KISS: Erectile Dysfunction

Based on EAU Guidelines, Sexual Health 2023

• Diagnostic evaluation of self-reported erectile dysfunction ED
  • Assess with medical and psychosexual history, and a focused physical examination looking for signs of penile deformities, prostatic disease, signs of hypogonadism and cardiovascular and neurological status
  • Assess for mental health issues and psychological distress which are frequently comorbid in ED, as well as cognitive factors such as dysfunctional and unrealistic expectations around sexual function and performance
  • Check simple bloods including a glucose and lipid profile (if not done in the previous year) and a morning sample of total testosterone (fasting between 7 am and 11 am) looking for modifiable and potentially reversible risk factors
  • ED significantly increases the risk of CVD, heart disease and stroke - assess cardiovascular risk status
• Management
  • Assess patients' needs and expectations, and offer conjoint medical and psycho-sexual treatment 
  • Provide education and counselling, and advise re necessary lifestyle changes and risk factor modification
  • Optimise control of underlying risk factors (e.g. hypertension, diabetes etc) as the first step of ED management
  • Treatment with phosphodiesterase type 5 inhibitors as a first-line therapeutic option
    • In patients who do not wish or are not suitable for vasoactive therapy, use topical or intra-urethral alprostadil
    • Referral for consideration of alprostadil intracavernous injections as an alternative option in well-informed patients
    • Vacuum devices are a first-line option in well-informed patients requiring non-invasive, and drug-free management
• Prescribing phosphodiesterase type 5 inhibitors
  • An absolute contra-indication to all these drugs is the concomitant use of nitrate, including nitrates used therapeutically (e.g. drugs for angina) and recreationally during sex (e.g. amyl nitrate, or ‘poppers’)
  • Note all of these drugs only work in the context of sexual stimulation
  • Drug choice depends on the likely frequency of use and patient choice
  • Sildenafil
    • Recommended starting dose is 50mg, adapted to response, most effective 30 to 60 minutes after ingestion
    • Efficacy reduced after a heavy meal due to impaired absorption
  • Tadalafil
    • Effective from 30 minutes after ingestion, with peak efficacy after 2 hours and maintained for up to 36 hours
    • Can use on-demand 10mg or 20mg dose, or for men with frequent use a daily dose of 5mg
    • Daily tadalafil can also improve urinary symptoms in men with comorbid BPH-related LUTs, and may improve erectile function in men who have had only a partial response to on-demand PDE5i therapy
  • Vardenafil
    • Effective from 30 minutes after ingestion, and efficacy reduced after a heavy meal
    • Recommended starting dose of 10mg adapted to the response
  • Avanafil
    • A highly selective PDE5i, so theoretically has a lower side effect profile (head-to-head comparisons not available) and is an option for men unable to tolerate sildenafil and tadalafil
    • Starting dose 100mg, 15 to 30 mins before sexual activity
    • Has shown efficacy in difficult-to-treat sub-groups e.g. men with diabetes
  • Management of non-responders to PDE5i
    • The most common cause of failure is incorrect drug use with failure to have sufficient sexual stimulation, use adequate doses or wait sufficient time
    • Advise at least 6 attempts with a particular drug; if continued failure try switching to an alternative PDE5i
    • Men with low testosterone need referral for testosterone treatment, this can be used concomitantly with PDE5i
    • In refractory cases, a combination approach may be tried e.g. daily tadalafil plus on-demand short-acting sildenafil