Undoubtedly, restoration of sexual function is of utmost significance aiming to increase patients’ QoL. However, treatment of ED is frequently frustrating and requires multifaceted approach. Achieving success is even harder in CKD patients. Treatment options include psychosexual therapy, management of endocrine disorders, correction of anaemia, avoidance of certain medications, drug therapy, transurethral or intracavernosal therapy, vacuum devices and surgical treatment. For those undergoing dialysis optimal delivery and optimisation of dialysis dose as well as correction of all metabolic alterations and anaemia are of utmost importance. The concept of lifestyle measures should be promoted (smoking cessation, regular physical activity, achieving optimal body mass index). With starting dialysis some of symptoms are improved but without achieving normalisation. Kidney transplantation can have additional beneficial effect, but not in all patients. The patient’s nutritional status should be monitored. In patients whom psychogenic cause is suspected, psychotherapy could be advised (rational emotional and/or group therapy).

Poor effectiveness of testosterone replacement therapy was reported in dialysis patients [45, 46]. The effect on libido is more pronounced than the effect on erectile function [46]. The response may be modulated by the patient’s nutritional status, activity level and growth hormone values. It has been recommended that this treatment should be initiated only in patients with clear clinical manifestations of biochemically confirmed hypogonadism [47]. Although data related to CV risk are inconclusive (risk for dyslipidaemia and sleep apnea), testosterone should be used with caution, and transdermal application (testosterone enanthate and cypionate) should be preferred. Side effect profile is similar in CKD patients as in other non-CKD hypogonadal patients.

Erythropoietin therapy is associated with lower probability of ED and improved sexual life in haemodialysis patients [41, 42, 48, 49]. Erythropoietin therapy increased global QoL decreasing sensation of fatigue and increasing exercise tolerance. It can lead to normalisation of the pituitary-gonadal feedback mechanism reducing LH, FSH and prolactin and increasing testosterone levels [49]. It is not resolved whether these endocrine changes are solely the result of correction of the anaemia or a direct effect of erythropoietin.

It might be questioned whether deficit in systemic and kidney NO synthesis could decrease the efficacy of PDE-5 inhibitors in CKD patients. However, improvement (60–85 %) in sexual performance and satisfaction was reported in patients undergoing haemodialysis using 50 mg of sildenafil [50, 51]. Nevertheless, in addition to some morphological changes, alterations in NO metabolism in advanced stages of CKD could be the reason of observing somewhat less responses in CKD patients. Sildenafil is the most known and widely used PDE-5 inhibitor which is mostly excreted in the faeces and only 13 % in the urine. Sildenafil pharmacokinetics do not appear to be affected by mild to moderate renal impairment, and clearance of sildenafil is neither reduced in patients with severe CKD nor cleared by haemodialysis [52]. It has similar efficacy in patients on haemodialysis and peritoneal dialysis [53]. The occurrence of side effects is similar to other patients and men groups. Hypotension is the most important problem, but intradialytic hypotension was not reported. However, some authors propose its use on non-dialysis days. Other PDE-5 inhibitors have been approved as well. As in the general population PDE-5 inhibitors are not indicated in patients receiving nitrates. They could be advised to patients with recent coronary events, uncontrolled hypertension and uncompensated heart failure only after the patient achieves normal result on maximal exercise stress testing. The dopamine agonist apomorphine is not contraindicated in patients either on nitrates or on antidepressants. Regarding relative deficiency of NO in CKD patients and its contribution to increased CV risk, some authors raised the question whether treatment with PDE-5 inhibitors could be promising therapy for the CV outcome and not only for improving erectile function.

Vacuum constrictor devices, intraureteral prostaglandins (alprostadil), intracavernous injections of vasoactive agents and penile prosthesis could be used in CKD patients as in all other men having ED. However, intracavernous injections should be cautiously used in uremic patients because of frequently presented platelet dysfunction.

Although some studies did not prove kidney transplantation to have beneficial effect on sexual and ED [43, 54–56], majority of authors [57–61] indicated that this therapy has a positive impact on sexual life. Renal transplantation reverts to normal hormonal alterations [58, 60]. It was reported that libido and penile tumescence are increased by 73 % [61]. However, Tsujimura et al. found that regardless of hormone profiles that had largely returned to normal after transplantation, only 30 % reported an improvement in sexual function [62]. Frequency of intercourse increased only by 37 %, indicating that some of the risk factors for sexual and ED remained after renal transplantation [63, 64]. The possible reasons for the absence of beneficial effect of kidney transplantation on sexual function in some patients are graft dysfunction, compromised penile vascularity, side effects of immunosuppressive and antihypertensive drugs, pre-existing hypertension or diabetes, smoking or some psychological problems (anxiety of the function of the graft). Pourmand et al. reported lower probability of erectile function improvement among patients whose graft was anastomosed to the common iliac artery (this is the source of major blood supply of the penis) [43]. No differences in sexual function were reported between patients treated with cyclosporine or tacrolimus [65]. Kaufman et al. reported that early renal transplantation may have a beneficial effect on the penile vasculopathy [17]. The Cochrane review and meta-analysis of Vecchio et al. based on analyses of data obtained in more than 320 patients concluded that PDE-5 inhibitors and zinc replacement are promising interventions for treating sexual dysfunction in CKD patients [66, 67]. However, they underlined that evidence is limited which points to an unmet need for studying interventions.

ED in CKD patients is a challenging issue. Nephrologists as well as all affiliated physicians and nurses should be aware of the high prevalence of various forms of sexual dysfunction in CKD patients and the impact this has on the QoL. There is a need for screening for sexual and ED as some, or maybe most, abnormalities could be cured or at last improved. Assessment of sexual function should be incorporated into the routine evaluation of all CKD patients. As ED could be considered as a symptom of endothelial dysfunction, all patients with this complaint must be carefully assessed for all other CV risk factors and silent coronary artery disease. As Holley and Schmidt concluded patients at all levels of CKD, socioeconomic status and gender deserve better QoL [68].