How to manage erectile dysfunction

You’ve got to have good conditions for sex, you’ve got to be aroused, you’ve got to have a good libido, you’ve got to preferably like the person you’re having sex with, factors that need to be just right for the tablet to work, it just doesn’t work solely on its own.

[Music] Welcome to the Australian Prescriber Podcast. Australian Prescriber, independent, peer-reviewed and free.

Problems with erections are commonly assessed and addressed in general practice, where it’s important to consider all the potential underlying causes before just simply prescribing. My name’s Dr Laura Beaton, I’m a GP in Melbourne, and I’m your host for this episode.

Today I’m joined by sexual health physician Dr Michael Lowy to talk through a multimodal approach to understanding and treating erectile dysfunction, which he outlines in Australian Prescriber. Dr Lowy is a lecturer in men’s health at the University of New South Wales and Sydney University. Welcome to the podcast, Michael.

Thank you for having me.

Thanks for being here. And look, I’ll be honest, as a female GP it’s actually quite rare that erectile dysfunction is the primary reason that someone books in to see me, but eventually it becomes apparent that it actually is a really important issue for lots of my patients. And so just to start off with today, can you take us through the steps that you initially take when you’re evaluating someone who comes to you with concerns about their erections?

I don’t have to discover that someone has ED, erectile dysfunction, because they come to me already with a referral, or they come to me through my website, so I’m at an advantage because we go straight into the issue. You said you don’t see many patients with erectile dysfunction. There are many, many medical conditions that many men have that would be associated with ED but the patients don’t tell you about it, and I think that the art of finding this out in general practice is asking your patients, particularly those with long-term diabetes, or any sort of chronic illness and ageing, whether they actually have an issue, and most men would have some concern but don’t know how to ask about it, or feel a bit embarrassed.

Once the issues come onto the table, what are the first key questions that you ask?

Well first I would just do a very general history, like every doctor does, just finding out a bit about the patient, their age, where they live, who they live with, what’s their job, a bit about their family, what medications they’re on, past medical issues. I do a fairly thorough but quick personal social history, and then men are actually not very good at actually describing problems, sometimes they waffle a bit, or a guy might think erectile dysfunction is actually premature ejaculation, or might think premature ejaculation is erectile dysfunction. They’re just not sure how to describe it, or they’re just not sure themselves.

So I really do need to ask very clearly, is your problem one of libido, like your loss of desire, or is it a difficulty with erection, either getting it or holding it, or is the problem with ejaculation or orgasm too fast, too slow, something not quite right about it. So I need the patient to actually describe it, and I also need to ask them questions like, make sure that this is not depression, and also need to find out about their relationship as well, if they’re in a relationship, is there something going on? Is this a presentation with the relationship? And I also need to ask, of course about, sleep apnoea because these guys who have sleep apnoea often have sexual problems, which may have an impact on their testosterone level, and furthermore there are many men who are developing a little bit of a dependency on watching porn and that can translate into sexual difficulties with another person.

So ultimately you start with basic social, medical stuff, get into more specific issues, and then there’s the peripheral things you need to ask about.

Dr. Laura Beaton (03:16):

And there’s a really helpful box in the article which goes through some of the major risk factors for erectile dysfunction, and I guess if you step through all of those, you have taken a medical history, a social history, substance use, psychological history, as well as a medication history and those of any potential physical anomalies which might lead to erectile detection, which would lead you down more of an examination pathway. How important is it that you really distinguish between erectile dysfunction versus premature ejaculation? How important is it that we know exactly what we’re dealing with?

The treatments are quite different, but it’s also a bit tricky when an older man with erectile dysfunction may then develop premature ejaculation as a consequence. Whereas the younger guy with PE, or premature ejaculation, generally doesn’t have an erection problem, and the older guy with ED doesn’t necessarily have to have PE as well. So there is a bit of a crossover, but ED is mainly treated with the oral medications that are described in the article, whereas PE is more training exercises, psychological approach, behavioural approach, and application of various anaesthetic agents and use of a condom. And then there are the SSRI treatments, the oral treatments that we use for PE that do not help ED.

How do you walk the line between how much prominence to put on a psychological cause of erection difficulties, versus how much it actually just might be exacerbating an underlying biological cause?

I usually give men the benefit of thinking that this is physiological, or organic, before I do psychological, unless it’s obviously psychological, there’s serious issues saying that, because most guys have a little bit of both, to be quite honest, and any guy who gets erectile dysfunction will be bothered by it, but may present with performance anxiety. So I start with an organic physiological approach, and then I go into the issues around anxiety, especially if they have a partner, how does the partner feel about it? And some guys who are not in a relationship actually avoid relationships because they’re so embarrassed about either having ED or PE, so it’s a bit tricky, and does involve certainly physiological, organic, and psychological issues.

