Erectile dysfunction (ED) is a common condition, but one that’s often overlooked in clinical practice.
A comprehensive investigation of ED, including consideration of known risk factors and comorbidities, is needed to accurately identify the underlying cause and institute effective treatment. This can have broad-ranging benefits for patients beyond addressing the impacts of the sexual dysfunction itself.
Erectile dysfunction causes and comorbidities
ED is a consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual activity1.
It can have many causes, including anatomical, vascular, neurological or endocrinological factors, side effects from medications, psychological conditions – or a combination of these2.
Several conditions have been linked with ED, including:
- Depression and its treatments, which can both cause, and be caused by, ED3
- Metabolic syndrome — comprising central obesity, hypertension, increased fasting blood glucose and dyslipidaemia4
- Cardiovascular disease — ED can be an early warning sign5.
Diagnosing and assessing erectile dysfunction
It’s important that GPs undertake a thorough patient assessment before treating ED to ensure the right causes — as well as any risk factors or comorbidities — are being addressed.
It is recommended GPs follow these steps2:
- Initiate a non-judgemental discussion about sexual health and provide the patient with an opportunity to discuss erectile problems
- Define the sexual problem/s — assess self-reported sexual function and differentiate between other conditions, like premature ejaculation
- Evaluate medical history for risk factors, comorbidities, sexual health and psychosocial status
- Perform a focused physical examination that includes a genital examination
- Order selective blood tests based on patient age, risk factors and physical examination findings. GPs should screen most men for hypogonadism, diabetes and dyslipidaemia.
Treating erectile dysfunction
ED can be treated successfully through different options that vary in modality, reversibility and invasiveness.
No single therapy will suit all men. Treatment decision-making should be shared, and consider patient needs, goals and expectations. GPs should talk to men and their partners about the risks, benefits and costs of different treatment options so they can make an informed choice — which may be to forego treatment altogether6.
Regardless of the treatment, regular follow-up is essential to ensure the best outcomes for the patient7.
Treating reversible causes, risk factors and comorbitities2
If the initial assessment uncovers any reversible causes of ED— for example, low testosterone, medication side effects or mental health conditions — treat these first.
If ED is caused or exacerbated by stress, relationship difficulties, depression or anxiety, GPs should consider referral to a mental health professional. An integrative treatment approach that addresses both psychological and medical factors can work well for patients.
Alongside treating the cause/s of ED itself, GPs should also work with the patient to reduce or eliminate modifiable risk factors, like smoking or lack of exercise, as well as ensure any comorbidities are well controlled.
Phosphodiesterase type 5 (PDE5) inhibitors2,7
PDE5 inhibitors — sildenafil, tadalafil and vardenafil — are taken orally.
They do not initiate an erection, so sexual stimulation is required for the drugs to work. GPs will need to adapt the dose according to response and side effects. See our clinical summary guide on erectile dysfunction for detailed dosing information.
Patient preferences, cost, side effects and satisfaction with previous use will determine the most appropriate PDE5 inhibitor. Patients may need to try at least two different drugs, and do a full course of each multiple times, to determine if the treatment is effective.
Common side effects include headaches, flushing, dyspepsia, nasal congestion, backache and myalgia. However, significant adverse effects are extremely rare.
PDE5 inhibitors should not be used by men who take prescription or recreational nitrate drugs.
Penile injections with the drug alprostadil allow an erection to occur within 5–15 minutes. If the erection is not adequate with alprostadil alone, it may be combined with other vasoactive drugs to increase efficacy or reduce side effects.
The initial trial dose should be administered by an experienced GP or other specialist, such as a urologist. Men need to be taught how to deliver the injections themselves. It is recommended that penile injections are used a maximum of three times a week, with at least 24 hours between uses.
Potential side effects include priapism, pain, fibrosis and bruising, particularly if the patient is on blood-thinning agents. This treatment is not suitable for men with a history of hypersensitivity to alprostadil or risk of priapism.
Vacuum erection devices
Vacuum erection devices draw blood into the corpora, and an occlusion ring is placed at the base of the penis to sustain the erection. There is a level of skill required to use them correctly1.
Vacuum erection devices are suitable for men who are not interested in, or have contraindications for, oral or injectable pharmacologic therapies.
Potential side effects include penile discomfort, numbness and painful ejaculation7. Because of this, most men do not use this treatment long-term2.
Vacuum erection devices are contraindicated in patients with bleeding disorders or those on anticoagulant therapy8.
A penile prosthesis is a concealed, surgically implanted device that is either inflatable or semirigid. It is a highly successful option9 for patients who prefer a permanent solution or who have not found another effective treatment for ED, although cost may be a barrier for some patients.
Vascular surgery for ED involves a microvascular arterial bypass and venous ligation surgery to increase arterial inflow and decrease venous outflow. However, it is not considered a standard approach to treating ED10.
- Montorsi et al., 2010. Summary of the recommendations on sexual dysfunctions in men. The Journal of Sexual Medicine
- Shoshany et al., 2017. Much more than prescribing a pill – Assessment and treatment of erectile dysfunction by the general practitioner. Australian Family Physician
- Perelman, 2011. Erectile dysfunction and depression: Screening and treatment. Urologic Clinics of North America
- Kaya et al., 2015. A comprehensive review of metabolic syndrome affecting erectile dysfunction. The Journal of Sexual Medicine
- Gandaglia et al., 2014. A systematic review of the association between erectile dysfunction and cardiovascular disease. European Urology
- Burnett et al., 2018. Erectile dysfunction: AUA guidelines. The Journal of Urology
- Healthy Male, 2020. Erectile dysfunction clinical summary guide
- Trost et al., 2016. External mechanical devices and vascular surgery for erectile dysfunction. The Journal of Sexual Medicine
- Saavedra-Belaunde et al., 2020. Epidemiology regarding penile prosthetic surgery. Asian Journal of Andrology
- Sooriyamoorthy & Leslie 2021. Erectile Dysfunction. In: StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK562253/