Obstetrics, Gynaecology & Urology

Guidelines on the management of erectile dysfunction

• British Society for Sexual Medicine •

Epidemiology and risk factors –– the symptoms of hypogonadism

–– other urological symptoms (past or present)
• Erectile dysfunction (ED) has been defined as
the persistent inability to attain and/or maintain • A digital rectal examination (DRE) of the
an erection sufficient for sexual performance prostate is not mandatory in ED but should be
conducted in the presence of genito-urinary or
• The risk factors for ED (sedentary lifestyle, protracted secondary ejaculatory symptoms
obesity, smoking, hypercholesterolaemia and
the metabolic syndrome) are very similar to the • Blood pressure, heart rate, waist
risk factors for cardiovascular disease (CVD) circumference and weight should be measured

• It is clear ED may be associated with other Laboratory testing

causes of CVD such as hypertension,
dyslipidaemia and endothelial dysfunction. ED • The choice of investigations depends on
may be the first presentation of serious medical the individual circumstances of the patient.
conditions such as diabetes or hypertension Serum lipids and fasting plasma glucose
should be measured in all patients

Diagnosis • Hypogonadism is a treatable cause of ED that

may also make men less responsive, or even non-
Initial assessment responsive, to phosphodiesterase type 5 (PDE5)
inhibitors; therefore, all men with ED should have
• Sexual history – a detailed description of the serum testosterone measured on a blood sample
problem, including the duration of symptoms taken in the morning between 08.00 and 11.00
and original precipitants, should be obtained
• Serum prostate specific antigen (PSA)
• Concurrent medical, psychiatric and surgical should be considered if clinically indicated.
history should also be recorded, as should the It should certainly be measured before
current relationship status, history of previous commencing testosterone therapy and at
sexual partners and relationships. Issues of regular intervals during testosterone therapy
sexual orientation and gender identity should also
be noted. Finally, the patient should be asked Cardiovascular system
about alcohol, smoking and illicit drug misuse
• Coronary heart disease (CHD) is associated
• The use of validated questionnaires, particularly with many of the same risk factors as ED.
the International Index of Erectile Function (IIEF) Coronary artery disease (CAD) is often just
or the validated shorter version of the SHIM one affected site in a generalised arteriopathy
(Sexual Health Inventory for Men) may be helpful that is also likely to affect the arterial inflow
to the corpora cavernosum of the penis
Physical examinations
• ED in an otherwise asymptomatic man
• All patients should have a physical examination. may be a marker for underlying CAD. All
A genital examination is recommended, and men with unexplained ED should have a
this is essential if there is a history of: thorough evaluation and any risk factors for
–– rapid onset of pain CHD that are identified should be addressed
–– deviation of the penis during tumescence

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 Obstetrics, Gynaecology & Urology
• A man with ED and no cardiac symptoms –– identifying and treating any
is a cardiac patient until proven otherwise curable causes of ED
–– initiating lifestyle change and
• Proactive management of ED in the risk factor modification
cardiovascular (CV) patient provides an ideal –– providing education and counselling
and effective opportunity to address other CV to patients and their partners
risk factors and improve treatment outcomes
Reversible causes of ED
• Men with previously-diagnosed CHD should
be asked about ED as part of their routine • Hormonal:
surveillance and management; ED treatments –– hypogonadism
should be offered to all who desire them –– hyperthyroidism/hypothyroidism
–– hyperprolactinaemia
• Current NICE guidance recommends that all men
with type 2 diabetes be asked annually about • Post-traumatic arteriogenic ED in young patients
ED, assessed, and offered oral treatment with
the medication with the lowest acquisition cost • Drug-induced ED – drugs may affect
sexual response in a number of ways:
• There is no evidence that currently licensed –– drugs that cause sedation may affect
treatments for ED add to the overall CV risk in sexual motivation and, indirectly, cause ED
patients with or without previously-diagnosed CVD –– drugs that affect CV function, such as
antihypertensive agents, may act centrally
Specialised investigations and may also affect penile haemodynamics
–– some drugs affect endocrine parameters
• Most patients do not need further investigations – anti-androgens and oestrogens may
unless specifically indicated. However, some affect both sexual desire and erection
patients wish to know the aetiology of their ED –– drugs that cause hyperprolactinaemia,
and should be investigated appropriately. Other such as phenothiazines, may also
indications for specialist investigations include: affect sexual desire and erection
–– young patients who have always had difficulty
in obtaining and/or sustaining an erection • Partner sexual problems
–– patients with a history of trauma
–– where an abnormality of the testes • Psychosexual counselling and therapy
or penis is found on examination
–– patients unresponsive to medical therapies • Radical prostatectomy
that may desire surgical treatment for ED
Lifestyle management
Penile abnormalities
• Lifestyle modifications can greatly reduce
• Surgical problems that cause ED, e.g. phimosis, the risk of ED, and should accompany any
tight frenulum and penile curvatures, should be specific pharmacotherapy or psychological
diagnosed clinically and are usually simple to treat therapy. However, pharmacotherapy
surgically, which results in a permanent cure of ED should not be withheld on the basis that
lifestyle changes have not been made

