Erectile Dysfunction

UK Management Guidelines for Erectile Dysfunction 1999 – Erectile Dysfunction Alliance

Assessment

Can be carried out by any professional(s) with experience of history taking and examination, provided appropriate protocols are followed.

Needa full assessment of the nature of the problem, to differentiate between ED and other problems, in particular, excluding GAD, depression, psychosis, BDD and alcoholism. Also need to identify factors that indicate organic vs psychogenic causation (flow diagram provided), although noted that ED is usually multi-factorial.

A full medical history, including medication (list provided)

A limited examination and investigation (blood pressure, dip-stick for glucose, examination of genitalia). Further examination as appropriate, depending on history (consider cardiovascular, neurological, endocrine and urinary systems) (list provided).

Common Causes

  • Psychogenic factors (anxiety / depression)
  • Heart disease
  • Hypertension
  • Diabetes
  • Medication
  • Alcohol / drug use

Treatment

Patient Choice key

  • Psychosexual therapy
  • Viagra
  • Caverject
  • MUSE
  • Vacuum therapy
  • Penile prostheses

Referral

Write to Dr Phil Kell at Archway Sexual Health clinic or Department of Andrology UCL.

Alternatively ask GP to refer directly.
Premature Ejaculation

BASHH summary – 2006

Definition:A universally accepted definition yet to be established. Persistent or recurrent ejaculation with minimal sexual satisfaction before or shortly after penetration and before a person wishes. Resulting in distress/interpersonal difficulties.

Prevalence:A systematic review suggested a prevalence of 15%

Assessment

  • Drug / alcohol use
  • Expectations, including cultural factors
  • Degree of control
  • Degree of distress, including cultural meanings (may not be a problem)
  • Primary (life long) or secondary (acquired)
  • Context for sex (where, when, with whom)
  • Quality of relationship and communication
  • Anxiety / depression and other psychiatric history
  • Sexual desire
  • Erectile difficulties
  • Urinary symptoms
  • Prostatitis symptoms
  • Clinical examination
  • General physical state / health

Organic Causes

  • Chronic prostatitis
  • Neurological disease
  • Pelvic injury
  • Vascular disease
  • Prostatic hypertrophy
  • Hypogonadal hypertrophy

Interventions

  • Treat erectile dysfunction and/or underlying cause first
  • Treatment on case by case basis ‘eclectic approach’
  • Education
  • Discussion of sexual norms
  • Facilitation of sexual negotiation
  • Squeeze technique / stop-start / sensate focus – limited treatment gains longer term
  • EMLA cream & SSRIs (not licensed) – no lasting effects
  • Pelvic floor exercises (no formal trials)

Referrals

Write to Dr Phil Kell at Archway Sexual Health clinic or Department of Andrology UCL.

Alternatively ask GP to refer directly.

Retarded Ejaculation

BASHH summary – 2006

Definition:The persistent or recurrent difficulty, delay in or absence of attaining orgasm following sufficient sexual stimulation causing personal distress.

Prevalence:A UK population based survey of 5000 16-44 year olds suggested a prevalence of 5%. Reduces with increasing age.

Assessment

  • Orgasmic and/or ejaculatory problem
  • Sexual desire, erectile difficulties
  • Personal, social, cultural issues
  • Brief psychiatric / medical history
  • Prescribed and non-prescribed drugs, including alcohol
  • Clinical examination of penis & nervous system (exclude peripheral neuropathy autonomic dysfunction & spinal cord pathology)
  • Serum glucose / investigation of nervous disease as appropriate

Organic Causes

  • Spinal cord injury
  • Retro-peritoneal lymph node dissection
  • Diabetes mellitus
  • Trauma / retroperitoneal surgery
  • MS
  • Radical prostatectomy or bladder neck surgery
  • Abdominal/pelvic surgery including abdominal aortic aneuysmectomy
  • Peripheral vascular disease
  • Mullerian and Wolfian duct malformation
  • Bilateral sympathectomy
  • Hypogonadism
  • Hypothyroidism

Drugs implicated in RE

  • Alcohol
  • Alpha blockers
  • Adrenergic Neurone Blockers
  • Anti-psychotics
  • Atypical anti-depressants (trazodone)
  • Beta blockers
  • Baclofen
  • Benzodiazepines
  • Mono-amine oxidase inhibitors (MAOIs)
  • Naproxen
  • Opiates
  • Selective serotonin re-uptake inhibitors
  • Thiazides diuretics
  • Tricyclic anti-depressants

Interventions

Treat erectile difficulties first.

Treat case by case: an eclectic approach

Changing pharmacological agents if possible

There is limited evidence for adding agents (not licensed for this):

  • Level III evidence for amantadine for fluoxetine induced RE
  • Level III evidence for bupropion for SSRI induced RE, Level Ib for buspirone
  • Level III evidence for cyproheptadine for imipramine, nortryptiline, fluoxetine, fluvoxamine, clomipramine & citralopram induced RE, but can cause drowsiness, which can affect sexual functioning.
  • Level III evidence for yohimbine for clomipramine, fluvoxamine, fluoxetine, sertraline & paroxetine induced RE

Level III & IV evidence for sex therapy. Meta-analysis success 42% - 82%

Can include sexual fantasy, masturbation exercises, use of sex aids, relaxation and addressing anxieties (eg fears of pregnancy, STIs)

Level IV evidence for hypnosis

Referrals

Write to Dr Phil Kell at Archway Sexual Health clinic or Department of Andrology UCL.

Alternatively ask GP to refer directly.
Vaginisimus

BASHH summary – 2006

Definition:Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with coitus and causes distress/interpersonal difficulty.

Prevalence:Common. Prevalence among general population unknown.

Assessment

  • Early traumatic sexual experiences
  • Sexual assault
  • Traumatic physical examinations
  • Sex education
  • Familial, religious and cultural beliefs
  • Relationship
  • Social circumstances
  • Medical history (particularly contraception, GUM & O&G problems)
  • Description of pain, fear of pain, avoidance responses.
  • Use of tampons.
  • Sexual history (problem primary, secondary, situational, global)
  • Genital examination to exclude organic pathology. Pelvic examination only if seems appropriate (note presence of spasm / distress), but can be extremely unhelpful if woman not ready.
  • Attitude to own genitals, self-touching and masturbation.

Organic Causes

  • UTIs
  • Vestibulitis
  • Post-menpausal oestrogen deficiency
  • Genital surgery trauma (eg episiotomy)
  • Radiotherapy
  • Arousal difficulties related to diabetes, MS or spinal cord injury

Interventions

  • MDT. Overlap with vulvar vestibulitis syndrome and dyspareunia.
  • Individualised approach, limited scientific evidence.
  • Check treatment goals – penile-vaginal intercourse may not be the desired outcome
  • Treatment with woman and partner if possible.
  • Education
  • Self-examination
  • Pelvic floor exercises
  • Behavioural and desensitisation techniques
  • Graded penetration (eg with dilators) with relaxation
  • Sensate focus
  • Psychotherapy
  • Couple therapy
  • Choice of gender or physician / therapist

Level III evidence for insertion training (success rates 72% to 100%, with 2-15 sessions)

Referrals

To Dr Helen Mitchell in Female Problem Clinic