Management of Erectile Dysfunction Reviewed

Laurie Barclay, MD

February 09, 2010

February 9, 2010 — The best practices to manage erectile dysfunction (ED) in the family practice setting are reviewed in an article published in the February 1 issue of American Family Physician.

"...ED is defined by the National Institutes of Health as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance," writes Joel J. Heidelbaugh, MD, from the University of Michigan in Ann Arbor. "ED is the most common sexual problem in men; it often causes serious distress, prompting men to seek medical attention they may not otherwise seek. It often has a profound effect on intimate relationships, quality of life, and overall self-esteem [and] may also be the presenting symptom or harbinger of undetected cardiovascular disease."

ED may result from organic causes related to vascular, neurogenic, hormonal, anatomic, or drug-induced conditions; psychological causes; or a combination of both. ED will affect up to one third of men during their lifetime, and it increases in incidence with age. Predictive factors associated with a greatly increased risk for ED are obesity, sedentary lifestyle, and smoking.

In most cases, history and physical examination are sufficient to diagnose ED. Medical history should determine the presence of diabetes or other comorbid conditions that can increase the risk for ED, medication history may reveal use of medications with sexual adverse effects, and sexual history should assess libido and ability to reach orgasm and to ejaculate. Physical examination should include cardiovascular and neurologic assessment, genital inspection, and digital rectal examination.

Although there is no preferred first-line diagnostic test, initial diagnostic evaluation should usually consist only of a fasting serum glucose level and lipid panel, thyroid-stimulating hormone test, and morning total testosterone level. Optional laboratory tests may include complete blood count; free testosterone, luteinizing hormone, and prolactin levels; sex hormone–binding globulin test; and/or urinalysis.

Evaluations that may be considered in selected patients with ED include psychological or psychiatric consultation, in-depth psychosexual and relationship evaluation, neurophysiologic penile and sphincter testing, nocturnal penile tumescence and rigidity assessment, specialized endocrinologic testing, and/or vascular diagnostics.

First-line treatment of ED consists of lifestyle interventions (weight loss, increased exercise, and smoking cessation), discontinuation or changing of medications that may cause ED, and pharmacotherapy with phosphodiesterase type 5 (PDE5) inhibitors.

The most effective orally administered drugs for treatment of ED are the PDE5 inhibitors, which have been shown to be effective for ED associated with diabetes mellitus, spinal cord injury, and antidepressant use.

"The three PDE5 inhibitors are considered to be relatively similar in effectiveness, but there are differences in dosing, onset of action, and duration of therapeutic effect," Dr. Heidelbaugh writes. "An open-label trial found that patients preferred tadalafil and vardenafil over sildenafil, yet most evidence supports equal effectiveness between sildenafil and vardenafil. PDE5 inhibitors are generally well tolerated, with mild transient adverse effects of headache, flushing, dyspepsia, rhinitis, and abnormal vision."

When PDE5 inhibitors are ineffective, alternative therapeutic options may include intraurethral and intracavernosal injections of alprostadil, vacuum pump devices, and surgically implanted penile prostheses.

For men with hypogonadism, testosterone supplementation generally improves ED and libido but is associated with a higher risk for prostate adenocarcinoma. Interval monitoring of hemoglobin, serum transaminase, and prostate-specific antigen levels is therefore required.

Cognitive behavioral therapy and therapy aiming to improve the quality of relationships may be helpful for couples affected by ED.

Risk for coronary, cerebrovascular, and peripheral vascular diseases is increased in men with ED. Because symptoms of ED may occur 3 years earlier, on average, than symptoms of coronary artery disease, screening for cardiovascular risk factors should be considered in men with ED.

Key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:

  • Diagnostic workup for ED should usually be limited to a fasting serum glucose level and lipid panel, thyroid-stimulating hormone test, and a morning total testosterone level (level of evidence, C).

  • Oral PDE5 inhibitors should be first-line treatment of ED (level of evidence, A).

  • PDE5 inhibitors are most effective in treating ED associated with diabetes mellitus and spinal cord injury, and sexual dysfunction associated with antidepressants (level of evidence, A).

  • Psychosocial therapy may be a useful adjunctive treatment of ED, as well as testosterone supplementation in men with hypogonadism (level of evidence, B).

  • Testosterone supplementation improves ED and libido in men with hypogonadism (level of evidence, B).

  • Screening for cardiovascular risk factors should be considered in men with ED (level of evidence, C).

"The economic impact of ED is multifactorial, with direct costs that include physician evaluation, pharmacotherapy, and diagnostic testing, and indirect costs that include lost time at work, lost productivity, and effects on the man's partner, family, and co-workers," Dr. Heidelbaugh concludes. "The Prostate Cancer Prevention Trial determined that men with ED have a significantly greater likelihood of having angina, myocardial infarction, stroke, transient ischemic attack, congestive heart failure, or cardiac arrhythmia compared with men without ED. Because most men are asymptomatic before an acute coronary syndrome, ED may serve as a sentinel marker for prompting discussions centered on promotion of cardiovascular risk stratification and modification."

Dr. Heidelbaugh has disclosed no relevant financial relationships.

Am Fam Physician. 2010;81:305-312. Abstract

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