And thinking about physiology, certainly there’s lots of medications that we know are associated with erectile dysfunction that are commonly used. What are the key ones that you ask about that are the major culprits?

Every medication that a guy takes has potential side effects, even if they’re not listed. The beta blockers, particularly the older style beta blockers, which are still very much used in cardiac cases. I call them erection unfriendly. They’re very good drugs, and I would never stop a beta blocker so a guy could get an erection, because there’s often other factors as well, there’s often atherosclerosis, ageing, high blood pressure, maybe diabetes, but beta blockers have a fairly significant contribution to erection problems.

Most of the more modern blood pressure tablets are okay and the old-fashioned thiazide diuretics, which I think they’re being used a bit these days, they can also have some contribution to sexual dysfunction. All the psychotropic drugs, all the SSRIs, can reduce libido and delay ejaculation. Alcohol is also an ejaculation-delaying thing. And that’s what many young men with PE have learned themselves, we never tell them this, but by being drunk in a sexual situation it may delay their ejaculation.

And just clinically I was interested, because I guess SSRIs are really commonly prescribed medications, and the teaching is that you know can swap out to a different SSRI, it may or may not have the same libido side effect. I wonder how often you find that actually swapping that solves the issue.

There are a couple of more modern antidepressant anti-anxiety agents that don’t have sexual side effects, and I usually write to the GPs, “Is it possible for the patient to change over?” They’re non-SSRI ones, and they’re well known. But if the patient really needs an SSRI, and particularly very effective ones, you can’t just stop it just to improve their sexual function. We can treat sexual dysfunction also without stopping it, and often just a small dose of a PDE-5 inhibitor or counselling may actually help the patient. So it’s always a bit tricky when you think by stopping medication you’ll improve the situation, but then by stopping that medication you exacerbate the original problem for which they’re on it. So I think each case stands on its own, but I do tend to ask patients on SSRIs where there’s an obvious impact on their sexual function that would it be possible to try a medication that has less impact?

One of the other risk factors is advanced age, and certainly with advanced age the chance that you potentially have accumulated other risk factors that also would be cumulative for erectile dysfunction may be taking place. And I guess I wonder, how cautious do we need to be when attributing erectile dysfunction to age alone? How important is it to be really thorough in our investigations that make sure we’re ruling out other causes?

Well look, certainly the Massachusetts Male Aging Study from 1987 established that at each decade of age there’s an increased risk of erectile dysfunction. At 60 years of age, 60% of men, 70 years of age, 70%, so it’s a well-known statistic. But there are men who are 70 or 80 who don’t have erectile dysfunction, it’s just that ageing does it. But ageing often has associated health issues, atherosclerosis, men with enlarged prostates, a big prostate is often associated with erection problems. There’s always other issues surrounding it, and the one that must always be investigated is the man with silent coronary artery disease. He’s about to have some sort of coronary artery incident who presents with erectile dysfunction. The studies show us that ED may present three to five years before a man presents with coronary artery ischaemia, so I’m recommending a lot of my patients, particularly the elder ones who have never been to a cardiologist, to go and have their heart checked in case this is the presenting symptom. That’s why ED is a key into other health problems in the body.

So considering that causes of erectile dysfunction are multimodal, let’s talk to the different modalities of treatment, and we’ll just start off with lifestyle and psychological support before we move on to pharmacological measures. What do you start off with recommending people?

I’ve been a GP myself, and it’s always been so hard for lifestyle changes in some men. Maybe modern men today are a bit more interested in gym, and stuff like that, but to get a guy who’s overweight, smokes, drinks a lot of alcohol, and generally doesn’t look after his diet, it’s not an easy task to improve that. If you can, fantastic, and I think it’s always worth a try. You just need some motivational counselling, and these guys often say they didn’t know their ED was a result of their health problems, and sometimes by clarifying that there may be an impetus for a change. So it’s really important to start with lifestyle changes for anything if you can, weight loss, more exercise, care with diet, can always benefit the patient, and good luck if they will respond.

Certainly maybe having better erections or more confidence in erections may be a motivating factor for some people.

Yes.

And can you just talk us through the oral phosphodiesterase-5 inhibitors, and the important parts about counselling. Because it’s not just a dose, take it at this time, it’s pretty complicated, and there’s some side effects that really we should be warning patients about.

