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Sexual dysfunction in a male. Etiology: 1) endocrine a) testicular failure (hypogonadism) - primary - secondary b) hyperprolactinemia c) diabetes mellitus 2) pharmacologic agents [4] a) androgen antagonists - histamine H2 receptor antagonists - cimetidine, ranitidine - spironolactone - ketoconazole - finasteride - dutasteride b) estrogen c) antihypertensive agents - centrally acting sympatholytics - clonidine - methyldopa - peripherally acting sympatholytics - guanadrel - guanethidine - beta-adrenergic receptor antagonists (beta blockers) - calcium channel blockers - thiazide diuretics d) digoxin e) anticholinergic agents f) antihistamines (H1 receptor antagonists) [2] - dimenhydramine, diphenhydramine, hydroxyzine, meclizine, promethazine g) antidepressants - monoamine oxidase (MAO) inhibitors - tricyclic antidepressants (TCA) - selective serotonin receptor antagonists - selective norepinephrine reuptake inhibitors - duloxetine, venlafaxine h) antipsychotic agents - lithium carbonate - haloperidol - thorazine i) central nervous system depressants - sedatives: barbiturates - anxiolytics: benzodiazepines j) drugs of habituation or addiction - alcohol - opiates - tobacco - marijuana - cocaine, amphetamines [2] k) anticonvulsants - phenytoin - carbamazepine - phenobarbital - primidone l) corticosteroids m) statins ? [3] n) NSAIDs - naproxen, indomethacin [2] o) Parkinsonian agents - levodopa, bromocryptine, biperiden, trihexyphenidyl, benztroine, procyclidine [2] 3) penile diseases a) Peyronie's disease b) previous priapism c) penile trauma 4) neurologic diseases a) anterior temporal lobe lesions b) diseases of the spinal cord c) loss of sensory input - tabes dorsalis - disease of dorsal root ganglia d) trauma to the pelvic splanchnic nerves (nervi erigentes) - radical prostatectomy & cystectomy - rectosigmoid operations e) diabetic autonomic neuropathy f) polyneuropathy 5) vascular diseases a) aortic occlusion (Leriche syndrome) b) atherosclerotic occlusion or stenosis of the pudendal &/or carvernosa arteries c) arterial damage from pelvic radiation d) venous leak e) disease of the sinusoidal spaces 6) psychogenic impotence a) anger b) depression Epidemiology: 1) 5% of men at 40 years of age 2) 15% of men at 70 years of age Laboratory: 1) serum chemistries a) serum glucose b) 8 AM serum testosterone, free testosterone* - serum FSH & serum LH if two 8-10 AM serum testosterone or free testosterone are low c) serum prolactin d) serum luteinizing hormone e) serum urea nitrogen f) serum creatinine 2) hemoglobin A1c * free testosterone may be necessary in obese due to lower sex hormone-binding globulin in serum thus total serum testosterone [2] Radiology: 1) pudendal arteriography 2) pulsed doppler analysis combined with intracorporeal injection of alprostadil Management: 1) general a) also see erectile dysfunction b) androgens - of little or no benefit [1] - testosterone replacement if testosterone is low [2] - intramuscular or transdermal c) yohimbine widely prescribed, but works only as placebo in psychogenic impotence d) injection of prostaglandin E2 (alprostadil) e) commercially available mechanical devices - vacuum to produce an erection - rubber band to constrict venous return at the base of the penis f) penile prosthesis - highest rate of complications 2) treatment of specific etiology a) prolactinoma - surgical removal - bromocryptine b) surgical correction of arterial disease c) control of diabetes d) reduce or refrain from alcohol 3) psychotherapy for dysfunctional relationships, anger, depression

Specific

erectile dysfunction (ED) impotence in diabetics

General

sexual dysfunction sign/symptom

References

  1. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 286
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2022
  3. Rizvi, K et al, Do lipid-lowering drugs cause erectile dysfunction? A systematic review Family Practice 2002, 19:95 PMID: 11818357 - Pedersen TR & Faergeman O Simvastatin seems unlikely to cause impotence. BMJ 1999, 16:318 PMID: 9888926 - Halkin A et al, HMG-CoA reductase inhibitor-induced impotence. Ann Pharmacother 1996, 30:192 PMID: 8835058
  4. Prescriber's Letter 13(9): 2006 Drugs That May Cause Male Sexual Dysfunction Detail-Document#: 220907 (subscription needed) http://www.prescribersletter.com