Erectile dysfunction (failure of genital response; impotence)
Essential information for patient and partner
Erectile dysfunction is the persistent or recurrent inability to attain or maintain an adequate erection. It is often a temporary response to stress or loss of confidence and responds to psychosexual treatment, especially if morning erections occur. It is frequently associated with sexual anxiety, fear of failure, concerns about sexual performance, and a decreased subjective sense of sexual excitement and pleasure. It may also be caused by physical factors (problems with the blood vessels or nerves) or by medication.
General management and advice to patient and partner (ref 213)
Advise patient and partner to refrain from attempting intercourse for several weeks. Encourage them to practise pleasurable physical contact without intercourse during that time, commencing with non-genital touching and moving through mutual genital stimulation to a gradual return to full intercourse at the end of that period. Partners must take it in turns to be active and passive in terms of touching, and to initiate/go second ('sensate focus' therapy).
Progression along this continuum should be guided by the return of consistent, reliable erections. A book containing self-help exercises (see Resources for patients and families) might be helpful. Inform patient and partner of the possibilities of physical treatment by penile rings, vacuum devices, intracavernosal injections and medication.
- Oral: sildenafil 50-100 mg taken on an empty stomach 40-60 min before intercourse enhances erections in 80% of patients, whether the cause is psychogenic or neurological (ref 214). Beware danger of interaction with cardiac nitrates (BNF section 7.4.5).
- Recent developments include two new phosphodiesterase type 5 inhibitors: tadalafil and vardenafil; both have fewer ocular side-effects than sildenafil (ref 215).
- Intraurethral: MUSE (prostaglandin E1) 125-1000 mg inserted 10 min before intercourse produces erections in 40-50% of patients (ref 216) (BNF section 7.4.5).
- Intracavernosal: prostaglandin E1 5-20 mg injected 10 min before intercourse produces erections in 80-90% of patients,(ref 217) but long-term acceptability is low.
These medications are less effective in predominantly vasculogenic cases. See current NHS Executive guidelines for prescription of the above, either privately or on the NHS.
213 Ralph D, McNicholas T; for the Erectile Dysfunction Alliance. UK Management Guidelines for Erectile Dysfunction. Br Med J 2000, 321: 499-503.
214a Montorsi F, Salonia A, Deho F et al. Pharmacological management of erectile dysfunction. Br J Urol Int 2003, 91(5): 446-454. (CI)
214b Vitezic D, Pelcic-Mrsic J. Erectile dysfunction: oral pharmacotherapy options. Int J Clin Pharmacol Ther 2002, 40(9): 393-403. (AI)
214c Werneke U, Crowe M. Review of patients with erectile dysfunction attending the Maudsley Psychosexual Clinic in 1999: the impact of sildenafil. Sex Relation Ther 2002, 17(4): 171-185. (CIV) Sildenafil has a very satisfactory efficacy/safety profile in all patient categories.
214d A Cochrane Review will be available soon. Fink H, Wilt T, MacDonald R et al. Sildenafil for erectile dysfunction (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Oxford: Update Software.
215a Kuan J, Brock G. Selective phosphodiesterase type 5 inhibition using Tadalafil for the treatment of erectile dysfunction. Expert Opin Invest Drugs 2002, 11(11): 1605-1613. (AI) This is a review. Tadalafil is likely to play an important role in the management of erectile dysfunction across a broad spectrum of aetiologies, once past the ongoing regulatory review process. Side-effects are generally mild to moderate.
215b A Cochrane Review will be available soon. Urciuoli R, Cantisani TA, Carlini M et al. Prostaglandin E1 for treatment of erectile dysfunction (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Oxford: Update Software.
216 Padma-Natham H, Hellstrom WJG, Kaiser RE et al. Treatment of men with erectile dysfunction with transurethral alprostadil. N Engl J Med 1997, 336: 1-7. (AII)
217 Linet OI, Ogrine FG. Efficacy and safety of intracavernosal alprostadil in men with erectile dysfunction. N Engl J Med 1996, 334: 873-877. (AII)
Last edited: 26/1/2004
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