependent on frequency of dosing and the strength of the medication. There is a common misunderstanding that these medications work without sexual stimulation or that they work first time; they do not, and it is critical that men give these medications the ‘best’ chance of success, which requires six to ten different doses, with sexual stimulation (unless they experience side effects with the medication). Furthermore, evidence suggests that 8–12% of treatment failures respond to a second or third PDE5I (National Institute for Health and Care Excellence [NICE], 2019), thus swapping to alternative PDE5Is may be beneficial.
To provide the ‘best’ conditions for these medicines to work, the first step is communication with the person the man is going to have sexual activity with. Sex is concerned with intimacy and communication, and any treatment needs to consider the context of any sexual activity.
When is sexual activity inadvisable?
Patients should refrain from attempting sexual activity if they have an unstable cardiac condition or if they cannot climb two flights of stairs without getting very short of breath or needing nitrates. Sexual activity does not involve a high energy demand, with metabolic equivalents (kcal/kg/hr) ranging from 2–6 (Hackett et al, 2018) which is similar to mowing a small patch of lawn. If the patient is not fit enough to do that, then sexual activity is not advised.
Referral pathway
Successful clinical management of ED can be difficult to achieve on the basis that the cardiovascular health of the man will slowly deteriorate as they age, making tumescence more difficult over time. Where primary care colleagues have time and space to engage men who have ED (or may develop it), commencing treatment with a PDE5I (where clinically indicated and not contraindicated) and ensuring any underlying cardiovascular or endocrine problems are identified, will be the most cost effective way forward (acknowledging that referral to secondary care results in a cost to the NHS). If the patient has taken between six and ten doses, correctly, but has not had any success, alternative treatments (Table 4) can be discussed, and, if agreeable, a referral to a secondary care provider or specialist area should be offered.
Summary
Erectile dysfunction remains a common problem for men, with the prevalence increasing as men age. Intervening early will help improve a man's confidence in maintaining an erection, although this needs to be in conjunction with lifestyle advice that seeks to improve cardiovascular health. Treatment options include PDE5Is, which are now available directly from chemists, and therefore the ‘traditional’ assessment (testosterone, physical examination, etc) may not have occurred. Furthermore, men may not have followed the dosing instructions and had unrealistic expectations of the efficacy of any intervention. Accurate assessment and correct trial of medication is recommended, but where this is unsuccessful, referral to a specialist clinic or secondary care is warranted. For any referral, recent testosterone levels will be needed to prevent additional testing being required.
KEY POINTS:
- Erectile dysfunction (ED) is common, with an increased prevalence with age
- The impact of ED can be profound on the man and his sexual partner
- Phosphodiesterase type 5 inhibitors (PDE5Is) are often the ‘first line’ intervention, but these need to be taken correctly, often, and with sexual stimulation for them to be effective
- Trialling doses over a sustained time period will enhance chances of success
CPD reflective practice:
- How could you create the opportunity to discuss erectile dysfunction (ED) with patients during consultations?
- Which investigations are needed when a patient reveals ED is a problem?
- How will this article change your clinical practice?