This SOP outlines guidelines for prescribing of medication used for Erectile Dysfunction(ED) and Premature Ejaculation ( PE) .
This applies to all healthcare professionals involved in assessing, prescribing, and monitoring patients being treated for Men’s health issues of ED and PE.
The generic term ‘patients’ is used throughout to refer to people receiving medicines. The Clinic will not provide services to anyone less than 18 years of age.
Erectile Dysfunction: Erectile dysfunction is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.
Premature Ejaculation: This is a common male sexual disorder characterised by brief ejaculatory latency (A time less than two minute), loss of control, and psychological distress
The use of medicines is underpinned by a series of legal, statutory and professional frameworks that include:
This SOP draws on the relevant aspects of these frameworks to ensure that the management of medicines is conducted safely, securely, and legally.
This SOP should be read in conjunction with the Medicines Management Policy covering the prescribing process, off-label prescribing, repeat prescribing, and monitoring.
A full medical and medication history, allergy check, Lifestyle history including smoking, alcohol consumption, recreational drugs and use of over-the-counter medication should be assessed. Baseline measurements include weight, height, BMI and BP should be obtained.
Assessment to include any relevant history of mental health issues that may be a contraindication to SSRI prescribing in this setting. Clinicians must conduct a mental health assessment to rule out any contraindication to SSRI prescribing.
Patients should submit a recent BP measurement obtained by their GP or local pharmacy and this should be recorded during the clinical assessment (sitting and standing measurements to be obtained).This could be submitted as an image when booking the consultation or during the video consultation.
Before prescribing, clinicians must ensure they have sufficient and reliable information. If more information is needed, they should seek patient consent to contact the NHS GP. If a patient refuses, they should not be prescribed medications by a GP Health Hub clinician.
Clinicians must explain the benefits, risks, administration, expected outcomes, monitoring, and follow-up arrangements. Document patient consent, understanding of risks, and the treatment plan in the medical notes. Documentation should include relevant medical history including mental health history.
Patients GP to be contacted to confirm details provided by patient accurate prior to initiating any medication.Patients will be advised of this on thewhen booking an appointmentand during the consultation.
Medication should be prescribed with lifestyle changes such as smoking cessation advise (Directing patients to their NHS GP to referral to local Smoking cessation Pathways), reducing Alcohol consumption and increasing physical exercise.
Dapoxetine and Paroxetine are two medications which can be used for treating Premature ejaculation.
Dapoxetine is a short-acting selective serotonin re-uptake inhibitor.
Method of administration– Oral administration, to be taken 1 to 3 hours before sexual activity.
Maximum daily dose is 1 dose per day: maximum of 60mg per day.
Information to be obtained prior to initiation:
A Review of treatment will be done after 4 weeks (or 6 doses) and then every 6 monthly.
Anxiety; asthenia; concentration impaired; constipation; diarrhoea; dizziness; drowsiness; dry mouth; gastrointestinal discomfort; gastrointestinal disorders; headache; hypotension; mood altered; nausea; paraesthesia; sexual dysfunction; sinus congestion; sleep disorders; sweat changes; syncope; tinnitus; tremor; vasodilation; vision blurred; vomiting; yawning
Akathisia; arrhythmias; behaviour abnormal; confusion; depression; eye pain; feeling abnormal; feeling hot; hypertension; level of consciousness decreased; mydriasis; pruritus; taste altered; thinking abnormal; vertigo; increased risk of fractures.
Patients should be advised to maintain hydration and to sit or lie down until prodromal symptoms such as nausea, dizziness, and sweating abate.
Paroxetine, a SSRI (Selective Serotonin Reuptake inhibitor) which is a common antidepressant, which is also used off-label to treat premature ejaculation (PE). It is thought to do this by increasing the amount of serotonin.
When taken daily, improvements in ejaculation delay can be noticed within a few days, but the maximum effect is usually achieved after 1–2 weeks of consistent use. Clinical studies report that after 4 weeks of daily paroxetine, many men experience a significant increase in IELT—from less than a minute to several minutes.
Method of administration– Oral administration#
Daily dosing regimen: Start at 10mg tablet taken at night, dose to be reviewed at 2 weeks of treatment, if the response is inadequate, the dose to be increased to 20mg once a day.
On demand regime: 20mg of Paroxetine is to be taken 4 hours prior to intended sexual activity.
Information to be obtained prior to initiation:
A Review of treatment will be done after 2weeks and then every 4 weeks until stable. Once stable every 6 monthly reviews.
Vision blurred
Diabetic control impaired
Acute glaucoma; hepatic disorders; peripheral oedema
Colitis microscopic
Patient is to be advised that it blurred vision not to drive or do skilled tasks.
Paroxetine is associated with a higher risk of withdrawal reactions. The dose should be reduced gradually over about 4 weeks, or longer if withdrawal symptoms emerge (6 months in patients who have been on long-term maintenance treatment)
Gastro-intestinal disturbances, headache, anxiety, dizziness, paraesthesia, electric shock sensation in the head, neck, and spine, tinnitus, sleep disturbances, fatigue, influenza-like symptoms, and sweating are the most common features of abrupt withdrawal of an SSRI
This is a very effective method but requires patience. Follow the steps below. The best way to practice this method is with a caring lover, although you may want to start with masturbation. With your partner engage in stimulation other than penetration (like masturbation or oral sex) and gradually allow yourself to reach that point just before ejaculation. At that point, signal your partner to stop and allow yourself to partially lose your erection. Allow yourself to relax before starting again. Each time you do this, bring yourself closer and closer to orgasm until you cannot control it any longer. Repeat these steps several times to get the hang of it. Doing this a number of times on different occasions will help you learn where your point of climax is. You should practice these steps for several days before you attempt intercourse. Once you are ready to try intercourse, lie on your back and direct your partner to slowly allow you to penetrate. As soon as you feel that you are about to climax, signal to your partner to stop stimulating you. Relax for a bit, and then begin again. You should soon be able to control your ejaculation and enjoy having sex.