You never prescribe someone treatment for a sexual dysfunction if they’re not fit enough to engage in sexual activity, and particularly if someone is on nitrates and has angina and gets breathless. But nitrates are a contraindication because the potential severe drop in blood pressure from both the PDE-5 inhibitor and the nitrate medication, and also the other risk is the amyl nitrite recreational drug that also is a potential health problem by taking it with an oral medication. So there are some people who you shouldn’t be prescribing these to, but they are the first-line treatment, and they’ve been very successful since introduction of sildenafil in 1998.

But what most guys don’t realise initially is that one, it might take up to five or six times to know if it really works or not, and sometimes you have to try different doses. But I remember in the very beginning some guys just took it and sat down and waited for an erection to occur. Realise that men really need to be taught, you’ve got to have good conditions for sex, you’ve got to be aroused, you’ve got to have a good libido, you’ve got to preferably like the person you’re having sex with, factors that need to be just right for the tablet to work, it just doesn’t work solely on its own. And so it does need a lead in time, it needs good conditions for sex, and again, they don’t always work so well, or the patient expectation, the guy may have an expectation, age of 60 or 70, that he’s going to get an erection like he had when he was 20, and this is just not going to happen. So you have to deal with the expectations and the counselling and the psychology of sex as well.

And I guess depending on the person’s preference, I actually am preferring now tadalafil at a daily low dose to allow for some more spontaneity for sex, and I guess it was really interesting to read in your article that that could actually help people if they’ve got BPH.

Yes.

Are there some other benefits to these PDE-5 inhibitors that maybe aren’t commonly known about?

Dr. Michael Lowy (13:25):

There are some off-label benefits that people discuss in my circle, but PDE-5 inhibitors are very good on the vascular tree of the body, and we know they actually work on the penile arteries. There is some thought, and there’s no papers on this, that it might be very helpful for the rest of the vascular tree. They’re not potentially tablets to treat for blood pressure, and they were certainly originally discovered as a treatment for angina, which never eventuated. But they’re not unhealthy, except for the very rare eye condition NAION [non-arteritic anterior ischaemic optic neuropathy], it’s a thing in the back of the eye that can occur very rarely, but only occurs generally in older unwell patients who have diabetes. So that NAION is a known risk, but it’s very rare, but in general these tablets are very, very safe.

And the common side effects I tend to talk to people about, flushing, headaches.

Yeah.

Any other common ones that you tend to rattle off?

All of them have the potential to flush your face, block your nose, have a headache, and a bit of gastric reflux, and tadalafil, they actually cause low back and leg pain. None of these side effects cause any long-term harm, but they may actually be so severe the patient doesn’t want to take them, but generally they dissipate over time.

Dr. Michael Lowy (14:43):

And that’s why I do prefer the daily dosing one, the tadalafil, because if you get side effects, they often settle down, and it really avoids the issue about spontaneity. Some guys complain they take a tablet an hour or two before planned sexual activity and then it doesn’t occur for whatever reason and they feel, what a waste of a tablet. Which it still will be working behind the scenes, so to speak, they probably wake up the next morning with a much firmer morning erection, and stuff like that. But it also has a psychological thing because men who take that tablet, they feel a little bit more sexual, it actually gives a little bit of a more positive feel. I do prescribe a lot of tadalafil, but we have other ones on the market too.

From my understanding the oral agents aren’t on the PBS, they’re on the RPBS for treating erectile dysfunction. What kind of cost are people looking at for these medications?

Since tadalafil and sildenafil became generic the cost dropped dramatically, and my understanding is a daily dosing of tadalafil 5 mg for 28 tablets is around $30, and sildenafil, in a pack of 12 of 100 mg is around $20. I’m not sure what’s happened with vardenafil, I’ve had no knowledge whether it’s even still on the market, and I think it’s not off patent. And the other one, the newer one, avanafil, they’re very, very good, second-generation PDE-5 inhibitor, but it’s around $15 a tablet, it’s still in patent, but it’s a very good medication, and if you’re taking something only every now and then it may be something to consider.

And I guess if the oral agents aren’t effective, in your article you go on that actually injections are the next option, how simple are these to administer? How effective are they?

Dr. Michael Lowy (16:29):

It sounds complicated, and it probably is the first time, but the patients who’ve been injecting for years are very, very comfortable with it, because they work very well. I mean, you’re putting the chemical into the target organ, it doesn’t have to go anywhere else in the body, it goes straight to the penis. And there are two ways you can do it. Alprostadil is the only one that’s officially on the market, not PBS. There’s a reasonable cost to it, it’s around $35 for two injections, but it comes nicely packaged, it doesn’t have to be refrigerated, you carry it with you anywhere, you can travel with it.

