|All men who present with ED should undergo cardiovascular risk assessment and have serum testosterone measured on an early morning blood sample.|
|Consider life-style advice, medication review and psycho-sexual counselling.|
In the absence of abnormal clinical findings, a trial of phosphodiesterase inhibitors is appropriate. Tadalafil and Sildenafil are currently on the Highland Formulary:
Tadalafil 10mg initially with titration up to 20mg according to the patient’s response. Take at least 30 minutes before intercourse and can be effective for up to 30 hours. Not affected by food.
Sildenafil 50mg initially with titration up to 100mg or down to 25mg according to the patient’s response. Take 1 hour before intercourse and can be effective for up to 6 hours. Onset of effect may be delayed by food.
Note: Sildenafil and Tadalafil are contra-indicated in patients receiving nitrates and Nicorandil and should be used with caution in patients on alpha-blockers e.g. Doxazosin, Tamsulosin. If prescribing after myocardial infarction/acute coronary syndrome, advise re-introduction at 1 month after cardiac event if patient is pain free and does not require nitrates or Nicorandil.
Both Tadalafil and Sildenafil should be tried at their maximum doses on several occasions before referring the patient to Urology for consideration of other therapies e.g. transurethral or intra-cavernosal Alprostadil or vacuum devices.
Due to the longer duration of action of Tadalafil, it may be more cost-effective and is also available at lower doses for once-daily administration if there is response to an on-demand regimen and anticipated frequent use (more than twice weekly).