Clinical practice recommendations provide evidence-based clinical guidelines on the management of erectile dysfunction in Australia

New clinical guidelines from the Urological Society of Australia and New Zealand (USANZ) and the Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) could help manage erectile dysfunction (ED) better "amid saturation advertising of online men's health platforms." The professional bodies recommend, among other things, a full and careful history and examination, tests to rule out common metabolic disorders, and further diagnostic testing only as required. These guidelines were published in the Medical Journal of Australia. 

Introduction

ED is the "persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity occurring for at least 3 months." It may cause or aggravate mental ill-health, affecting both physical and psychological quality of life, as well as impairing social relationships in some cases.

It is relatively common today, reported in up to 30% of adult males. The causes include psychogenic factors, as well as impaired neurologic control, loss of vascular supply, or changes in the endocrine function, as well as endothelial dysfunction. The condition is more common in older men, those who are sedentary, overweight, smoke, or have impaired fat metabolism.

Since these risk factors are common to cardiovascular disease (CVD) as well, ED is considered a predictive marker for the risk of CVD and death in the future and benign prostatic hyperplasia (BPH) or other symptoms relating to the lower urinary tract. In other words, ED patients with a history of heart disease or with CVD risk factors should be tested as required.

Most cases in Australia are managed by general practitioners (GPs), to be referred to specialists only when the response is inadequate or further testing is required. This helps cut costs and stretch funds, underlining the important place of GPs in the treatment of almost all disorders at the primary care level. The current paper is the first on this condition from Australian medical professionals that have passed peer review.

Summarized recommendations

The guidelines dwell on the need for a careful medical history in the context of today's changing sexual mores and expectations. The physician must rule out common causes that can affect vascular function, including medications, drugs, tobacco, or alcohol. Psychogenic causes are more common in younger men.

Screening for metabolic factors is important to bring hidden cardiac disease to light and predict the risk of future CVD.

The physical examination should cover the circulation, neurological and genitourinary systems, besides confirming the diagnosis.

Laboratory tests are usually ordered for blood sugar and lipid profiles. Other hormones may be tested as required, such as when suspected of hypogonadism. This could be raised by low libido, poor response to the oral phosphodiesterase type 5 inhibitor (PDE5i) drug class, or a history of diabetes. The treatment would then be testosterone replacement.

Special tests include a psychiatric assessment, imaging for the vascular flow in the penis, a nocturnal penile tumescence (NPT) test, and other tests used only to pick up a suspected specific neurologic condition. The first might be useful if there is performance anxiety, identify stress factors or enhance treatment adherence, but it is costly, time-consuming, and not widely available.

Penile imaging studies are cheap, safe, and simple, assessing this organ's vascular system. NPT is not widely used as its clinical utility is controversial, and its measurement non-standardized. For all advanced testing options, the patient must be educated and decisions made in tandem.

Management

The large role played by cardiometabolic risk factors in ED emphasizes the importance of lifestyle modifications in treating this condition. Moreover, organic disease of this organ or the vascular or neurologic systems requires specific treatment. Those with psychosexual issues must be counseled appropriately. All these measures must be coordinated to provide an optimal outcome.

If anginal pain is reported or tests show a high risk of CVD, follow-up investigations for heart disease may be requested, or the patient may be referred to a cardiologist. The CVD would then merit primary treatment, with ED treatment postponed until this time.

Multiple therapies are now available, but with all of them, the patient must be monitored every 6-12 months to maximize the chances of success.

Oral drugs beginning with oral PDE5i should first be prescribed unless contraindications exist. This includes unstable angina or nitrate therapy, which may precipitate dangerous hypotension and heart attacks. This must be accompanied by advice on when to use the drug and its relationship with food as well as with alpha-blocker drugs, which should be used only outside a 4–6-hour window of PDE5i treatment.

In case the response is poor, second and third-line treatment approaches are used. This includes intracavernosal injection of drugs that relax the penile vasculature, producing an erection. These include prostaglandin E1 (PGE1) and combinations such as papaverine with phentolamine, with or without PGE1.

This mode of treatment is obviously relatively unpopular due to its invasive nature, the need for repeated treatments, and the fear of complications. Priapism is an unwelcome complication and may cause permanent damage.

Penile prosthesis implants are the definitive treatment for ED and have been used for almost half a century in Australia. These are recommended in case of oral treatment failure or unwillingness to use these drugs.

"Up to one in four males with ED will likely require a penile prosthesis implant as their definitive treatment," according to Professor Eric Chung. Inflatable and malleable implants are available. This is considered safe and effective but is an irreversible method. Careful patient selection and surgical practice are required to boost success rates.

Newer treatments include regenerative therapies, promoting the regrowth of vascular tissue as well as rejuvenating the neural and hormonal control of erection by angiogenic and other growth factors. Stem cell therapy and platelet-rich plasma are examples of cell-based regenerative therapy being investigated for this purpose as well.

Again, using low-intensity extracorporeal shock waves to encourage the endothelium to regenerate has gained ground as safe and effective, though less so than implants. Professor Chung published the first clinical study on this modality in Australia in 2015. He also authored the only published paper that examines the procedure after five years, along with helping to issue the Asia-Pacific guideline on this therapy.

This is especially recommended in younger, healthier patients without overt CVD. Still, he said, "There is so much information that we don't fully know yet about this type of therapy, including types of machines, right shockwave setting and longer term safety."

As with all new therapies, the risk-benefit ratio must be stringently scrutinized before their widespread introduction. Another author, Dr. Christopher Love, added that online men's health platforms were a good place to start for men with ED, but "he had concerns about "shopfront clinics" offering shockwave therapy and other regenerative treatments, such as platelet-rich plasma injections, at significant cost to patients but with little or no proven benefit.".

Safety risks with genomic or epigenetic changes in the longer term, as well as potential immune reactions and infection risks, need to be identified in more stringent clinical trials. Considering the lack of high level evidence in men with ED, there is a serious concern due to commercialisation and financial gain over patient wellbeing in this vulnerable patient demographic."

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.