Top tips for ten minutes:

Top Tip n° 35
Top Tips in Two minutes: Erectile Dysfunction (ED)
ED is increasingly becoming a common presentation to GPs. Prevalence of complete ED: 5% in 40yr-olds, 10% in 60s, 15% in 70s and 30-40%in 80s. • Can have a severe effect on psychological and social well-being, and can negatively impact • May be a marker for hypertension, diabetes or depression Causes: Vascular (33%), DM (25%) (Diabetes Mellitus), Nerve disorder (8%), Pelvic surgery (7%), Drugs (6%), Psychogenic (10-15%) Most can be managed in primary care. Can initiate treatment after correction of reversible risk factors due to the availability of oral agents e.g. Viagra (Sildenafil), Levitra (Vardenafil), Cialis (Tadalafil) and Uprima (Apomorphine)) • History: differentiate physical (gradual onset, loss of nocturnal/morning erections) from psychogenic (sudden onset, maintains nocturnal erections, often associated relationship problems), smoking, drugs including recreational, alcohol • Physical Exam: external genitalia - phimosis, balanitis, penile ulceration, a short penile frenulum & penile induration due to Peyronie’s disease. Any painful, penile condition may inhibit erection simply by virtue of the pain it induces. Also assess general body habitus for What next
and when:
• Urine dip for DM (+/- blood glucose), • Hormone tests including testosterone, FSH/LH (pituitary hypogonadism), Prolactin (prolactin • LFTs (liver disease) • Blood lipids, • (+/- PSA if LUTs or abnormal DRE) (Lower Urinary Tract Symptoms) (Digital Rectal • Specific tests e.g. cavernography etc rarely necessary for specific conditions (e.g. venous • Investigate and exclude treatable causes (including drugs) • Treat risk factors (if possible) • Address life-style issues • Consider psychosexual counselling, couple therapy or psychiatric referral if predominantly psychogenic ED although physical treatment may be used in selected patients • First-line treatment for organic erectile dysfunction is a PDE-5 inhibitor, initiated in general practice; this is effective in 65-75% of patients regardless of the cause of the erectile dysfunction • Other treatments are only indicated if PDE-5 inhibitors are ineffective, associated with severe side-effects or contraindicated (because of concomitant use of nitrates, either for angina or recreationally), alternative oral treatment Apomorphine Consider urological referral if above failed or contraindicated for other options including: Self-administered penile prostaglandin injections (Caverject®),Intra-urethral administration of prostaglandin (MUSE®), Vacuum erection assistance devices, Insertion of penile prostheses, Re-vascularisation of the penis using by-pass surgery or angioplasty Where else:
Flow chart on investigation and management, Guidelines, information and referral protocol available Referrals to Urology Department, Addenbrooke’s Hospital or Hinchingbrooke Hospitals. References:
Drug & Therapeutics Bulletin (2004) 42, 49-52 Web links:
Who are you:
Nimish Shah, Consultant Urologist, Addenbrooke’s and Hinchingbrooke Review date:
Review due:


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