COMMENTARY

Erectile Dysfunction: Small Symptoms, Big Consequences

Richard M. Plotzker, MD

Disclosures

June 16, 2020

Like many other gatherings at the forefront of medicine, ENDO 2020, the annual meeting of the Endocrine Society, gave way to a virulent microbe. Traditionally, posters outlining various groups' research studies dominate this meeting. Those in attendance wander among the posters and glance at the titles, and when one catches the viewer's attention, there is usually a person who will happily guide the viewer through the protocol and results. This interaction won't occur this year, but many of the research summaries have been made available.

One study that has received some publicity originated in Belgium. It is a component of a survey of 1913 men from the European Male Ageing Study who had been assessed clinically from 2003 to 2005. In the subsequent 15 years, 25% of the men at sites that kept ongoing survival data died. On review of premorbid data, impairment of sexual function — either by laboratory or by symptoms — seemed to predict reduced longevity.

Doctors like to be able to predict the future. In the short term, for individuals, we do pretty well. With COVID-19, for example, we can quickly assess who can be sent home from the emergency department with reassurance and instructions to quarantine after what is often a brief encounter. Experienced physicians can look at chest images, pulse oxygen values, and symptoms, and very quickly determine who will need intensive care.

We do fairly well with populations, learning over time that diabetes, hypertension, and hyperlipidemia shorten longevity. We do less well in selecting individuals within a risk group, opting to treat everyone with certain clinical parameters similarly.

Symptoms, Not Labs

Using data collected 18 years earlier with the destiny of the participants known, the reviewers of this study looked in reverse for observable findings that might portend a less favorable outcome. The data revealed clues related to male sexual function that are easily adaptable to periodic office care. Total testosterone did not predict outcome unless it was unusually low. Compensatory FSH rise also only became predictive in the highest quartile of participants. There was some predictability to LH elevations (5.7 ± 3.3 U/L in those who died), but such levels probably would not stand out in an office visit.

What would catch the attention of clinicians are the symptoms. The best predictors of mortality seemed to be self-reported erectile dysfunction and poor AM erectile function. Self-reported libido did not differ among those who survived and those who did not. The men in the study were asked about this as part of the research protocol and therefore consistently elicited symptoms. In an office setting, this can be hit-or-miss and is usually subordinate to other history or review of systems obtained in a clinical encounter.

Men with diabetes — for whom sexual symptoms may provide a clue of vascular disease elsewhere — are typically asked about this at office follow-up. With hypertension being a universally accepted risk factor for vascular disease, a fair number of people with or without diabetes lose sexual function in response to antihypertensive medicine.

In an unselected group of men seeking periodic health assessment, however, blood pressure, anginal symptoms, and cholesterol are assessed while the more subtle sexual symptoms become review-of-systems negative. And once identified, there is no consensus on how aggressively to pursue the possibility of concurrent but silent vascular disease elsewhere.

Although the COVID-19 experience has forced us into patient care from remote sites, we can at least still question our patients as they convey symptoms and respond to our questions. That is not the case for the burgeoning number of websites offering prescriptions for PDE5 inhibitors on the basis of a computerized questionnaire, by a contracted physician with authority to write prescriptions with a commercial incentive to provide the medicine. This postmortality analysis of preexisting sexual function, predictable more by symptoms than by lab testing, suggests that this practice of simply suppressing symptoms without further consideration of cause may not be in the best interest of the growing number of men who seek it.

Richard M. Plotzker, MD, is a retired endocrinologist with 40 years of experience treating patients in both private practice and hospital settings. He has been a Medscape contributor since 2012.

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