Erectile Dysfunction

Erectile dysfunction ( ED )  Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance

Very common disorder Massachusetts Male Aging Study ( MMAS ) 1987-97 an important study revealed that 52 % men ( aged 40-70 yrs ) reported erectile dysfunction Prevalence and severity ↑es with age ED is a strong

of CVD in particular


Risk factors Shares both unmodifiable and modifiable risk factors with CVD
○ diabetes
○ obesity
○ dyslipidemia
○ metabolic syndrome
○ lack of exercise
○ smoking , alcohol Age Poor physical and psychological health Lower urinary tract symptoms and BPH

Causes – vasculogenic Generalised CV disease Hypertension Hyperlipidemia Diabetes Smoking Major pelvic surgery or Radiotherapy ( pelvis or retroperitoneum ) Neurogenic -Degenerative disorders -eg multiple sclerosis , Parkinson’s , multiple atrophy etc Spinal cord trauma or diseases Stroke CNS tumours Hormonal-Hypogonadism Hyperprolactinaemia Hyperthyroidism , Hypothyroidism Cushing’s disease Hypopituitarism following traumatic brain injury Anatomical-Eg cavernous fibrosis , Peyronie’s disease and penile fracture , micropenis , hypospadias , epispadias Psychological-Can be predisposing ( risk factors ) precipitating 
( present ) or maintaining ( ongoing ) causes

History –Detailed medical and sexual history
 Comorbid conditions eg hypertension , peripheral vascular disease , diabetes , obesity , renal disease
 Sexual history should include
○ sexual orientation
○ previous and current sexual relationships
○ current emotional status
○ onset and duration of erectile problem
○ previous consultations and treatments

Validated psychometric questionnaires such as
○ International Index for Erectile Function ( IIEF ) or
○ Sexual health Inventory for Men ( SHIM ) – shorter version of IIEF can be used
 Two question scale for depression ( if depression suspected)
○ during the past month have you often been bothered by feeling down , depressed or hopeless ?
○ during the past month have you often been bothered by little interest or pleasure in doing things ?
 Lifestyle including alcohol , tobacco , illicit drugs 
 Symptoms of hypogonadism – loss of libido , loss of body hair , spontaneous hot flushes
 Pelvic surgery , radiation , trauma

Examination-Focused physical examination
○ body weight
○ waist circumference
○ heart rate
○ blood pressure
○ pulses and sensation
 Examine genitalia 
○ may reveal hypogonadism ( small testes )
○ Peyronie’s disease
 Check for gynaecomastia and reduced body hair
 DRE- if symptoms of enlarged prostate
○ obstructive urinary symptoms in ED erection loss happens before orgasm whereas in premature ejaculation it happens afterwards 

Calculate the 10 year CV risk ( eg using QRisk2 calculator )

○ If not tested recently consider fasting blood glucose or Hba1c and lipid profile
○ ECG can be considered in younger men (< 60 )
 Controversy exists on the ideal endocrine workup

Free testosterone in 
the morning
( between 9-11 AM )

 Repeat testosterone SHBG Check FSH LH Prolactin levels 

Lifestyle –Usually responds well to combination of lifestyle changes and drugs Lifestyle advice ( where applicable )
○ weight loss
○ smoking cessation
○ ↓ alcohol intake
○ ↑ exercise

All PDE5-Inhibitors slow the degradation of cGMP Inhibition leads to prolonged activity of cGMP Decreases the intracellular Calcium conc , maintains smooth muscle relaxation Rigid penile erections Men with Coronary Heart Disease- Most men can safely resume sexual activity and use PDE-5Is. 
Exception being Unstable heart disease H/O recent MI ( CKS NHS – within 6 months ) Poorly compensated heart failure Unstable dysarrythmia

Contraindications- If on nitrates in any form 
( risk of severe hypotension ) Who have lost sight in one eye due to non-arteritic anterior ischaemic optic neuropathy Hypotension ( systolic < 90 ) Recent stroke Unstable angina
 Vardenefil is CI in 
○ severe hepatic impairment
○ end stage renal disease patients on dialysis
○ known hereditary retinal degenerative disorders as retinitis pigmentosa
 Sildenefil is CI in
○ severe hepatic impairment
○ hereditary degenerative disorders as PRetinosa
 Tadalafil is CI in men with
○ NYHA class2 or greater heart failure in the last 6 months
○ uncontrolled arryhtmias
○ uncontrolled hypertension
 Caution-CV disease LV outflow obstruction Anatomical deformation of penis ( eg angulation , cavernosal fibrosis or Peyronie’s disease ) Predisposition to priapism eg
○ sickle cell disease
○ Multiple-myeloma
○ Leukaemia

35 % patients may
 fail to repond- common causes Diabetes , severe neurological or vascular diseases Start low and
 titrate upwards if ineffective