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  Erectile dysfunction
 
Author: Arthur Burnett Last modified: December 19, 2001
DIAGNOSTIC CRITERIA

  EPIDEMIOLOGY

  • The prevalence of erectile dysfunction in 1992 was estimated to be 18 percent among men 50-59 years of age, according to the National Health and Social Life Survey.
  • Prevalence estimates of complete and mild erectile dysfunction among men 40-70 years of age during 1987-1989 exceeded 10 and 50 percent, respectively, according to the Massachusetts Male Aging Study.
  • Incidence estimates of erectile dysfunction approached 26 cases per 1,000 men annually during 1995-1997, based on longitudinal analyses of the Massachusetts Male Aging Study.

  RISK FACTORS

  • Cardiovascular disease- diabetes mellitus, heart disease, hypertension, decreased HDL levels
  • Neurologic disease or injury- spinal cord injury, multiple sclerosis, Parkinson's disease
  • Pelvic trauma- radiation or surgery for prostate cancer or other pelvic disease
  • Psychosocial factors- depression, anger, interpersonal relationship issues
  • Hormonal factors- hypogonadism, hyperprolactinemia, thyroid disorders
  • Age
  • Penile deformities- micropenis, congenital chordee, Peyronie's disease

  SIGNS AND SYMPTOMS

  • Definition- consistent inability to attain and maintain penile erection sufficient for satisfactory sexual intercourse of greater than 3 months\' duration
  • Circumstances for achievable erections- stimuli during sexual encounters, erections on awakening, role of self-stimulation
  • Circumstances associated with erectile difficulty- performance anxiety, inability to perform with a designated partner, motivational factors affecting love-making
  • Associated sexual issues (distinct from erectile dysfunction)- libido, ejaculation, orgasm
  • Other issues- availability, interest and health of partner, changes in medical status or other events relating to onset of dysfunction

  DIFFERENTIAL DIAGNOSIS

  • Sexual dysfunctions- poor libido, ejaculatory disorders
  • Penile deformities- micropenis, congenital chordee, Peyronie's disease
  • Hypogonadism- hypothalamic disorders, pituitary disorders, testicular disorders, androgen-insensitivity syndromes

  LABORATORY FINDINGS

  • Serum chemistries- evaluation of chronic diseases such as diabetes, renal insufficiency and liver disease
  • Complete blood count- evaluation of chronic disease
  • Total testosterone- a fasting morning level is recommended; if low, proceed with serum free(or bioavailable) testosterone, prolactin, leutinizing hormone
  • Thyroid function tests- evaluation if clinical suspicion of thyroid dysfunction
  • Lipid profile- evaluation for hyperlipidemia in men with suspected cardiovascular disease
  • PSA- evaluation as needed for prostate pathology prior to treatment of hypogonadism (with exogenously administered testosterone)
 
TREATMENT
SILDENAFIL CITRATE (VIAGRA) 25, 50, 100 MG PO, 1 HR BEFORE SEXUAL ACTIVITY
  • First line therapy
  • FDA-approved oral therapy for erectile dysfunction
  • Presence of sexual stimulation is required for efficacy
  • Contraindicated for men receiving nitrate therapy in any form that in combination may produce severe hypotension
  • Side effects include headaches (16%), flushing (10%), dyspepsia (7%), nasal congestion (4%), visual disturbances (3%)
  • Concomitant use of agents metabolized through the cytochrome P450 3A4 system in the liver such as erythromycin, cimetidine, ketoconazole and the statins may necessitate lowering doses of sildenfil bec
PROSTAGLANDIN E1 (ALPROSTADIL [MUSE]) 125, 250, 500, 1000 MCG INTRAURETHRALLY
  • Second line therapy
  • In-office instruction and titration is highly recommended
  • On-demand use
  • Contraindicated for patients with priapism histories
  • Side effects include local urogenital pain (29%), minor urethral bleeding (5%), dizziness (4%), hypotension (3%)
PROSTAGLANDIN EI (ALPROSTADIL [PROSTIN VR, CAVERJECT, EDEX]) 5-60 MCG INTRACAVERNOSALLY
  • Second line therapy
  • FDA-approved for penile injection
  • In-office instruction and titration is highly recommended
  • Intracavernosal drug mixtures also contain papaverine and phentolamine in varying combinations with alprostadil
  • On-demand use
  • Contraindicated for patients with priapism histories or histories of severe coagulopathy
  • Side effects include priapism (1%), penile fibrosis (5-10%), penile pain (10%)
 
IMPORTANT POINTS/RECOMMENDATIONS
  • A stepwise treatment approach is applied customarily based on ease of administration, reversibility, invasiveness and cost.
  • The stepwise approach for clinical decision-making about erectile dysfuncton treatment (after specific treatment for an underlying disorder) consists of: oral erectogenic agents, vacuum constriction d
  • Psychosocial therapy or counseling (optimally, for the patient and his partner) can be offered for both organic (physical cause) and psychogenic (no discernible physical cause) presentations of erecti
  • Correction of reversible causes of erectile dysfunction including change of or discontinuation of medications adversely affecting erectile function, corrective surgery (for pelvic or perineal trauma),
  • It is important to recognize that patients vary in their acceptance of treatment for sexual disorders, and consideration of patient and/or partner needs, expectations, and priorities is an essential e
 
REFERENCES
  1. Process of Care Consensus Panel. ;  The process of care model for evaluation and treatment of erectile dysfunction. ;  Int J Impot Res 11(2):59-74.

  2. NIH Consensus Development Panel on Impotence ;  NIH Consensus Conference: Impotence ;  JAMA 270(1): 83-90.

  3. Burnett AL ;  Erectile dysfunction: a practical approach for primary care ;  Geriatrics 53(2): 34-5, 39-40, 46-8, 1998.

  4. Johannes CB, Araulo AB, Feldman HA, Derby CA, Kleinman KP, McKinlay JB ;  Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Masssachusetts male aging study ;  J Urol 163(2): 460-3, 2000.

  5. Rowland DL, Burnett AL ;  Pharmacotherapy in the treatment of male sexual dysfunction ;  J Sex Res 37: 226-43, 2000.

  6. Jardin A, Wagner G, Khoury F, Giuliano F, Padma-Nathan H, Rosen R (eds.) ;  Erectile Dysfunction. World Health Organization First International Consultation ;  Health Publication Ltd: Plymouth, United Kingdom, 2000.

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