Camden Erectile Dysfunction pathway This pathway has been developed from published guidance, in collaboration with local urologists.

This guidance is to assist GPs in decision making and is not intended to replace clinical judgment.

Patient presents with erectile dysfunction (part of the metabolic syndrome until proven otherwise)

History  Medical history – CVD, hypertension, DM Patient information  History of pelvic/genital surgery leaflet  Psychosexual history  Any medications that could cause ED (e.g. antihypertensives, beta blockers, diuretics, antidepressants etc)  Risk factors for metabolic syndrome eg sedentary lifestyle, obesity, smoking, ETOH  Problem getting an erection/keeping an erection/both?  Energy levels – loss of libido, body hair  Consider hormonal, neurogenic or anatomical causes  Give cycling advice if cycles

Examination Hypogonadism  BP, weight, HR, waist circumference (characterised by abnormal  External genitalia if indicated testosterone, TSH, LH, Young man who has always had  Body hair, gynaecomastia prolactin)  ED  DRE if indicated  History of trauma to genital area  Penile/testicular abnormality

Endocrinology Referral

Investigations Urology Referral  HbA1c, lipids and bloods (FBC, U+Es)  (Consider testosterone – before 10am– if low, repeat and do NB Admit to Hospital FSH, LH, TSH, prolactin) If PRIAPISM – persistent Erection > 4 hours

Refer 2 2WW Any abnormality identified raising suspicion of cancer Management  Patient and partner education if required  Modify lifestyle factors  Management of CVD/CHD risk  Management of diabetes  Refer for Psychosexual Counselling for psychological issues Patient does not have CHD

Treatment  Review medication for potential cause  1st line PDE5I: Generic sildenafil.  2nd line: PRN tadalafil (only if idiosyncratic reactions to sildenafil, not for non-responders). Patient has CHD Daily tadalafil (2.5mg and 5mg doses) NOT Patient can resume recommended sexual activity and use  For all treatments except generic sildenafil, PDE5I patients must meet NHS criteria. If they do not, a private prescription should be issued. Conditions Unstable heart disease NOT present History of recent MI Poorly decompensated heart failure Refer to urology if no response after 8 doses of maximum dose with Unstable dysrhythmia Erectile Dysfunction Prerequisites sexual stimulation or PDE5 inhibitors are contraindicated Taking nitrates for Referral Patients must meet NHS criteria for all pharmacotherapy except FBC, U&E ss, HbA1C, Lipids AND Min generic sildenafil. trial 4/52 medication unless medication Other treatments, including alprostadil, initiated by specialist – NHS contraindicated Conditions present criteria apply Vacuum devices – initial device to be supplied by specialist Advice and Guidance to cardiology

Comments & enquiries relating to medication: CCCG Medicines Management Team [email protected] Pathway created by NCL led by Camden CCG Refer to current BNF or SPC for full medicines information Clinical Cabinet + GB July 2016

Clinical Contact for this pathway for queries: Review due – March 2020 [email protected] Cycling Advice

Nearly every cyclist who has erectile dysfunction as a result of cycling will have experienced prior symptoms of pain, numbness or tingling in the perineum due to pressure on the perineum affecting the underlying blood vessels and nerves.

· If cycling >3hours/week try period of time without cycling · Ride in the correct position ie changing position frequently during ride and sitting more upright rather than leaning forward over handlebars to reduce pressure on the perineum · Use a properly fitted seat, level or angled slightly downwards – never tilt saddle upwards. · Use a seat with a cut out to reduce pressure on the perineum · Wear padded cycle shorts

Examples of dug causing ED Antihypertensives – thiazides, beta blockers Psychotropics drugs – phenothiazine's, tricyclics, MAOI s SSRIs, Lithium Hormone modifying drugs – cyproterone acetate, oestrogens, 5-alpha reductase inhibitors, corticosteroids, progesterone Recreational drugs – alcohol, tobacco, cannabis Others – digoxin, ranitidine, carbamazepine, spironolactone

NHS Criteria

Laid down by department of Health as described in the Health Service Circular 1999/148 (amended 2009) .

NHS criteria for erectile dysfunction pharmacotherapy (excluding generic sildenafil which can be prescribed on the NHS to any patient with erectile dysfunction regardless of cause, where this is clinically appropriate).  Patients suffering from any of the following:

Diabetes Multiple Sclerosis Parkinson s Disease Poliomyelitis Prostate cancer Severe pelvis injury Single gene neurological disease Spina Bifida Spinal cord injury

 Patients receiving treatment for renal failure by dialysis

 Patients who have had thee following surgery Prostatectomy Radical pelvic surgery Kidney Transplant  Patients who were receiving NHS prescriptions for alprostadil, apomorphine, moxisylyte, slidenafil or thymoxamine HCL on 14th September 1998  None – UK Nationals (EEA nationals) may have the right to NHS provision of erectile dysfunction therapy. Contact the medicines management team for further guidance.

PDE5 inhibitors are contraindicated in patients:

 Receiving nitrates in any form  In whom vasodilation or sexual activity is not recommended including those with unstable heart disease, recent stroke, unstable angina, a history of recent MI – within 6/12, poorly compensated HF, or unstable dysrhythmia – refer to CVD risk for more info  Who have lost sight in one eye due to non-arteritic anterior ischaemic optic neurology (NAION)  With hypotension (systolic<90mmHg),  Sildenafil – CI in severe hepatic impairment or hereditary retinal degenerative disorders such as retinitis pipgmentosa Tadalafil – CI - men with NYHA class 2 or greater heart failure in last 6/12, uncontrolled arrhythmias, or uncontrolled hypertension

 Caution in patients with: Cardiovascular disease Left ventricular outflow obstruction Anatomical deformation penis A predisposition to priapism eg in sickle cell disease, multiple myeloma or leukaemia

Side Effects PDE5 inhibitors include

 Headache  Nasal Congestion Full Camden MMT Prescribing Advice  Flushing  Dyspepsia  Myalgia

Non-UK National (EEA and non-EEA nationals)

In England Alprostadil, avanafil, tadalafil, Viagra, are permitted to be prescribed for the management of erectile dysfunction for the following patients:

A) A man who is a national of an A state who is entitled to treatment by virtue of Article 7 (2) of Council Regulations 1612/68© as extended by the EEA agreement by virtue of any other enforceable Community right now has erectile dysfunction and was on 14 September 1998 receiving a course of treatment under a national health insurance system of an EEA State for this condition with any of the following drugs – Alpropstadil (Caverject). (Muse), (Viridal) Apomorphine Hydrochloride (Uprima)Moxisylyte Hydrochloride (Erecnos) Sildenafiil (Viagra) Tadalafil (Cialis) Thymoxamine Hydrochloride (Erecnos);

C) A man who is not a national of an EEA state but who is the member of the family of such a national who has an enforceable Community right to be treated no less favourable than the national in the provision of medical treatment and has erectile dysfunction and was sbeing treated for that condition on 14th September 1998 with any of the following drugs - Alpropstadil (Caverject). (Muse), (Viridal) Apomorphine Hydrochloride (Uprima)Moxisylyte Hydrochloride (Erecnos) Sildenafiil (Viagra) Tadalafil (Cialis) Thymoxamine Hydrochloride (Erecnos);for

Please contact the medicines management for further guidance where necessary.