Erectile Dysfunction (ED)

Clinic A/P, adults

Pt has an inability to achieve and maintain an erection sufficient for sexual activity.
The 3 most common male sexual dysfunctions are ED, decreased libido, and ejaculatory dysfunction (e.g. premature ejaculation).
H&P and dx studies
Most often is mixed (psychogenic and organic) factors.
R/o med s/e as the cause of ED. Look for antihypertensives, sympatholytics, anticholinergics, antidepressants, anxiolytics, antipsychotics, antiepileptics, antiandrogens, ketoconazole, niacin, cimetidine, and opiates.
R/o depression.
Ddx and Causes.
Labs:  AM testosterone, A1C, lipid panel, TSH, CBC, PSA.
Prolactin if there is decreased libido.
Treatment
Lifestyle changes: Stop smoking, lose weight, increase physical activity, decrease alcohol intake
D/c or modify any culprit drugs like SSRIs.
Psychotherapy as needed.
Medical mgt of  CV risk factors.
Testosterone replacement therapy if male hypogonadism is diagnosed.
1st-line Rx: PDE5i. E.g. Cialis 10 mg po prn once daily. Take at least 30 minutes prior to anticipated sexual activity as one single dose and not more than once daily.
If priapism (painful erection lasting more than 4hrs) occurs, go to the ER.
2nd-line Rx: 1) Vacuum-assisted erection devices;  2) Intraurethral administration of alprostadil (prostaglandin E1); 3) Penile self-injection (Intracavernosal injection therapy) with alprostadil (prostaglandin E1);
Last resort Rx: Surgery (penile prosthesis) and rarely penile revascularization. 

—/END/—

ED Pearls and Links

  • Sildenafil 20 mg tablets come as generic. Thirty tablets of Sildenafil 20mg cost only $18.21. Viagra is also sildenafil but at a dose of 25 mg and up but costs much more. For example, 10 tablets of Viagra 25 mg cost $485.37.
  • Thyroid disorders are associated with ED (Sex Med Rev, 2019). Get TSH.
  • Labs to r/o comorbid conditions like DM, HLD, hypothyroidism. PSA and AM testosterone levels. Check prolactin if decreased libido.
  • Medical mgt of  CV risk factors is effective for improving sexual function in some men with ED
  • No PDE5i is better than the other. Similar side effects as well.
  • Measurement of serum testosterone is recommended by for men with ED b/c low testosterone and ED often coexist. Testosterone replacement has been shown to help ED and increase libido.
  • “ED is a common symptom of depression, and erectile function may be restored as psychotherapy or antidepressant drugs alleviate the depression.”
  • The 3 most common male sexual dysfunctions are erectile dysfunction (ED), decreased libido, and ejaculatory dysfunction (e.g premature ejaculation).
  • Alcoholism decreases libido.
  • Premature Ejaculation.

 

References / Resources

Sex Med Rev. 2019 Jan;7(1):57-70. https://www.ncbi.nlm.nih.gov/pubmed/30057137

print