The squeeze technique is really just a variation of the Masters and Johnson method, except that the assisting partner squeezes the tip or base of the penis just before the point of climax to essentially cancel the orgasm. The "squeeze" forces blood out of the penis and reduces the erection. You may want to use the squeeze technique if the Masters and Johnson method alone is not working.
products which purport to lessen the sensations felt by men during intercourse so that they can last longer. The limitation that many men feel these creams have is that they make intercourse less pleasurable by decreasing stimulation.
masturbation before sexual intercourse will increase the amount of time a man can then last during intercourse. This technique is not very effective
Are an effective means of reducing the amount of stimulation experienced during sex. Some men find that a condom helps them prevent premature ejaculation by decreasing sensations. If one condom does not decrease the stimulation enough, then put on one more. Condoms provide excellent protection against Sexually Transmitted Diseases and pregnancy, so they’re certainly worth a try.
Different Sexual positions Can affect a man's ability to control his ejaculation. The typical "missionary" position (man on top of his partner) is not the best position while attempting to control ejaculation. Try lying on your back, allowing the partner to control penetration. In this position you are more relaxed and can guide your partner easily. Change of thrusting - You can do this by slowing the tempo of thrusting and by changing the angle or depth of penile penetration. Certain positions may allow you to last longer.
It can be helpful for men to learn to focus more on the non-genital aspects of the sexual experience and to feel pleasure in other parts of the body. Some men claim that focusing their thoughts on something mundane like football scores or a maths problem helps them reduce sensation and hold out longer.
Sildenafil is Phosphodiesterase inhibitor which causes vasodilation leading to increase blood flow to the penis. This requires sexual stimulation to work.
Route of administration: Oral. To be taken an hour before sexual activity. Time to onset of activity is 25mins to 30mins. Rate of absorption is reduced by food.
Duration of activity : 4 to 5 hours
Dose:Initially 50 mg, to be taken approximately 1 hour before sexual activity, adjusted according to response to 25–100 mg (max. per dose 100 mg) as required, to be taken as a single dose; maximum 1 dose per day.
Contraindication:
General cautions:
Alopecia; anaemia; anxiety; cough; diarrhoea; dizziness; fluid retention; gastrointestinal discomfort; gastrointestinal disorders; headaches; increased risk of infection; insomnia; nasal complaints; nausea; night sweats; pain; skin reactions; tremor; vasodilation; vision disorders
Arrhythmias; chest pain; drowsiness; dry eye; dry mouth; eye discomfort; eye disorders; eye inflammation; fatigue; feeling hot; gynaecomastia; haemorrhage; hypertension; hypotension; myalgia; numbness; palpitations; sinus congestion; tinnitus; vertigo; vomiting
Acute coronary syndrome; arteriosclerotic retinopathy; cerebrovascular insufficiency; glaucoma; haematospermia; hearing impairment; irritability; optic neuropathy (discontinue if sudden visual impairment occurs); oral hypoaesthesia; priapism; retinal occlusion; scleral discolouration; seizure; severe cutaneous adverse reactions (SCARs); sudden cardiac death; syncope; throat tightness
Tadalafil is a Phosphodiesterase 5 inhibitor which causes vasodilatation leading to increase blood flow to the penis.
Route of administration: Oral . Time of onset varies between 16minutes to 36 hours. Not affected by food intake.
Duration of action: up-to 36 hours.
1.On demand use:Initially 10 mg (max. per dose 20 mg), to be taken at least 30 minutes before sexual activity, subsequent doses adjusted according to response, the effect of intermittent dosing may persist for longer than 24 hours, continuous daily use not recommended; maximum 1 dose per day.
2. Daily use: In men who anticipate sexual activity at least twice a week.
5 mg once daily, reduced to 2.5 mg once daily, adjusted according to response.
Flushing; gastrointestinal discomfort; headaches; myalgia; nasal congestion; pain
Arrhythmias; chest pain; dizziness; dyspnoea; eye pain; fatigue; gastrooesophageal reflux disease; haemorrhage; hypertension; hypotension; nausea; oedema; palpitations; skin reactions; tinnitus; vision disorders; vomiting
Acute coronary syndrome; angioedema; cerebrovascular insufficiency; eye erythema; eye swelling; haematospermia; hyperhidrosis; memory loss; optic neuropathy (discontinue if sudden visual impairment occurs); priapism; retinal occlusion; seizure; Stevens-Johnson syndrome; sudden cardiac death; sudden hearing loss (discontinue drug and seek medical advice); syncope
For Duloxetine Schedule follow up at 4, 8, and 12 weeks, then quarterly. Monitor weight, BMI, BP, and side effects which should be documented.
For Paroxetine follow-up will be done after 2weeks and then every 4 weeks until stable. Once stable every 6 monthly reviews.
Sildenafil and Tadalafil follow up at 4, 8 and 12 weeks, then quarterly reviews
Clinicians must seek explicit consent to share treatment details with the NHS GP. If the patient refuses, document the discussion and respect the decision. They should not be prescribed weight loss medication if they do not consent for notes to be shared with their NHS GP.
Maintain clear, accurate records of eligibility, exclusion, consent, prescribing decisions, monitoring, and adverse events.
Clinicians must complete training in Men’s health, stay updated with guidelines, and engage in annual CPD.
This SOP will be reviewed annually. Compliance is monitored through audits, with findings reported to the directors of GP Health Hub Limited.
Person Responsible: Dr Wewage Anthony Shanika Dep
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