Treatment • Lifestyle factors include:

–– psychosocial issues
• The primary goal of management of ED is –– adverse side-effects of non-prescription drugs
to enable the individual or couple to enjoy a –– influence of any co-morbidities,
satisfactory sexual experience. This involves: including those in the partner

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 Obstetrics, Gynaecology & Urology
Management algorithm according to graded cardiovascular risk

Sexual inquiry

Clinical evaluation

Low risk Intermediate risk High risk

Cardiovascular Sexual activity

Manage ED in primary
assessment and deferred until cardiac
care setting
restratification condition stabilised

Risk factors and CHD evaluation, treatment and follow-up for all patients with ED

Grading ED management recommendations

Cardiovascular status upon presentation
of risk for the primary care physician
Low risk
• Controlled hypertension
• Asymptomatic ≤3 risk factors for
CAD – excluding age and gender • Manage within the primary care setting
• Mild valvular disease • Review treatment options with patient
• Minimal/mild stable angina and his partner (where possible)
• Post successful revascularisation
• CHF (NYHA class I)
Intermediate risk

• Recent MI or CVA (i.e. within last 6 weeks)

• Asymptomatic but >3 risk factors for
• Specialised evaluation recommended
CAD – excluding age and gender
(e.g. exercise test for angina,
• LVD/CHF (NYHA class II)
echocardiogram for murmur)
• Murmur of unknown cause
• Patient to be placed in high or low risk
• Moderate stable angina
category, depending upon outcome of testing
• Heart transplant
• Recurrent TIAs

high risk

• Severe or unstable or refractory angina

• Uncontrolled hypertension
• Refer for specialised cardiac
• (SBP >180 mmHg)
evaluation and management
• CHF (NYHA class III, IV)
• Treatment for ED to be deferred until
• Recent MI or CVA (i.e. within last 14 days)
cardiac condition established and/
• High risk arrhythmias
or specialist evaluation completed
• Hypertrophic cardiomyopathy
• Moderate/severe valve disease

ED=erectile dysfunction; CAD=coronary artery disease; NYHA= New York Heart Association; MI=myocardial infarction;
CVA=cerebral vascular accident; LVD=left ventricular dysfunction; CHF=congestive heart failure; TIA=transient ischaemic
attack; SBP=systolic blood pressure.

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 Obstetrics, Gynaecology & Urology
• The potential advantages of lifestyle changes This regime may be more cost effective
may be particularly pronounced in those with in such cases and clinical trials suggest a
psychogenic ED, but patients with serious marked reduction in reported adverse events
medical illnesses such as diabetes may also
benefit from these changes, e.g. weight loss • Vacuum erection devices:
–– are highly effective in inducing erections
Hypogonadism and testosterone regardless of the aetiology of the ED
replacement therapy –– reported satisfaction rates vary
considerably from 35% to 84%
• The cause of hypogonadism should always be –– long-term usage of vacuum devices
sought before treatment with testosterone is also varies but is considerably higher
initiated, but this does not mean that treatment than for self-injection therapy
for ED should be deferred. Prior assessment and –– most men who are satisfied with vacuum
safety monitoring should be performed according devices continue to use them long term
to contemporary authoritative guidelines –– adverse effects include bruising, local
pain, and failure to ejaculate. Partners
• Men with a total serum testosterone that is sometimes report the penis feels cold
consistently <12 nmol/l might benefit from up –– serious adverse events are very rare
to a 6 months trial of testosterone replacement but skin necrosis has been reported
therapy for ED and should be managed according
to current guidelines (see algorithm below) Second-line treatment

