Erectile dysfunction

Scope

  • The management of new presentation Erectile Dysfunction (ED) in the adult male population
  • Incidence of ED is approximately proportional to age, i.e. 60% of 60 year olds, with half that number severely affected. ED aetiology is usually a combination of organic and psychological causes
  • 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

Please note pre-referral criteria are applicable in this referral.

If referring for erectile dysfunction the patient must have tried the basic ED therapy and investigation unless contraindicated. Referrals submitted without this information will be returned. Please see the Referral Section.

Assessment

History and Examination

  • Erectile Dysfunction is diagnosed from the patient's history
  • It is important to check that the patient is actually describing Erectile Dysfunction (poor quality erections) rather than:
    • Decreased libido
    • Peyronie's disease (penile curvature)
    • Ejaculation problems
  • Continuing early morning erections and young age suggests a psychological component to the problem

Investigations

  • The degree of 1st line investigation is contentious, we would recommend:
    • Blood pressure
    • Cholesterol
    • Glucose
    • Testosterone
    • PSA
    • Rectal examination and examination of genitalia (DRE & LUTS)
    • Prolactin
    • Thyroid function
  • It is useful to try to establish a cause for the patients symptoms but this is not always possible and rarely alters management
  • It is important to exclude other disease as a cause of Erectile Dysfunction, e.g. diabetes, high cholesterol, low testosterone and Metabolic Syndrome and hypertension.

Management

  • Patients should be encouraged to stop smoking, increase exercise & lose weight
  • In most cases oral therapy can be started in general practice
    • There is usually little to be lost by a trial of oral therapy for Erectile Dysfunction. There are currently three licensed products commissioned by the CCG All PDE 5 inhibitors will only work in the sexual environment
    • Where PDE5s are contraindicated (e.g. nitrates) please refer for consideration and training by other therapies
    • Where PDE5i successful subsequently titrate down
  • Many drugs can theoretically cause Erectile Dysfunction, but general changes of medication rarely result in an improvement in Erectile Dysfunction
    • Beta-Blockers are often associated with Erectile Dysfunction and it may be worth trying patients on alternative treatment.
  • Patient fails to respond to treatment
    • Side effects not common, similar in all three
      • Headache and Flushing – commonest
      • Dyspepsia – not usually problematic
      • Visual disturbance (colour) –rare and transient
    • Although all are similar compounds, experience indicates that patients rarely get the same side effects with all three
    • Patients with low testosterone under 8nmol/L refer, or 8-13nmol/L borderline testosterone, referral may be indicated
  • Psychosexual counselling where relevant (RELATE)

Joint formulary: Section 7.4 Drugs for genito-urinary disorders

Joint formulary: Chapter 2, Management of hypertension

Referral

Referral Criteria

  • Refer patients with low testosterone, under 8nmol/L to Endocrinology
  • Referral may be indicated for patients with borderline testosterone 8-13nmol/L
  • Patients who are suffering severe distress as a result of impotence (prescribed in specialist centres only)
  • All PDE-5 inhibitors have similar efficacy overall
  • Refer those in whom PDE-5 inhibitors are contraindicated

There are specific NHS prescribing restrictions on GPs for the treatment of ED. This means that referral to access medication or other interventions will need to be considered earlier for some groups of patients than others.

For patients eligible only for generic sildenafil see guidance on prescribing for erectile dysfunction consider referral for men who have failed to respond to 8 doses of generic sildenafil at maximum dose with sexual stimulation.

For other men see guidance on prescribing for erectile dysfunction, which is likely to be the majority of men, consider referral for those who have failed to respond to 8 doses at the maximum dose with sexual stimulation of two different PDE-5 Inhibitors.

If referring for erectile dysfunction the patient must have tried the basic ED therapy and investigation unless contraindicated. Referrals submitted without this information will be returned.

Referral Instructions

Referrals related to low testosterone levels

e-Referral service selection

  • Service: Endocrinology and Metabolic Medicine
  • Clinic type: Not Otherwise Specified
  • Service: DRSS- Northern-Urology-NEW Devon CCG-99p
Referrals to Urology

e-Referral service selection

  • Service: Urology
  • Clinic type: Erectile Dysfunction/Andrology
  • Service: DRSS- Northern-Urology-NEW Devon CCG-99p

Referral Forms

DRSS referral form

Supporting Information

Pathway Group

This guideline has been signed off by the Northern Locality on behalf of NEW Devon CCG.

Publication date: September 2015
Amended: June 2016

 

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