2. Definition
The inability to attain and/or maintain an erection sufficient for
satisfactory sexual performance and persistent in 3 months.
National Institute of Health. JAMA. 1993
Erectile dysfunction is a multidimensional but common male sexual dysfunction that involves an alteration in any of the
components of the erectile response, including organic, relational and psychological.
Faysal A. Yafi, Wayne J. G. et al. 2016
4. Epidemiology
Massachusetts Male Aging Study (MMAS) reported an
overall prevalence of 52% ED in non institutionalized men
aged 40-70 years in the Boston area; specific prevalence
for minimal, moderate, and complete ED was 17.2%,
25.2%, and 9.6%, respectively.1
European Male Ageing Study (EMAS) reported a
prevalence of erectile dysfunction ranging from 6% to
64% depending on different age subgroups and
increasing with age, with an average prevalence of 30%.2
1. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J
Urol. 1994;151:54–61.
2. Age-related changes in general and sexual health in middle-aged and older men: results from the European Male Ageing Study (EMAS).Corona G, Lee DM, Forti G, O'Connor DB, Maggi
M, O'Neill TW, Pendleton N, Bartfai G, Boonen S, Casanueva FF, Finn JD, Giwercman A, Han TS, Huhtaniemi IT, Kula K, Lean ME, Punab M, Silman AJ, Vanderschueren D, Wu FC, EMAS
Study Group. J Sex Med. 2010 Apr; 7(4 Pt 1):1362-80.
9. Sexual History
The sexual history must include information about:
sexual orientation, previous and current sexual relationships, current emotional status, onset and
duration of the erectile problem, and previous consultations and treatments
The sexual health status of the partner(s)
Detailed description of the rigidity and duration of both sexually-stimulated and morning
erections and of problems with sexual desire, arousal, ejaculation, and orgasm
Validated psychometric questionnaires (IIEF/SHIM), help to assess the different sexual function
domains (i.e. sexual desire, EF, orgasmic function, intercourse, and overall satisfaction), as well as
the impact of a specific treatment modality.
Screen for symptoms of possible hypogonadism (testosterone deficiency), including decreased
energy, libido, fatigue, and cognitive impairment, as well as for LUTS
EAU Guidelines 2019
11. 5-Item International Index of Erectile
Function (IIEF-5).
ED Classification according IIEF-5 Score:
Severe (5-7),
Moderate (8-11),
Mild – Moderate (12-16),
Mild (17-21),
No ED (22-25).
14. Laboratory testing
• CBC, Blood chemistry
• Fasting glucose or HbA1C and lipid profile
• Early morning total testosterone
Additional test (optional):
• ECG
• prostate-specific antigen (PSA)
• prolactin
• LH
Ask routine laboratory test to identify and treat any reversable risk factors and lifestyle factors that can
be modified.
EAU Guidelines 2019
15. ED & Cardiovascular
Disease (CVD)
• Share the same pathophysiology (vasculopathy,
endothelial dysfuntion)
• Patients with CVD and CVD’s risk factors has
increasing risk of having ED
• ED may be a manifestation of a CVD, even as a
sentinel of silent CVD
EAU Guidelines 2019
17. Indication for specific diagnostic test
Young patients with a history of pelvic or perineal trauma (who could benefit from
potentially curative vascular surgery.)
Patients with penile deformities which might require surgical correction (e.g., Peyronie’s
disease, congenital curvature).
Patients with complex psychiatric or psychosexual disorders.
Patients with complex endocrine disorders.
At the request of the patient or his partner.
Medico-legal reasons (e.g., implantation of penile prosthesis, sexual abuse).
EAU Guidelines 2019
18. Specific Diagnostic Test
• Include specific diagnostic tests in the initial evaluation of ED in the presence of the
indicated conditions
EAU Guidelines 2019
23. Treatment Option (First-Line)
Identify the “curable” cause of ED
Controlled the Underlying conditions such as Diabetes, hypertension, hypercholesterolemia,
obstructive urinary symptoms, BPE, CVD, evaluation of antidepressant & antihypertensive
currently used
It is important to tell the patient
“ED can be treated successfully, but it cannot be cured”
The only exception was psychogenic ED, post-traumatic arteriogenic ED, hormonal
causes need specific treatment
Lifestyle modification
Modifiable risk factors (stop smoking, exercise to reduce body weight for obese patient)
EAU Guidelines 2019
24. Treatment Option (First-Line)
Oral Pharmacotherapy
PDE5-I drug
Sildenafil
Tadalafil
Valdenafil
Avanafil
Please be advised, PDE5I is not an initiator of erection, patient still need
sexual stimulation to facilitate erection.
