Erectile dysfunction: new advice for vulnerable group

THE first evidence-based Australian clinical guidelines on the management of erectile dysfunction (ED) are a timely reminder of standard of care for this vulnerable patient group amid saturation advertising of online men’s health platforms this footy finals season.

Published in the MJA, the guidelines have been devised by a panel of experts appointed as representatives of the Urological Society of Australia and New Zealand and the Australian Chapter of Sexual Health Medicine for the Royal Australasian College of Physicians.

ED affects up to a third of Australian men, and is defined as 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.

The guidelines note that, in Australia, most cases of ED are identified and managed by GPs, with specialist referrals for men who have an incomplete response or require further investigations and treatment.

“This shared care model … reflects the optimal utilisation of health care resources and recognises that general practitioners play an important gatekeeper role in primary care,” the guidelines state.

The main recommendations of the guidelines are:

• a comprehensive clinical history and a tailored physical examination are essential;
• laboratory testing should include fasting glucose, lipid profile and total testosterone level;
• specialised diagnostic tests are recommended in selected cases and the patient should be counselled accordingly;
• lifestyle changes and optimisation of existing medical conditions should accompany all ED treatment regimens;
• oral phosphodiesterase type 5 inhibitor (PDE5i) is an effective first line medical therapy;
• a penile prosthesis implant can be considered in men who are medically refractory or unable to tolerate the side effects of medical therapy; and
• pro-erectile regenerative therapy remains largely experimental.

Guidelines co-author, Professor Eric Chung, Professor of Surgery at the University of Queensland, said a major message from the guidelines was the importance of cardiometabolic screening in patients with ED to stratify cardiovascular risk and identify occult cardiac disease.

“ED shares many of the risk factors for cardiovascular disease (CVD) and epidemiological studies have shown that those with CVD are more likely to have severe ED and drug-refractory treatment,” Professor Chung told InSight+.

“Furthermore, the presence of ED, in itself, serves as an important marker for future CVD, and studies have shown that the severity of ED correlates with higher CVD death and overall death.”

Lifestyle interventions were pivotal and existing standard ED therapies were often effective and safe following cardiovascular risk stratification, he said.

For those who failed medical therapy (oral drugs and injectables), a penile prosthesis implant was a safe, effective and durable treatment option, he said.

“Penile prosthesis implants have been around for close to 50 years now and in Australia, there are three major companies that market such devices,” he said. “Up to one in four males with ED will likely require a penile prosthesis implant as their definitive treatment.”

Professor Chung warned that there was “a lot of hype and false advertisements about ED treatment”.

In 2015, he published Australia’s first clinical study of low intensity extracorporeal shockwave therapy in ED – a promising form of regenerative therapy that aspires to promote endothelial revascularisation. He has also published the only paper that examines shockwaves beyond 5 years, as well as an Asia-Pacific guideline on shockwave therapy.

Still, Professor Chung 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.

“While regenerative therapy could work in the carefully selected group of males with ED, much data is missing and it should only be offered in the setting of clinical trials, where there should not be any exchange of monetary payment and after careful informed consent,” he said.

Professor Chung said patients should also be warned against using online men’s health platforms offering ED treatments.

“They often prey on vulnerable males and charge a significant amount of money,” he said. Professor Chung said that in his opinion, “some of these companies sometimes practise dangerous medicine and do not refer patients appropriately who need further assessment such as cardiovascular checks”.

However, guidelines co-author, Dr Christopher Love, a urologic and prosthetic surgeon in Victoria, said he believed some of the new online men’s health platforms were “not a bad place to start” for men with ED.

Dr Love is the medical advisor for one such platform and approves the templates used in phone consultations by the site’s doctors, which he said include basic cardiovascular risk assessment.

“A lot of men, initially, just need to talk with someone and gain an understanding about performance anxiety, and perhaps commence first line oral therapy,” he said. “Many patients like the anonymity of not having to discuss sexual dysfunction with the GP they’ve known since they were 4 years old.”

He stressed the importance of an appropriate cardiovascular risk assessment of patients with ED, saying: “ED should be regarded as an early warning sign of potential cardiac disease”.

Dr Love said that like the other guidelines authors, 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.

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