A 63 year old man comes to you for a routine check of his blood pressure. During the consultation you notice an entry in his notes about difficulty with erections that was never followed up.
What issues you should cover
Is this an ongoing problem?—Healthcare professionals often fail to initiate discussion of possible erectile dysfunction, whether because of embarrassment, lack of knowledge, or pressure of time. Patients find it even more difficult to raise the issue with their doctors, even though erectile dysfunction can have a major effect on their quality of life and on their partners and can place considerable strain on the relationship. Erectile dysfunction may also be an important indicator of underlying medical problems.
Causes—These can be divided roughly into psychogenic origins (such as a new partner, relationship problems, and depression) and organic causes (such as diabetes, cardiovascular disease, and iatrogenic causes). Smoking and alcohol are important risk factors for or causes of erectile dysfunction. Patients, when prompted, can often identify psychological triggers for their problem and will often have had dysfunction of rapid onset after a particular stressful event. Symptoms among patients with psychogenic dysfunction are often variable, and patients may report normal morning erections. Patients with organic dysfunction will typically have a history of more gradual onset. Erectile dysfunction is often associated with use of particular drugs, such as antihypertensives and antidepressants.
Does he have a normal libido?—Evaluating this will help you to determine whether he has a low testosterone concentration. If his libido is normal, and your examination shows no sign of testosterone failure, it is not necessary to check his serum testosterone concentration.
What you should do
Remember that the more embarrassed you seem as a health professional the more embarrassing this problem will be to the patient. Be positive and optimistic. Tell him that many men with erectile dysfunction, particularly when it has a psychogenic cause, find that their problem resolves after medical treatment.
Be aware of erectile dysfunction as a potential marker for generalised arteriosclerosis. Studies have shown the development of erectile dysfunction to be a predictor of coronary heart disease in high risk patients. Consider carrying out a formal 10 year cardiovascular risk assessment.
Examine his external genitalia, particularly for any anatomical abnormality (such as hypospadias or Peyronie's disease) and presence of pubic hair, and make a rough assessment of testicular size (to exclude testicular atrophy). Check his blood pressure, and carry out a formal cardiovascular examination if he is at high risk.
All men with erectile dysfunction should be tested for undiagnosed diabetes mellitus. Further investigations, such as lipids, testosterone, prostate specific antigen, prolactin, creatinine, and thyroid function tests, should be targeted at appropriate patients.
Try to treat the cause if possible: consider psychosexual counselling for psychogenic dysfunction, encourage him to stop smoking, and control hypertension. Consider changing any drugs he is taking.
Offer him drug treatment. In Britain this will usually be one of the three currently available phosphodiesterase inhibitors: sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) (table). These drugs are absolutely contraindicated in men who use nitrates or who have severe cardiac disease. Discuss the side effects of these treatments; the commonest of these are headache, indigestion, facial flushing, and nasal congestion. Start with the lowest dose available and increase if necessary on the basis of effectiveness and side effects (which are often dose related). It is worth trying an alternative drug if one has not worked or has produced side effects, as individuals' responses to different formulations are idiosyncratic.
Most patients with erectile dysfunction can be safely and effectively managed in primary care. General practitioners are particularly well placed to take a holistic approach, and referral should be reserved for patients with erectile dysfunction that does not respond to first line medical treatments and patients with anatomical abnormalities.
Table 1.
Characteristics of drugs for erectile dysfunction
| Drug | Speed of onset of action | Duration of action |
|---|---|---|
| Sildenafil (Viagra) | 30 to 40 minutes* | 4 hours |
| Vardenafil (Levitra) | 20 minutes | 4 hours |
| Tadalafil (Cialis) | 30 to 40 minutes | 24 to 36 hours |
Note: absorption of sildenafil is altered by consumption of food.
Useful reading
Kirby R, Holmes S, Carson C. Erectile dysfunction. 3rd ed. Oxford: Health Press, 2002. (Fast facts series)
UK Sexual Dysfunction Association (formerly the Impotence Association). www.sda.uk.net
Webber R. Erectile dysfunction. In: Clinical evidence. Issue 13. London: BMJ Publishing, 2005:1120-6 (www.clinicalevidence.org/ceweb/conditions/msh/1803/1803.jsp)
This is part of a series of occasional articles on common problems in primary care
The BMJ welcomes contributions from general practitioners to the series