The aetiology of erectile dysfunction (ED) is largely organic. ED is increasingly common in an ageing population with more widespread cardiovascular risk factors. As well, there has also been a cultural shift towards awareness and a willingness to address the condition. Despite this, ED remains undertreated (about 50% of affected men) and of those who seek treatment, a proportion drop out and remain unsatisfied.

Dr Trent Barrett, Urologist

Dr Trent Barrett, Urologist

Primary care

The initial management of ED occurs in primary care. A history needs to focus on cardiovascular risk factors, as erectile dysfunction can herald other cardiovascular disease. Medical treatments are well established with ‘blue pills’ and other phosphodiesterase-5 inhibitors (PDE5-I) being entrenched in the public consciousness since the late 90s. They remain first line therapy with reported success ranging from 43-89%.

For those who fail medical therapy, second line therapies include either vacuum erection devices (VED) or intracavernosal injections (ICI). These therapies work well, but the long-term satisfaction rates are poor (50-64% satisfaction after two years for VED and a 40-68% drop out rate for ICI). Both of these therapies require external equipment and can interrupt the natural flow of a sexual encounter.

Surgical care

Third line therapy involves surgical implantation of a penile prosthetic. These are either rigid, or more commonly inflatable devices that generate erections on demand. The three-piece inflatable device (IPP) is the gold standard. It involves implanting inflatable cylinders within the penile corpora. These are connected internally to a fluid reservoir in the retropubic space and a pump within the scrotum that is used to activate and deactivate the device. The penis appears natural in its flaccid and erect state after the device is implanted.

Patients are kept in hospital overnight and are able to recommence intercourse at around six weeks. The ability to have a reliable and concealable internal method of achieving erections is appealing to patients, with long-term satisfaction rates around 90%.

Surgical therapy can be offered to patients who fail first- and second-line therapy or it can be discussed with motivated patients who have side effects or dissatisfaction with the non-surgical treatments. It is important that the initial discussions include information about surgical therapy.

Patients may be poorly compliant with medical ED therapy because they perceive a barrier to escalating their treatment. There is a big jump in terms of perceived complexity and invasiveness between the first line oral (PDE5-I) and second line interventional (VED, ICI) therapies. It is understandable that they discontinue treatment, inhibited by the idea of second line therapies and are not informed about the options beyond this. Through outlining a comprehensive, stepwise approach to the management of ED (including the endpoint of surgical management) patients can be kept engaged.

Key messages 

  • Patients presenting with ED need medical workup for cardiovascular risk factors
  • Conservative stepwise therapies are offered but will not be effective/acceptable in all
  • Discuss surgical therapies early illustrate a practical end point to management

References available on request.

Questions? Contact the editor.

Author competing interests: nil relevant disclosures.

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