Basics
Organic vs psychogenic causes but often both
Gradual onset, loss of self-stimulated erections and normal libido more suggestive of organic cause
Organic causes include
Vascular – vascular risk factors, diabetes
Structural – peyronnie’s
Hormonal – hypogonadism, thyroid disorders, hyperprolactinaemia
Neurogenic – pelvic/prostatic surgery, central or spinal neurological disease

Examination – should check genitalia and also do DRE if > 50 yrs or has LUT symptoms

Investigations – lipids, glucose, 9am testosterone in all. Consider PSA, prolactin, TSH

Management includes lifestyle advice (stop smoking, trial off cycling as ED can be caused by pressure on pudental artery/nerve)
Medical therapy: PDE5 inhibitors – if two ineffective, refer for alprostadil penile injections (MUSE), penile vacuum pump, penile prosthesis.
PDE5 inhibitors
Cannot be used if high risk of cardiac event eg. unstable angina, recent stroke/MI, resting hypotension, severe CCF
Cannot be taken with nitrates or nicorandil. GTN cannot be taken within 24 hr of taking sildenafil or 48hr after tadalafil
Common side effects are flushing, headache, indigestion, nasal congestion and vision disturbance.
Should be taken on empty stomach (aborption blocked by fatty meals) and 1 hr prior to intercourse.
Tadalfil can be taken daily (5mg) or on demand, and also improves LUTS.