But the other ones we use, also very effective, we can make much stronger mixed as a compound, a tri-mix, where we’ve got three chemicals made by a compounding chemist that has a special licence. There’s only a handful of chemists who are allowed to produce sterile injections, and I know them all, and those injections must be kept in the fridge, but it’s a bit cheaper because you buy it by bulk. And if alprostadil on its own doesn’t work, then you might consider a tri-mix. These are very effective medications, but look, it does involve preparing the needle, and then injecting it into your penis. So the first time I actually do it with the patient in my room, I just don’t write a script, the patient must be shown how to do it. It’s a bit tricky, it needs a little bit of confidence, and they can always keep in touch with me if they have any problems, but usually they’re okay, if they’re motivated to do it, but I can understand that there is an issue about injecting your penis, it can be a little bit scary at first.

And is the risk of priapism more with the injectables compared to the oral agents?

Look, I know in theory the oral agents can induce priapism, I’ve never seen it, in all my years working in this area. In the old days when penile injections started, we tended to be bit gung-ho and started at a higher dose rather than a lower dose. These days I’ve no problems, I just start with a low dose, even if it doesn’t work, just so that the patient can build up to the dose that works, and that really minimises the risk of priapism. And very strict instructions: do not inject more than once in 24 hours, do not inject more than once or twice a week. We’re very, very careful about keeping the dose at a safe level where priapism doesn’t occur. And occasionally it does, sometimes there’s some health issues with the guy and they get to priapism, and most emergency departments have a protocol for dealing with that.

And I guess finally let’s touch on the devices that are available, if you’ll excuse the pun. What situations are these most useful in?

You mean the vacuum devices?

Yeah, and you also mentioned in the article implants and also shockwave therapy.

Well, shockwave therapy’s been around for about 10 years, it’s still a bit experimental in that it hasn’t been fully accepted. And a number of centres have shockwave therapy, the physios actually use it a lot for frozen shoulder and golfer’s elbow, and that sort of stuff, and they’re very effective for tendonitis issues. Shockwave therapy tends to work better in older men with vascular erection problems, and it does require a number of treatments. And there’s so many different machines out there and they’ve all got a different protocol, so it’s a little confusing, but there is a role for it, but it’s still to be defined.

And the other therapy that is still being investigated is the PRP, platelet-rich plasma injections, where you take blood from the arm, spin down the blood, check platelets, it’s a bit like stem cell therapy. But there’s no protocol, and there’s a few commercial clinics that do it, and I just can’t recommend it because we just don’t know enough about it. To the best of our knowledge, I don’t think it’s that effective. But time might tell, you might need another 5, 10, 20 years for this to be established.

I think vacuum devices are great. Young men don’t like them because it’s a bit of an effort to use them, and the sex shops sell them as penis enlargers, which they’re not, they’re just erection creators, and the ones in the sex shops tend not to be the good quality, you need to go to a proper place. There are people I know who import them. And older couples like them because they’ve got more time, it takes time to learn how to use it, and they’re not in a hurry, and it’s non-invasive, there’s no chemicals. It’s got some advantages, but it doesn’t have the speed and intimacy, or the quickness, I should say, of injections.

And then there’s penile implants, they’ve been around for 30, 40 years, and they’re very fine pieces of engineering. And it’s all internal, there’s nothing outside, it’s all inside, the rod’s in the penis, a little pump in the scrotum, and a reservoir tucked up in the abdomen. And it is a final operation, you can’t actually put it in and take it out and go back to something else. It’s irreversible ED, and you really need to be counselled when you have it done.

Thanks, Michael, for your time today going through these key points from your article. Were there any other points that you wanted to get to our listeners?

Dr. Michael Lowy (20:41):

In summary, I’d like to say that firstly it’s always important to start the conversation, it’s something that the patient doesn’t always bring up. It’s important to address lifestyle changes, manage risk factors, and optimise existing medical conditions. Assess cardiac risk, cardiac testing and cardiac review. Oral PDE-5 inhibitors are the first-line treatment for ED. Correct hypogonadism, we haven’t mentioned that today, but if someone is obviously hypogonadal, that needs to be corrected. Not common, not always there, but something to remember. Second-line therapy, injections and vacuum devices, and penile implants are there for refractory, difficult-to-treat cases. And please be careful with new treatments, they’re still experimental, it’s good to use treatments that are proven and that we have a lot of experience with.

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The full article we discussed today is available for free online on the Australian Prescriber website. The views of the host and the guest on this podcast are their own and may not represent Australian Prescriber or NPS MedicineWise.