Erectile Dysfunction

This guideline applies to adult males

Introduction

This is a symptom not a disease and can be due to primary organic or psychogenic causes but most cases are mixed
Lifestyle changes can help men with ED and reduce cardiovascular risk factors
First line treatment is with oral phosphodiesterase-5 inhibitors (PDE5) and second line treatment uses intraurethral or intracavernosal prostaglandins

For all men, arrange blood tests to assess for an underlying cause and cardiovascular risk:

1st line: HbA1c and lipid profile
2nd line: only if PDE5-I failure or other signs of hypogonadism: HbA1c, lipid profile & Testosterone (sample taken before 11am)
3rd line: If testosterone low (<8)- repeat Testosterone (sample pre 11am) 1 month later & Prolactin, FAI, SHBG, FSH, LH

Consider arranging additional investigations:

PSA- please see Prostate Cancer / Elevated PSA if DRE is abnormal and patient is over 50 years old with symptoms of prostate cancer or back pain or lower urinary tract symptoms (LUTS).
TFT, LFT, UE.

Assess psychosexual factors, previous medical history, calculate cardiac risk stratification. Please see Assessment | Diagnosis | Erectile dysfunction | CKS | NICE

Encourage lifestyle changes eg exercise, smoking cessation and weight loss. See Healthy Cornwall and reduce alcohol consumption

Psychosexual counselling is available at Brook

1^st Line treatment- sildenafil (short acting)
2^nd line: vardenafil (short-acting) and Tadalafil (long-acting). Can be used for spontaneous or anticipated frequent sexual activity (at least twice a week).
Note contraindications and cautions related to PDE-5 inhibitors and concurrent use with Nitrates, alpha-blockers. Do not prescribe PDE-5 inhibitors to men with unstable angina or angina occurring during sexual intercourse

See NICE CKS for further information for further contraindications and cautions

Dose adjustment/avoid use in hepatic and renal impairment may be needed.
If treatment is deemed successful, subsequently titrate down dose or switch to once daily rather than short acting
A patient with ED should receive six doses of an individual PDE-5 inhibitor starting at low dose and up titrating to the maximum dose (with sexual stimulation) before being classed as a non-responder. Patients who fail to respond to the maximum dose of at least two different PDE-5 inhibitors should be referred. ¹

Request advice & guidance from urology via eRS

Intermediate or high cardiac risk and sexual activity may be unsafe, or PDE-5 inhibitor use is contraindicated. Advise stopping all sexual activity until specialist assessment/advice.

Suspected Penile Cancer- refer using fast track suspected urological cancer form
In the event of priapism (painful prolonged erection for more than 4 hours- arrange emergency hospital admission under urology. This is a rare side effect of PDE-5 inhibitors.

Young or lifelong history of difficulty in obtaining or maintaining an erection (possible primary erectile dysfunction).
There is a history of pelvic, perineal, or genital trauma.
No response to two different PDE-5 inhibitors.
Contraindications to PDE-5 inhibitors.
Penile Deformity- ask patient to bring photos of erect penis to outpatient appointment

A diagnosis of hypogonadism is suspected (low serum testosterone level) or there are other abnormalities of testosterone, FSH, LH or prolactin.
Testosterone replacement is being considered
Psychosexual counselling is available at Brook

Review date	05 December 2025
Next review date	05 December 2027
Clinical editor	Dr Melanie Schick
Contributors	Mr Mathialagan Murugesan, Consultant Urologist (Andrology), RCHT.