MRCGP exam update: Treatment of erectile dysfunction

Current situation

  • Erectile dysfunction (ED) is very common. In the UK, one in 10 men will suffer from ED at some stage in their lives.
  • Although the introduction of oral medication for ED raised its profile, only about half those affected report their symptoms of ED to their GP.
  • Smoking and alcohol are important risk factors.

What is the evidence?

  • Oral phosphodiesterase-5 (PDE-5) inhibitors have become the treatment of choice for most patients as they are more convenient than injections or vacuum devices.
  • About 80 per cent of men report improved erections with PDE-5 inhibitors in a randomised controlled trial (J Urol 2002; 168: 1,332).
  • Healthy older men who develop ED could be harbouring occult cardiovascular disease (CVD), according to a recent study (JAMA 2005; 294: 2,996). ED was shown to be an independent risk factor for CVD of similar magnitude to family history or smoking.
  • However, improved cardiovascular risk factor control is likely to increase the efficacy of PDE-5 inhibitor therapy in the treatment of ED (Am J Hypertens 2006; 19: 915).
  • In men with ED from five nations, sildenafil produced substantial improvements in self-esteem, confidence and sexual relationship satisfaction, in addition to improvements with erectile function (J Gen Intern Med 2006; 21: 1,069).
  • Some dietary supplements marketed for the treatment of ED have actually been shown to contain PDE-5 inhibitors (J Urol 2005; 174: 636). This is concerning because many of these products claim to be free of adverse effects but may be fatal to patients concomitantly using nitrates.
  • One study found that most clinicians and patients preferred tadalafil over sildenafil (BJU Int 2006; 98: 623).

Implication for practice

  • Virtually all patients now choose oral medication as first-line treatment for ED.
  • Tadalafil has a much longer duration of action than the other drugs. In addition, its absorption is unaffected by fatty foods.
  • Fasting glucose is an important investigation. A recent study found men under the age of 45 years with ED had an increased risk of diabetes — in those between 26 and 35 years,
  • ED nearly tripled the odds of having diabetes (J Urol 2006; 176: 1,081).

Available guidelines

European Association of Urology Guidelines on Erectile Dysfunction, March 2006 (PDF link)

Useful websites National Library for Health NICE

Dr Louise Newson is a GP in the West Midlands and author of ‘Hot Topics for MRCGP and General Practitioners’, Pas Test 2006

Key points

  • ED is still underdiagnosed.
  • PDE-5 inhibitors are the mainstay of treatment.
  • Young men with ED have increased risk of diabetes.
  • Healthy older men who develop ED could be harbouring occult CVD.

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