Approach to managing erectile dysfunction

In males with erectile dysfunction, initial management includes addressing risk factors.

Consider referral for psychosexual or relationship therapy, particularly if a strong psychogenic component to the erectile dysfunction is likely. Psychological reactions to organic erectile dysfunction are common and complicate diagnosis and management. Management should include supportive counselling and realistic treatment goals for both partners.

Assess exercise tolerance in males with erectile dysfunction, to determine whether they are at risk of death or significant morbidity from sexual exertion.

Males are generally considered at low risk of death or significant morbidity from sexual exertion if they:

• do not have uncontrolled hypertension
• have not had a recent myocardial infarction (within the last 8 weeks)
• can climb two flights of stairs in 10 seconds.

Males are considered at high risk if they have any of the following:

• an acute coronary syndrome in the last two weeks (without revascularisation)
• high-risk arrhythmias (eg exercise-associated ventricular tachycardia, poorly controlled atrial fibrillation, implanted cardioverter defibrillator delivering frequent shocks)
• severe aortic stenosis
• symptomatic hypertrophic obstructive cardiomyopathy
• New York Heart Association class IV symptoms (symptoms of heart failure at rest and increasing discomfort with any physical activity).

Anyone at high risk warrants cardiology assessment before engaging in sexual intercourse.

In individuals who do not fall into the low- or high-risk groups described above (including males with peripheral or cerebrovascular atherosclerotic disease who do not have clinical evidence of coronary artery disease), consider exercise stress testing to define risk. If the individual can complete 4 minutes of the Bruce treadmill protocol, they are classed as low risk. If not, they are classed as high risk. Anyone unable to use a treadmill (eg with poor mobility) should be considered for chemical stress testing.

In males with low cardiac risk, erectile dysfunction can be treated using phosphodiesterase type 5 (PDE5) inhibitors, vacuum erection devices, intracavernosal therapy or penile implants.

Oral PDE5 inhibitors are first-line therapy for males who are fit for sexual activity and are not taking nitrates. They are likely to be effective for organic and psychogenic erectile dysfunction. They can also be combined with vacuum devices or intracavernosal injections.

Vacuum erection devices are generally safe, and although their expense varies, they are relatively inexpensive and incur only a one-off cost. Their use requires minimal manual dexterity. This contrasts with intracavernosal injections, which require reasonable manual dexterity and adequate vision to administer safely. Both types of therapy can be used alone or together if PDE5 inhibitors are ineffective or contraindicated (eg by concurrent nitrate use). Both require caution in anticoagulated individuals; gentle use of a vacuum device may be preferable to injections.

If all other treatments are unsuccessful, penile implants (semirigid or inflatable) can be used in carefully selected patients. Penile implants have very good satisfaction rates, but they are expensive, require surgery and natural erections will never occur once they are placed.

Testosterone therapy should not be used unless diagnostic criteria for androgen deficiency are met. In androgen-deficient males, testosterone alone is associated with a small but significant improvement in erectile function. It is not clear whether testosterone replacement enhances erectile function in androgen-deficient males already taking optimal treatment with PDE5 inhibitors, although testosterone will benefit other sequelae of androgen deficiency.