History and Examination

• Erectile Dysfunction is diagnosed from the patient’s history.
• It is important to check that the patient is actually describing ED (poor quality erections) rather than:
  • Decreased libido
  • Peyronie's disease (penile curvature)
  • Ejaculation problems

Ask about possible causes of ED:

• Psycho-social issues (continuing early morning erections and young age suggest a psychological component)
• Medication history: b-blockers, opiates, antihistamines, SSRI’s, steroids, antipsychotics
• Smoking
• Excessive alcohol
• Obesity (weight loss can reverse ED in 30% of men)
• Cycling more than 3 hours/week
• Symptoms/ signs of hypogonadism (testosterone test indicated): decreased libido, small testes, gynaecomastia, and lack of body hair.

• BP
• Rectal examination and examination of genitalia (DRE & LUTS)
• Tests are aimed at excluding other disease as a cause of ED and assessing cardiovascular disease risk (higher risk of CVD in ED)
  • e.g. diabetes, high cholesterol, low testosterone and Metabolic Syndrome and hypertension.

1st line testing for all men to assess CVD risk and diabetes as underlying cause:

• HbA1C
• Cholesterol, HDL, Chol/HDL and non-HDL

(There will be a prompt at request in the GP system to add on a PSA and/ or testosterone if clinically indicated from the history and examination)

Blood samples for testosterone must be taken BEFORE 11am
(to avoid an artificially low result)

2nd line testing (if PDE-I failure):

• 80% of men will respond to PDE-i inhibitor treatment. In those men who do not respond, check testosterone to look for hypogonadism as a cause of non-response to PDE5 inhibitor.
• A person with erectile dysfunction should receive eight doses of a PDE5 inhibitor (at least 2 months treatment) at a maximum dose with sexual stimulation before being classified as a non-responder.
  • Testosterone ( Before 11am)
• If Testosterone low (under 8nmol/L): Repeat Testosterone after 4 weeks (levels vary overtime, 30% are normal on repeat testing)

If 2 low Testosterone results (under 8nmol/L): Test for causes of persistently low testosterone

• Prolactin, FAI, SHBG, FSH, LH

*Test groups available on GP order comms test requesting software

• Psychological causes: Psychosexual counselling where relevant (RELATE)

If appropriate, interventions to help:

• Lifestyle change: stop smoking, increase exercise and lose weight
• Alcohol advice
  
• Medication review: consider stopping/ switching drugs that can cause ED

Following 1st line testing:

• Cardiovascular risk assessment
• Offer PDE-I (80% respond to PDE5-inhibitors regardless of the cause of ED)

All PDE5 inhibitors have similar efficacy overall. (See Formulary section 7.4.5 drugs for erectile dysfunction)

With the exception of generic sildenafil, the other formulary drugs for the treatment of erectile dysfunction may only be prescribed on the NHS under certain circumstances; see Formulary
Guidance on prescribing for erectile dysfunction for more information.

Side effects not common, similar in all three:

• Headache and Flushing – commonest
• Dyspepsia – not usually problematic
• Visual disturbance (colour) –rare and transient

Although all are similar compounds, experience indicates that patients rarely get the same side effects with all three.

Where PDE5 inhibitors are successful subsequently titrate down.

If PDE5 inhibitor failure: 2nd line testing:

• Testosterone (Before 11.00am)

If low Testosterone(under 8nmol/L): Repeat Testosterone test at 4 weeks.

If 2 low Testosterone results (under 8nmol/L), test for possible causes:

• Prolactin, FAI, SHBG, FSH, LH

Patients with persistently low testosterone under 8nmol/L reconsider if obesity could be lowering testosterone/ refer to endocrinology for consideration of testosterone replacement therapy/ further investigation.

Referral Criteria

• Refer patients with persistently low testosterone, under 8nmol/L to Endocrinology
• Refer patients with Peyronies disease to urology
• Patients who are suffering severe distress as a result of impotence (prescribed in specialist centres only)
• Refer those in whom PDE-5 inhibitors are contraindicated for consideration and training of other therapies.

There are specific NHS prescribing restrictions on GPs for the treatment of ED. This means that referral to access medication or other interventions will need to be considered earlier for some groups of patients than others.

• For patients eligible only for generic sildenafil (See Guidance on prescribing for erectile dysfunction) consider referral for men (with a normal testosterone) * who have failed to respond to 8 doses of generic sildenafil at maximum dose with sexual stimulation.
• For other men (with a normal testosterone) (See Guidance on prescribing for erectile dysfunction), which is likely to be the majority of men, consider referral for those who have failed to respond to 8 doses at the maximum dose with sexual stimulation of two different PDE-5 Inhibitors.

*Added due to testing changes - patients with a low testosterone and no response to PDE5-I will be referred for low testosterone

If referring for erectile dysfunction the patient must have tried the basic ED therapy and investigation unless contraindicated. Referrals submitted without this information will be returned.

Referral Instructions

Referrals related to low testosterone levels

e-Referral service selection

• Service: Endocrinology and Metabolic Medicine
• Clinic type: Not Otherwise Specified
• Service: DRSS-Western-Endocrinology-Devon ICB-15N

Referrals related to Peyronies Disease requiring surgery

Mr Richard Pearcy, Consultant Urologist, Andrologist at Derriford Hospital
e-Referral service selection

• Service: Urology
• Clinic type: Erectile Dysfunction/Andrology
• Service: DRSS-Western-Urology-Devon ICB-15N

Referral Form

DRSS Referral Form

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: September 2015
Updated: March 2023