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Management of Erectile Dysfunction

Erectile dysfunction is a deeply distressing yet treatable condition that affects millions of men throughout the world. The body of information about this disorder is expanding rapidly. Guidelines are available to assist primary care providers in safely and effectively managing this condition.


In 1992, the National Institutes of Health (NIH) convened a conference to gain a better understanding of impotence: its risk factors, etiology, diagnosis, treatment and consequences. The NIH Consensus Panel on Impotence determined that the term "erectile dysfunction" rather than "impotence" should be used to describe the inability to achieve and maintain penile erection sufficient to allow acceptable sexual intercourse or acceptable satisfaction in all areas of sexual function.1

Approximately 30 million men in the United States are affected by erectile dysfunction, and the prevalence increases with age.1 Historically, erectile dysfunction has been divided into three categories: physical (organic), psychological (psychogenic) or mixed etiology.2-6 Psychogenic causes include performance anxiety, depression, relationship conflicts and psychological disorders.4,7 Organic causes can be vascular (arterial, venous, cavernosal, mixed), neurogenic (central nervous system, peripheral neuropathy, postsurgical, traumatic injury), hormonal (hypogonadism) or drug-induced.4,7 Medications associated with erectile dysfunction include antihypertensives, antidepressants, anticonvulsants and sedatives.4,7 Recreational drugs such as alcohol, cocaine and tobacco also have been implicated.2,4,6,8

Current clinical thinking suggests that erectile dysfunction is an early predictor for cardiovascular disease (CVD)2,5,8-11and it may assist clinicians in identifying subclinical disease and common co-morbidities such as diabetes mellitus, metabolic syndrome, hypertension, vascular disease and high cholesterol.5,8,9,12 The most prevalent presentation of erectile dysfunction is organic in nature.11


The primary care provider is often the first professional a patient turns to for advice about erectile dysfunction. Knowing how to treat, when to refer and where to refer will assist the primary care provider in achieving the primary goal of erectile dysfunction therapy: restoring normal sexual function and quality of life.4-6,8

Conduct the patient assessment in a relaxed and open manner.4,8 Full medical, surgical, psychosocial and sexual histories are needed, as is a discussion about lifestyle factors. A thorough history may reveal red flags for co-morbidities and risk factors for CVD. Discuss issues such as obesity, smoking, prescription and recreational drug use, since these are considered reversible causes of erectile dysfunction.4,9,10 Ask about onset, attempts to self-treat, associated pain or history of trauma, and stress in personal, sexual and work life.7 A thorough history is vital because it may reveal specific contraindications to therapy.1,11

Rosen et al created the International Index of Erectile Dysfunction (IIEF), a 15-point multidimensional self-report instrument for the evaluation of sexual function in men, for use in clinical trials.13 When it became clear that such a tool was needed in the clinical setting, Rosen and colleagues abbreviated the IIEF to create the IIEF-5, usually referred to as the Sexual Health Inventory for Men (SHIM).14 The SHIM assesses sexual function over the preceding 6 months and is a useful diagnostic aid for the primary care setting.15 However, it is not a replacement for the patient interview.1 Possible scores on the SHIM range from 5 to 25, with higher numbers indicating better sexual well-being.14,15 Table 1 outlines this concise set of questions.

In addition to height, weight, body mass index (BMI) and blood pressure, a focused examination should include a thyroid evaluation, pulmonary status assessment, cardiac rhythm assessment, an abdominal examination including measurement of waist circumference, a genital examination, assessment of secondary sex characteristics, and a digital rectal examination to assess the prostate gland.1,8,11 Recommended laboratory studies include total and free testosterone, prostate-specific antigen (PSA), thyroid-stimulating hormone (TSH), prolactin, lipid panel, fasting glucose, complete blood count (CBC), and renal function studies.1,7,11

Primary Care Management

Guidelines from the American Urological Association (AUA) recommend managing erectile dysfunction in a stepwise approach.11 First-line therapies are lifestyle modification, management of cardiovascular risk factors and, provided no contraindications are present, a trial of oral phosphodiesterase(PDE-5) inhibitors. Prior to initiating PDE-5 inhibitors, assess the patient for cardiovascular risk. Men who have intermediate to high cardiac risk should have a cardiology consult prior to starting PDE-5 inhibitors.9 Patients at intermediate (or indeterminate) risk include patients whose cardiac conditions are in doubt or who have more than three cardiac risk factors, excluding gender. High-risk patients include those whose cardiac conditions are severe enough that sexual activity may pose a serious risk. Most high-risk cardiac patients have experienced moderate to severe cardiac symptoms prior to presenting for complaints of erectile dysfunction.9

