There is a dedicated ED clinic based at Ayr Hospital. At this clinic patients can be shown how to do intracavernosal injections. The clinic does not prescribe testosterone, and referrals for low testosterone should be directed to Endocrinology.
Advice where required via clinical mail box: aa.clinicalurologyayrhospital@aapct.scot.nhs.uk.
UCS, urgent or routine outpatient referrals via SCI gateway.
Erectile dysfunction pathway1.
1. NHSGGC. Erectile dysfunction.
Reproduced and adapted with kind permission of NHSGGC.
Through SCI Gateway.
For professional to professional referrals and advice related to psychosexual health, please contact Sexual Health Services (contact details only available through intranet)
Patients should be informed that there is a range of treatments which will help to resolve their problem. Almost all patients can be treated, provided they are prepared to use second line (intracavernosal self injection, vacuum pump, MUSE) and third line (penile implant) treatment options. They should be encouraged to report back if first line treatment (tablets) fail. While we recommend that only first line treatment is carried out in Routine General Practice, there is further explanation of other treatment options listed for information and as a reference for discussion with patients.
This is the first line treatment for most patients. There is no direct comparison between the three 5-PDE inhibitors in good quality comparative trials, but essentially they all work similarly well in terms of efficacy, safety and tolerability. The overall efficacy in the broad population is around 68%, with a lower response rate in difficult patients such as diabetics (48%-56%)
Contraindication to all 5-PDE inhibitors are short or long acting nitrates.
Consider cardiology review for patients presenting for ED treatment who receive nitrates to amend angina treatment. It may be worth considering whether patients really need their nitrates. For instance, some patients may have a GTN spray for angina, which they rarely use. These might be suitable for discontinuing their nitrates. Discuss options with patient - possibly start a shorter acting 5 PDE inhibitor under specific instructions that they absolutely must avoid taking/being given nitrates while have taken the 5 PDE inhibitor – this requires good patient compliance.
Others may be considered for change of long acting nitrates to other drug groups at their next cardiology review.
There is a “learning curve” for these drugs.
All 5 PDE inhibitors have similar transient side effects of:
There is no increased incidence of myocardial infarction with these drugs. All drugs are contraindicated in patients taking nitrates as they potentiate their effect. 5 PDE inhibitors also interfere with alpha-blockers. (This may be circumvented in patients taking alpha-blockers for bladder outflow obstruction by taking the alpha-blocker in the morning and the 5PDE inhibitor in the evening, eg. tamsulosin, alfuzosin, doxazosin.) Patients with significant cardiac disease should be assessed cardiologically before using 5PDE inhibitors (see below).
Sexual activity is mild exercise and should be within the physical capacity of most men. Peak heart rates and systolic pressures achieved during intercourse only reach 60-70% of the maximum values achieved in a treadmill test. The workload equates with walking at 3 miles per hour on the flat for older men or with walking at 4.2 mile per hour up a 16% gradient (or cycling at 10 miles per hour) for younger men. Priapism: this very rare, but potentially devastating complication of a prolonged painful erection of more than 4 hours is an emergency requiring immediate treatment. Patients should be warned about it, so they can seek help early. Latest after 24 hrs smooth muscle necrosis occurs, resulting in impotence.
Several alprostadil preparations are available and injection is now aided by a self injection pen. Intracavernosal injections work in a high proportion of patients, but require the preparedness to accept the injections and the dexterity to apply them.
Alprostadil given transurethrally avoids the need for intracavernosal injection, but is overall less effective and has a higher incidence of penile pain leading to discontinuation of treatment. MUSE application is somewhat complex, requiring insertion after micturition, manual dexterity and good eyesight. Initial tuition is recommended (there is a patient video from the manufacturer). Longterm studies and follow-up have not been reported. It can be used in needlephobic and in anticoagulated patients.
A vacuum device consists of an external cylinder fitted over the penis to allow the air to be pumped out, resulting in engorgement of the penis with blood. A constriction ring is then fitted to the base of the penis to maintain this “erect” state. It is suitable for a wide range of patients with chronic or occasional ED, whatever the cause. Satisfaction rates with this are reported as varying widely, probably reflecting physicians enthusiasm and patient teaching to some extend. It probably works well in couples that jointly decide to use this method, although the method has some definite disadvantages.
Vacuum pumps can be bought directly by mail order and are a single investment cost compared to ongoing costs of medication. Those patients wishing to try this method straight away can be given the list of manufacturers. Most patients may wish to try the method first and should be directed to the Urology Department, where some dedicated pumps are available for patients to try.
This is third line treatment reserved for those who have failed other treatments, have contraindications to other treatments or decline other treatments. This has a high patient and partner satisfaction rate and is a very effective treatment. Penile prosthesis insertion will however irreversibly damage penile cavernosal tissues and a return to other treatment forms is subsequently impossible. In reality most patients wishing to undergo surgery for ED have nonfunctioning cavernosal tissues already. Technical success rates are high and the risk of infections is low with modern antibiotic covered prosthesis and prophylaxis.
Exceptionally patients may be considered for vein ligation surgery, vein or graft surgery or arterial revascularisation surgery for ED.
RefHelp - NHS Ayrshire and Arran