Erectile Disorders Erectile Dysfunction

Erectile dysfunction (ED) refers to "the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance" (NIH Consensus Development Panel on Impotence, 1993). Sexual function declines with age, and normal erectile function depends on a number of body systems—cardiovascular, endocrine, muscular, nervous, psychological (Lue, 2000). Disorders in any of these can lead to ED, although many factors often are involved.

As many as 30 million men have ED (Fink et al., 2003, 2002). Risk factors include diabetes, cardiovascular diseases (e.g., hypertension, coronary heart disease, hyperlipidemia), lifestyle (e.g., alcohol, obesity, smoking), depression, neurologic disease or damage, pelvic or vascular surgery, and medications, and other endocrine and urologic disorders (Fink et al., 2002. Medications such as antidepressants and anti-hypertensives are often implicated, and medications play a role in as many as 25% of cases (McVary, 2007) (see eTable 40-1). As many as two thirds of men with cardiovascular

Box 40-6 Erectile Dysfunction Treatment Options

Alprostadil* +

Intracavernosal (Caverject, Edex)* Intraurethral (Muse)* Topical Apomorphine (sublingual)* Cognitive-behavioral therapy Ginseng

Phosphodiesterase (type 5) inhibitors Sildenafil (Viagra)* Tadalafil (Cialis)* Vardenafil (Levitra)* Yohimbine (Yocon, Yohimex, generic)

Papaverine^ (alone or mixed with phentolamine or phentolamine and alprostadil)

Penile prosthesis surgery Psychosexual counseling

Therapeutic lifestyle changes—smoking cessation, weight loss, limited alcohol consumption Vacuum device*

Modified from Tharyan P, Gopalakrishanan G. Erectile dysfunction. Clin Evid 2009;05:1803.

*These treatments have good evidence of benefit.

tHarms may limit use. Alprostadil may cause penile pain.

¿Harms may limit use. Papaverine injections may alter liver function and cause penile bruising or fibrosis.

disease experience ED before the onset of cardiac symptoms (Billups, 2005), suggesting clinical risk assessment in men presenting with ED.

Assessment should include a general health history, with particular focus on risk factors and psychosocial issues, such as substance use, libido, and partner relationship. Clinical survey tools such as the sexual health inventory for men (SHIM) can aid in diagnosis and treatment (Cappelleri and Rosen, 2005). Surgical and medication history is essential. The examination should focus on genitourinary, endocrine, and vascular function. Laboratory work includes urinalysis, blood count, and assessment of renal function and glucose, lipid, and serum testosterone levels. Hyperprolactinemia may cause ED, although this occurs in fewer than 2% of cases (Mikhail, 2005). Thus, determination of prolactin levels, along with free testosterone and luteinizing hormone (LH) levels, should be reserved for patients with signs or findings consistent with hypogonadism (e.g., low serum testosterone level) (Lue, 2000).

Alprostadil (intracavernosal, intraurethral), apomorphine, and phosphodiesterase type 5 (PDE-5) inhibitors are effective ED treatments (Box 40-6). Potentially beneficial alternative therapies include yohimbine and Korean red ginseng, with yohimbine having the stronger evidence base (Tharyan and Gopalakrishanan, 2009). Attention to lifestyle issues is important. For example, weight loss may improve sexual function in obese patients (Esposito et al., 2004). Discontinuing potentially causative medicines is an option, although risks and benefits of this choice and its effect on other conditions must be considered. The advent of oral treatment with PDE-5 inhibitors has made these medications the drugs of first choice (Table 40-8). Cardiovascular disease is a concern with PDE-5 inhibitors because these patients may be taking nitrates or may experience cardiac symptoms from sexual exertion. The medicine itself does not cause ischemia. Furthermore, no increase in cardiovascular events or death was found in randomized trials (Fink et al., 2002). Patients with antidepressant-induced ED, primarily from selective serotonin reuptake inhibitors (SSRIs), may benefit from the addition of a PDE-5 inhibitor, a switch to a different anti-depressant (e.g., bupropion), or a drug holiday (Rudkin et al., 2004; Sturpe et al., 2002). PDE-5 inhibitors may also be beneficial in patients with ED from diabetes or spinal cord injury.

One unintended consequence of widely publicized ED treatments is the negative emotions when these treatments fail, which they often do (Fink et al., 2002; Tomlinson and Wright, 2004). Psychosexual counseling and cognitive-behavioral may be beneficial, although evidence is limited for these interventions (Tharyan and Gopalakrishanan, 2009).

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