Three PDE-5 inhibitors have been approved by the Food and Drug Administration to treat erectile dysfunction: sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis).8,11 Table 2 provides information about these medications. PDE-5 inhibitors can be effective for men with diabetes mellitus, spinal cord injury, multiple sclerosis and depression, as well as for men who have undergone radical prostatectomy and radiotherapy for prostate cancer.16 PDE-5 inhibitors are contraindicated in recent myocardial infarction, high-risk CVD and with concurrent nitrate therapy.8,9,11,16 Because all three medications are metabolized by the liver, adjustments should be made for patients with reduced hepatic function.7,11

Failure to respond to PDE-5 inhibitors may require patient re-education and counseling about modifiable factors such as drug timing, the need for adequate sexual stimulus, avoiding excessive alcohol consumption, and interaction with fatty foods.16-19 Although little evidence supports the superiority of one PDE-5 inhibitor over another,11 there is evidence that patients who do not respond to one PDE-5 inhibitor may respond successfully to another.11,17,18,20 If re-education and a sufficient trial on a PDE-5 inhibitor do not produce acceptable results, or if definite contraindications to PDE-5 therapy exist, the AUA recommends advancing to next-line therapies.11

Second- and third-line therapies are beyond the scope of the primary care provider and should be initiated by a urologist or endocrinologist. Psychotherapy and behavioral therapy may benefit patients in whom no organic cause can be identified and/or in patients who refuse medical and surgical interventions.1 Second-line therapies include alprostadil intraurethral suppositories, vacuum devices, intercavernosal injections and testosterone therapy. A surgically implanted penile prosthetic is considered third-line therapy, and it is typically indicated only when first- and second-line treatments are unsuccessful.7,8,11

Working Together

Finally, it is essential that a man and his partner are educated that ED is not a diagnosis of finality. If a man and his partner can accept that changes in sexual function are a result of the aging process, they can begin to accept that choices for treatment are not limitless.1

Johanna L. Nehring is a family nurse practitioner in the critical care unit at Atlanticare Regional Medical Center in Atlantic City, N.J. She has completed a disclosure statement and report no relationships related to this article.


1. NIH Consensus Conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA. 1993;270(1):83-90.

2. Feldman H, et al. Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts male aging study. Prev Med. 2000;30(4):328-338.

3. Griffiths L, et al. A study of the management of erectile dysfunction in general practice. J Clin Pharm Ther. 2005;30(3):297-304.

4. McCoid JD. Therapeutic management of erectile dysfunction. Nurse Prescribing. 2007;5(4):143-147.

5. Rosenberg MT. Diagnosis and management of erectile dysfunction in the primary care setting. Int J Clin Pract. 2007;61(7):1198-1208.

6. Steggall MJ. Erectile dysfunction: pathology, causes and patient management. Nurs Stand. 2007;21(43):49-56.

7. Oommen M, Hellstrom W. What to do when a patient presents with erectile dysfunction: urologic symptoms in primary care. Medscape Urology. 2008. Accessed Jan. 18, 2012.

8. Smith IA, et al. Erectile dysfunction - when tablets don't work. Aust Fam Physician. 2010;39(5):301-305.

9. Kostis JB, et al. Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference). Am J Cardiol. 2005;96(12B):85M-93M.

10. McVary K. Erectile dysfunction. N Engl J Med. 2007;357(24):2472-2481.

11. Montague DK. The management of erectile dysfunction: An AUA update. J Urol. 2005;174(1):230-239.

12. Shabsigh R, et al. Randomized study of testosterone gel as adjunctive therapy to sildenafil in hypogonadal men with erectile dysfunction who do not respond to sildenafil alone. J Urol. 2004;172(2):658-663.

13. Rosen RC, et al. The international index of erectile function (IIEF): A multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49(6):822-830.

14. Rosen RC, et al. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Dysfunction (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11(6):319-326.

15. Cappelleri JC, Rosen RC. The Sexual Health Inventory for Men (SHIM): A 5-year review of research and clinical experience. Int J Impot Res. 2005;17(4):307-319.

16. Ellsworth P, Kirshenbaum E. Current concepts in the evaluation and management of erectile dysfunction. Urol Nurs. 2008;28(5):357-369.

17. Broderick GA. Oral pharmacotherapy and the contemporary evaluation and management of erectile dysfunction. Rev Urol. 2002;5(Suppl 7):S9-S20.

18. McCollough AR, et al. Achieving treatment optimization with sildenafil citrate (Viagra) in patients with erectile dysfunction. Urology. 2002;60(2 Suppl 2):28-38.

19. Shabsigh R, et al. The triad of erectile dysfunction, hypogonadism and the metabolic syndrome. Int J Clin Pract. 2008;62(5):791-798.

20. Carson CC, et al. Erectile response with vardenafil in sildenafil nonresponders: A multicentre, double-blind, 12-week, flexible-dose, placebo-controlled erectile dysfunction clinical trial. BJU Int. 2004;94(9):1301-1309.






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