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erectile dysfunction (ED)

Inability to achieve or maintain erection sufficient to initiate & complete satisfactory intercourse. It is clinically relevant if it occurs > 50% of attempts at sexual activity or persists for > 3 months. (see impotence) Etiology: 1) 60% organic etiology a) vasculogenic (54% of men over 65 years of age [2]) b) neurologic c) hormonal d) smooth muscle abnormalities e) obesity may be risk factor due to endothelial dysfunction [4] f) ED may be a manifestation of metabolic syndrome X [6] g) ED may be a harbinger of cardiovascular disease [7] h) pelvic/peritoneal trauma i) radiation or surgery in the pelvis, retroperitoneum [1] j) Peyronie's disease [2], if painful, most likely cause of ED k) hemochromatosis [34] 2) 40% psychogenic a) interpersonal relationship problems b) mood disorders c) affective disorders 3) risk factors [8] a) diabetes mellitus [25] - dulaglutide (Trulicity) may reduce risk of ED. but does not improve pre-existing ED [29] b) vascular disease, smoking c) hypertension d) treatment of prostate cancer (HR=1.5) [14] e) age 4) drug-induced erectile dysfunction (see impotence) - 5-alpha reductase inhibitors not a common cause of ED [24] - in the real world, dustateride can cause erectile dysfunction that may persist long after discontinuation [31] Epidemiology: 1) affects 20 million men 40-70 years of age 2) 52% of men 40-70 years of age 3) 67% of men by age 70, 78% of men > age 75 4) 64% of men with myocardial infarction Laboratory: - laboratory evaluation in the absence of findings suggestive of systemic disorder is not indicated [1] - low 8 AM serum testosterone & high serum LH associated with erectile dysfunction [11] - confirm low 8 AM serum testosterone prior to obtaining serum LH [1] - complete blood count (CBC) - iron studies - serum ferritin (rule out hemochromatosis) Special laboratory: - cardiac stress testing if symptoms consistent with cardiovascular disease [1] Complications: - erectile dysfunction is a harbinger of cardiovascular disease in some men [1,16] Management: 1) discontinuation of offending agents (see impotence) 2) cardiovascular risk assessment for at risk patients - stress testing for at risk patients - 5 METS without ischemia defines low risk [1] 3) life style changes treating cardiovascular risk factors & modulating endothelial nitric oxide synthase can improve ED - smoking cessation - physical activity & conditioning (exercise) - healthy diet - benefit likely through cardiovascular risk reduction [27] - dietary flavonoids may reduce risk (RR=0.9) [20] - weight reduction - statin for dyslipidemia not responsive to life-style changes 4) psychosocial therapy or counseling for both organic & psychogenic ED - psychotherapy for dysfunctional relationships, anger, depression - bupropion suggested to treat depression & erectile dysfunction (NEJM) [35] 5) phosphodiesterase-5 inhibitor (PDE-5 inhibitor) a) sildenafil (Viagra), vardenafil, tadalafil, avanafil others b) some OTC supplements contain compounds that appear to inhibit phosphodiesterase 5 (not recommended) [9] c) coadministration of alpha-blockers or nitrates may lead to profound hypotension - coadministration of nitrates contraindicated - elderly may be prescribed PDE-5 inhibitor with nitroglycerin provided cautioned not to take sildenafil within 24 hours of nitroglycerin use despite history of myocardial infarction or attendance in cardiac rehabilitation provided no cardiac symptoms at 3-4 METs [2] - coadministration of alpha-blockers with caution [1] d) placebo effect of phosphodiesterase-5 inhibitors is small to moderate [26] e) better survival with PDE5 inhibitors for ED in patients with stable coronary artery disease [28] 6) FDA approves OTC topical gel Eroxon for erectile dysfunction [36] - can help users get an erection within 10 minutes 7) PDE-5 inhibitor contraindicated - alprostadil - intraurethral pellet - Medicated Urethral System for Erection (MUSE) - contraindications: priapism - intracavernosal injection - contraindications: priapism, coagulopathy - papaverine or phentolamine intracavernosal injection - vacuum constriction device, Erectaid Pump - penile prosthesis 8) androgens a) of little or no benefit [1] b) testosterone replacement if testosterone is low [2] - intramuscular or transdermal c) testosterone replacement of no benefit when added to sildenafil [15] 9) platelet-rich plasma injections of no benefit for erectile dysfunction [37] 10) penile revascularization is not recommended (MKSAP19) [1,5] 11) risk-stratified guidelines for treatment of ED a) low-risk 1] criteria a] asymptomatic & < 3 major cardiac risk factors b] controlled hypertension c] mild stable angina d] s/p successful PCI e] s/p MI > 6-8 weeks prior f] mild valvular heart disease g] NYHA class 1 heart failure 2] recommendation: a] sexual activity OK b] may treat with PDE-5 inhibitor unless using nitrate b) intermediate risk 1] criteria a] asymptomatic & >= 3 major cardiac risk factors b] moderate stable angina c] recent MI, 2-6 weeks prior d] LVEF < 40% or NYHA class 2 heart failure e] peripheral arterial disease f] history of TIA or stroke 2] recommendation - cardiac stress testing & restratification prior to further sexual activity or treatment for ED c) high risk 1] criteria a] unstable angina or refractory angina b] uncontrolled hypertension c] NYHA class 3 or 4 heart failure d] recent MI < 2 weeks prior e] high-risk arrhythmia f] obstructive cardiomyopathy g] moderate to severe vavlular heart disease, especially aortic stenosis 2] recommendation - defer sexual activity or ED treatment until after cardiac condition has stabilized & risk has diminished 12) over-the-counter gel MED3000 [Eroxon] will be on the market 2025. - erections in < 10 minutes after a single application to glans [38] * major cardiac risk factors - hypertension, diabetes mellitus, smoking, dyslipidemia, sedentary lifestyle, familty history of premature CAD

Interactions

disease interactions

Specific

corporo-venous occlusive erectile dysfunction erectile dysfunction due to arterial insufficiency

General

impotence penile disorder

References

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