Resident Editor: Scott R. Bauer, MD, ScM
Faculty Editor: Benjamin Breyer, MD
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BOTTOM LINE ✔ ED is most common sexual problem in men ✔ Smoking cessation is the most effective lifestyle intervention ✔ First line therapy is to address lifestyle and psychosocial factors |
Background
· Erectile dysfunction (ED) is defined as inability to achieve or maintain an erection sufficient for satisfactory sexual performance.
- Causes can be vascular, neurogenic, hormonal, or psychogenic.
· Most common sexual problem in men, increases with age (prevalence: ~40% mild to 5% complete at age 40 and ~70% mild to 15% complete at age 70)
- New ED has high PPV for future CAD (similar to smoking), usually 2-5 years before clinically significant CAD develops.
Signs and Symptoms
• Sexual history
- Onset: gradual and progressive ED suggests organic cause, rapid onset in absence of prostate cancer treatment or overt trauma suggests psychogenic cause.
- Erection health: assess nocturnal/early AM erections (complete loss suggests neurologic or vascular disease), loss of erection after penetration (suggests anxiety or vascular steal syndrome). Clearly distinguish ED from premature ejaculation, difficulty with ejaculation/orgasm, poor libido.
- Psychosocial: perform interpersonal violence screen, assess for interpersonal conflict, stress, performance anxiety, desire.
• General history
- Review PMH for DM, HTN, HLD, metabolic syndrome, CVD, BPH, neurologic disease, depression, hypogonadism, alcohol use disorder, pelvic, penile, or perineal trauma, surgery or XRT, back or spine injury.
- Risk increased with smoking, recreational drugs (amphetamines, barbiturates, cocaine, MJ, opioids), obesity, sedentary lifestyle, LUTS. Cycling not associated with ED.
- Review medications for antihypertensives (BB, CCB, thiazides, clonidine, methyldopa, spironolactone), antidepressants and antipsychotics (SSRI, SNRI, TCA, lithium, phenothiazines), others (digoxin, anti-cholinergics, alpha-blockers, cimetidine, phenytoin, steroids, fibrates).
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International Index of Erectile Function (IIEF-5) Questionnaire: |
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Over the past 6 months: |
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1. How do you rate your confidence that you could get and keep an erection? |
Very low 1 |
Low 2 |
Moderate 3 |
High 4 |
Very high 5 |
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2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration? |
Almost never/never 1 |
A few times (much less than half the time) 2 |
Sometimes (about half the time) 3 |
Most times (much more than half the time) 4 |
Almost always/always 5 |
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3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? |
Almost never/never 1 |
A few times (much less than half the time) 2 |
Sometimes (about half the time) 3 |
Most times (much more than half the time) 4 |
Almost always/always 5 |
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4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? |
Extremely difficult 1 |
Very difficult 2 |
Difficult 3 |
Slightly difficult 4 |
Not difficult 5 |
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5. When you attempted sexual intercourse, how often was it satisfactory for you? |
Almost never/never 1 |
A few times (much less than half the time) 2 |
Sometimes (about half the time) 3 |
Most times (much more than half the time) 4 |
Almost always/always 5 |
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Scoring: >22 normal; 12-21 mild; 8-11 moderate; <8 severe |
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Evaluation
• Assess severity and track symptoms with IIEF-5 (above)
• Physical Exam
- Blood pressure.
- BMI and waist circumference.
- GU exam: assess for testicular size, asymmetry or masses.
- Assess for secondary male sex characteristics, gynecomastia, galactorrhea.
- Peripheral and femoral pulses (suggest PVD).
- If pituitary disease is suspected, assess visual fields.
- If concerning neurologic symptoms or LUTS, perform DRE and cremasteric reflex to assess sacral nerve and prostate.
• Labs/tests
- Check fasting glucose or A1c and lipid panel in all men.
- Only consider TSH, morning serum testosterone, prolactin if additional symptoms.
- Consider evaluation for hypogonadism if signs/symptoms or not responding to initial therapy.
- Duplex doppler ultrasonography or angiography of the penile deep arteries may be used by Urology to assess penile vasculature.
- Nocturnal penile tumescence testing (NPT) not commonly done.
Treatment
· First line therapy: Treat underlying medical disease, change potential contributing medications, smoking cessation, weight loss (10% of total body weight in obese men), increase physical activity, healthful diet, stress reduction techniques, address psychosocial stressors and relational issues (refer to sex therapist), attempt intercourse when well rested.
· Second line therapy: Phosphodiesterase-5 inhibitors (no proven superiority of any one agent, doubles likelihood of successful intercourse, efficacy decreased in DM):
- Sildenafil (Viagra), vardenafil (Levitra), avanafil (Stendra), tadalafil (Cialis)
- Take 1-2 hours before sexually activity on an empty stomach (except tadalafil/Cialis long-acting, 36hr half-life, not used prn).
- Do not take medication more than once per 24 hours.
- Side effects include headache, flushing, dyspepsia, nasal congestion, changes in color perception.
- Contraindicated in men taking nitrates. Recommend discussion with cardiologist if symptomatic CAD (moderate angina, MI within 2 months), CHF (NYHA class >I), uncontrolled HTN. Caution if chronic hypotension. Avoid use with alpha-adrenergic blockers, drugs that affect cytochrome P450 CYP3A4, and drugs that prolong QT interval.
· Third line therapy (refer to Urology): penile self-injectable drugs, intraurethral alprostadil (prostaglandin E1), vacuum devices, surgical implantation of a penile prosthesis.
· For men with hypogonadism, trial of 1st and 2nd line therapies and if fail refer to endocrine for possible initiation of testosterone replacement.
· Psychosexual therapy is effective for ED due to depression or performance anxiety, can be added as adjunctive therapy.
When to refer
· If 1st or 2nd line therapies fails, if surgery is required, or for further diagnostic imaging.
References
Feldman HA, Goldstein I, Hatzichristou DG, et al: Impotence and its medical and psychosocial correlates: Results of the Massachusetts Male Aging Study. J Urol, 1994;151:54–61.
McVary KT. Clinical practice. Erectile dysfunction. N Engl J Med 2007;357(24):2472-81.
Montague, DK, Jarow, JP, Broderick, GA, et al. Chapter 1: The management of erectile dysfunction: an AUA update. J Urol 2005; 174:230.
Rew KT and Heidelbaugh JJ. Erectile Dysfunction. Am Fam Physician 2016; 94(10): 820-827.