• A range of well-tolerated testosterone • Intracavernous injection therapy

formulations is available
–– long-acting (three-monthly) testosterone • Intraurethral alprostadil
injection or daily application of a transdermal
testosterone gel are acceptable to most men Third-line treatment

First-line treatment • Penile prosthesis:

–– should be offered to all patients who are
• PDE5 inhibitors (e.g. sildenafil, unwilling to consider, failing to respond to, or
tadalafil, vardenafil): unable to continue with medical therapy or
–– have proven efficacy and safety both external devices. All patients and their partners
in non-selected populations of men should be counselled pre-operatively, see and
with ED and in specific sub-groups of handle all the available devices and, if possible,
patients (e.g, men with diabetes and speak to other patients who have had surgery
those who have had a prostatectomy) –– particularly suitable for those with severe
–– sildenafil and vardenafil are relatively organic ED, especially if the cause is
short-acting drugs, having a half life of Peyronie’s disease or post priapism. All
approximately 4 hours, whereas tadalafil has patients should be given a choice of either
a significantly longer half life of 17.5 hours a malleable or inflatable prosthesis
–– are not initiators of erection but require sexual
stimulation in order to facilitate an erection. It
is currently recommended that patients should Patient/partner education –
receive eight doses of a PDE5 inhibitor with consultation and referrals
sexual stimulation at maximum dose before
classifying a patient as a non-responder • The primary reason for referral to the clinician
–– tadalafil is licensed for daily use at 2.5 mg and should be elicited. The motivating factors
5 mg for PDE5 responders who anticipate and expectations should be clarified as well
sexual activity more than twice per week. as the intention, or otherwise, of the partner

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 Obstetrics, Gynaecology & Urology
Algorithm for androgen therapy in a man presenting with ED
Male with ED Male with ED. Failure of PDE5i
First-time presentation No previous T testing

Screen all ED patients for T Screen all ED patients for T

T normal T low T low T normal

ED therapies T therapy Alternative

(e.g. PDE5i) Combination ED therapies,
therapy, e.g.
e.g. T + PDE5i injections,
Unsatisfactory
prosthesis
response
Unsatisfactory Satisfactory
response response

Satisfactory
Continue
response
Alternative T therapy
therapies,
e.g. injections, Continue T = testosterone;
prosthesis Unsatisfactory combination PDE5i =
phosphodiesterase
response therapy
type 5 inhibitors

to accept any specific pharmacological, –– radical pelvic surgery severe pelvic injury
physical or psychological therapies –– renal failure treated by dialysis or transplant
–– single gene neurological disease
• An understanding by the patient and partner of –– spinal cord injury spina bifida
basic anatomy and physiology and the purpose –– NHS drug treatment before
of blood and specialist investigations is helpful 15th September 1998
–– if patient is suffering severe distress
• An explanation of the principles of the on account of their ED
treatment options is valuable
• The GP is recommended to refer if severe distress
• Provision of educational information is is suspected. It is the role of the specialist to
valuable reinforcement for patients endorse that judgement. It is recommended that
the following should be taken into account:
–– significant disruption to normal
Government guidance on good social and occupational activity
practice – HSC/177 (1999) –– marked effect on mood, behaviour,
social and environmental awareness
• ED associated with the following medical –– marked effect on interpersonal relationships
conditions are deemed to qualify for
prescription at NHS expense: • After an initial titration period, 1 tablet per week
–– diabetes multiple sclerosis is considered to be appropriate for the majority
–– Parkinson’s disease poliomyelitis of patients, but when more is required the GP
–– prostate cancer prostatectomy should prescribe that quantity at NHS cost
full guideline available from…
British Society for Sexual Medicine, Holly Cottage, Fisherwick, Near Lichfield, Staffordshire WS14 9JL (% – 01543 432622)
http://www.bssm.org.uk/
British Society for Sexual Medicine. Guidelines on the management of erectile dysfunction July 2009

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