Intended for healthcare professionals

Clinical Review ABC of sexual health

Erectile dysfunction

BMJ 1999; 318 doi: (Published 06 February 1999) Cite this as: BMJ 1999;318:387
  1. Wallace Dinsmore,
  2. Christine Evans

    Treatment of erectile dysfunction is initiated after taking a patient's history and examination (see previous articles), and possibly investigation.

    Medical management

    In highly selected patients with a clear psychological problem psychotherapy or sex and couple therapy can be used, but these are time consuming and are available to only a small number of patients. Erectile dysfunction is of a largely psychological nature in a third of patients, in a third it is largely physical, and the remaining third have both physical and psychological factors.

    The first line treatment for erectile dysfunction with most practitioners is now with alprostadil by an intracavernosal injection or an intraurethral pellet, even in patients with minor psychological problems. In this group the treatment may break the “failure cycle,” especially if given in combination with limited psychotherapy and sensate focus techniques.

    Investigation of erectile dysfunction


    • Blood pressure

    • Glucose (blood or urine)

    If reduced sex drive

    • Testosterone—total, serum hormone binding globulin (SHBG), and free androgen index (FAI)

    • Follicle stimulating hormone (FSH)

    • Luteinising hormone (LH)

    • Prolactin—especially for reduced sex drive in a younger man

    Other possible investigations

    • Nocturnal erection testing by “snap gauge” or Rigiscan

    • Vascular function

    Doppler colour ultrasound

    Response to injected drugs


    Injected treatment

    Papaverine was introduced in the early 1980s as the first effective intracavernosal injection treatment for erectile dysfunction. Given in doses of 7.5-90 mg, initially alone and later with phentolamine as a synergist in the ratio of 30:1, these treatments did not have a product licence but they were effective, cheap, and easy to use, although they had a high incidence (up to 25%) of prolonged erection.

    Alprostadil (prostaglandin E1) was given a product licence in 1994 and is supplied in 5, 10, and 20 μg doses. Patients are usually started on a small dose in the clinic but are advised that the injection may be more effective in a more relaxed atmosphere at home. …

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