EAU Guidelines 2019
27. PDE5 Inhibitor
Avanafil1,2
Latest PDE5I, available in 2013
Recommended starting dose 100 mg, 15 – 30
minutes before sexual intercourse
Maximum dosing frequency once a day
Mean percentage of successful intercourse
Dosage Successful
Sexual
Intercourse
Placebo
50 mg 47% 28%
100 mg 58% 28%
200 mg 59% 28%
1. Wang, R., et al. Selectivity of avanafil, a PDE5 inhibitor for the treatment of erectile dysfunction: implications for clinical safety and improved tolerability. J Sex Med, 2012.
9: 2122. https://www.ncbi.nlm.nih.gov/pubmed/22759639
2. Goldstein, I., et al. A randomized, double-blind, placebo-controlled evaluation of the safety and efficacy of avanafil in subjects with erectile dysfunction. J Sex Med, 2012.
9: 1122. https://www.ncbi.nlm.nih.gov/pubmed/22248153
29. PDE5 Inhibitor Safety Issue
Cardiovascular Safety
Sildenafil, Tadalafil, Vardenafil no increase in myocardial infarction rate
It is CONTRAINDICATED in
Patient suffered from myocardial infarction, stroke, life threatening arrythmia within the LAST 6 MONTHS
Resting hypotension < 90/50 mmHg or hypertension >170/100 mmHg
Unstable angina, Angina with sexual intercourse or CHF NYHA IV
Nitrates result in cGMP accumulation and unpredictable blood pressure drop. If patient taken PDE5I,
develop angina, nitrate should be postponed base of PDE5I drugs half-life.
Co-administrative with other anti hypertensive agent, considered safe
Interaction with alpha-blocker orthostatic hypotension
EAU Guidelines 2019
30. Management of non-PDE5I responder
Most common causes
Failure to use adequate sexual stimulation
Inadequate dose
Failure to wait an adequate amount of time between taking medication and attempting
sexual intercourse (ingestion of high fat meal, before taking drugs)
EAU Guidelines 2019
31. Treatment Option (First-
Line)
Vacuum erection devices (drug free management)
Satisfactory is as high as 90%, for patient without
bleeding disorder or anticoagulant therapy1
Adverse event (< 30% patient)
Pain
Unable to ejaculate
Petechiae
Bruising
Numbness
Remove the ring, before 30 minutes after intercourse
Prevent skin necrosis
EAU Guidelines 2019
32. Treatment Option
(First-Line)
Topical/intraurethral Alprostadil
Vasoactive agent, topical route (300 ug) or
medicated pellet (500 ug) via urethral meatus
Intercourse achieved in 30-65.9% patients
Provides alternative treatment for intracavernous
injection patients, who prefer less invasive even
though it is less-efficacious treatment
Adverse effect
Local pain
Penile erythema
Dizziness / hypotension
UTI
EAU Guidelines 2019
33. Treatment Option (First-Line)
Shockwave therapy
Low-intensity extracorporeal shockwave therapy
EAU recent studies showed that LI-SWT could improve the IIEF and Erection Hardness
Score of mild ED patient.
Still unclear for definitive recommendation
EAU Guidelines 2019
34.
35.
36. Treatment Option (Second-Line)
Not responding to oral drugs offered intracavernous injection
Intracavernous Alprostadil, dose 5 – 40 ug
Erection appears after 5 to 15 minutes
Satisfaction rates
87 – 93.5% in patients
80 – 90.3% in partners
Complications
Penile pain, prolonged erection, priapism
Fibrosis
EAU Guidelines 2019
38. Treatment Option (Third-Line)
Penile prostheses
Patient who failed pharmacotherapy and prefer a permanent solution
2 classes of implant
Inflatable
Semi-rigid
2 surgical approaches
Penoscrotal
(+) Excellent exposure, avoid dorsal nerve injury, direct visualization of pump placement
(-) Blind reservoir placement or need to do separate incision to insert reservoir under direct vision
Infrapubic
(+) Insert reservoir under direct vision
(-) risk of dorsal nerve injury when inserted the pump
EAU Guidelines 2019