Erectile Dysfunction

Erectile dysfunction (impotence) is the inability to achieve or maintain an erection of sufficient quality for satisfactory intercourse. It does not refer to ejaculation, fertility or libido. Look for a cause (e.g. psychogenic, hormonal—uncommon, drug-induced, vascular disease).

Investigations First-line blood tests:

Others: nocturnal penile tumescence, LFTs, esp. GGT (alcohol effect)

Management

Treat cause. If psychogenic, refer for personal or sexual counselling.

If androgen deficiency stepwise trial:

1. oral: testosterone undecanoate (Andriol)

2. IM: testosterone enanthate (Primoteston Depot) or testosterone esters (Sustanon)

3. subcutaneous implantation: testosterone implants (last 5–6 mths)

If functional: oral mediation (PDE-5 inhibitors)

• sildenafil (Viagra) 50–100 mg (o) ½–1 h before sex

• tadalafil (Cialis) 10–20 mg (o) 1–2 h before sex

• vardenafil (Levitra) 10–20 mg (o) ½–1 h before sex

• avanafil (Spedra) 100–200 mg (o) 15–30 mins before sex

If erection >2 hrs take 2 × 60 mg pseudoephedrine tabs.

Avoid in those on nitrates for angina.

Intrapenile injection prostaglandin E (alprostadil):

• intracavernosal injections

• self-administered after supervised teaching

• max. of 3/wk (use 2 pseudoephedrine tabs for prolonged erection >2 h)