erectile dysfunction (ED)
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Introduction
Inability to achieve or maintain erection sufficient to initiate & complete satisfactory intercourse. It is clinically relevant if it occurs > 50% of attempts at sexual activity or persists for > 3 months. (see impotence)
Etiology
- 60% organic etiology
- vasculogenic (54% of men over 65 years of age[2])
- neurologic
- hormonal
- smooth muscle abnormalities
- obesity may be risk factor due to endothelial dysfunction[4]
- ED may be a manifestation of metabolic syndrome X[6]
- ED may be a harbinger of cardiovascular disease[7]
- pelvic/peritoneal trauma
- radiation or surgery in the pelvis, retroperitoneum[1]
- Peyronie's disease[2], if painful, most likely cause of ED
- hemochromatosis[34]
- 40% psychogenic
- interpersonal relationship problems
- mood disorders
- affective disorders
- risk factors[8]
- diabetes mellitus[25]
- dulaglutide (Trulicity) may reduce risk of ED. but does not improve pre-existing ED[29]
- vascular disease, smoking
- hypertension
- treatment of prostate cancer (HR=1.5)[14]
- age
- diabetes mellitus[25]
- drug-induced erectile dysfunction (see impotence)
- 5-alpha reductase inhibitors not a common cause of ED[24]
- in the real world, dustateride can cause erectile dysfunction that may persist long after discontinuation[31]
Epidemiology
- affects 20 million men 40-70 years of age
- 52% of men 40-70 years of age
- 67% of men by age 70, 78% of men > age 75
- 64% of men with myocardial infarction
Laboratory
- laboratory evaluation in the absence of findings suggestive of systemic disorder is not indicated[1]
- low 8 AM serum testosterone & high serum LH associated with erectile dysfunction[11]
- confirm low 8 AM serum testosterone prior to obtaining serum LH[1]
- complete blood count (CBC)
- iron studies
- serum ferritin (rule out hemochromatosis)
Diagnostic procedures
- cardiac stress testing if symptoms consistent with cardiovascular disease[1]
Complications
- erectile dysfunction is a harbinger of cardiovascular disease in some men[1][16]
- disease interaction(s) of depression with erectile dysfunction
- disease interaction(s) of erectile dysfunction (ED) with diabetes mellitus type-2
- disease interaction(s) of erectile dysfunction (ED) with psoriasis
- disease interaction(s) of obstructive sleep apnea (OSA) with erectile dysfunction (ED)
Management
- discontinuation of offending agents (see impotence)
- cardiovascular risk assessment for at risk patients
- stress testing for at risk patients
- 5 METS without ischemia defines low risk[1]
- life style changes treating cardiovascular risk factors & modulating endothelial nitric oxide synthase can improve ED
- smoking cessation
- physical activity & conditioning (exercise)
- healthy diet
- benefit likely through cardiovascular risk reduction[27]
- dietary flavonoids may reduce risk (RR=0.9)[20]
- weight reduction
- statin for dyslipidemia not responsive to life-style changes
- psychosocial therapy or counseling for both organic & psychogenic ED
- psychotherapy for dysfunctional relationships, anger, depression
- bupropion suggested to treat depression & erectile dysfunction (NEJM)[35]
- phosphodiesterase-5 inhibitor (PDE-5 inhibitor)
- sildenafil (Viagra), vardenafil, tadalafil, avanafil others
- some OTC supplements contain compounds that appear to inhibit phosphodiesterase 5 (not recommended)[9]
- coadministration of alpha-blockers or nitrates may lead to profound hypotension
- coadministration of nitrates contraindicated
- elderly may be prescribed PDE-5 inhibitor with nitroglycerin provided cautioned not to take sildenafil within 24 hours of nitroglycerin use despite history of myocardial infarction or attendance in cardiac rehabilitation provided no cardiac symptoms at 3-4 METs[2]
- coadministration of alpha-blockers with caution[1]
- coadministration of nitrates contraindicated
- placebo effect of phosphodiesterase-5 inhibitors is small to moderate[26]
- better survival with PDE5 inhibitors for ED in patients with stable coronary artery disease[28]
- FDA approves OTC topical gel Eroxon for erectile dysfunction[36]
- can help users get an erection within 10 minutes
- PDE-5 inhibitor contraindicated
- alprostadil
- intraurethral pellet
- intracavernosal injection
- contraindications: priapism, coagulopathy
- papaverine or phentolamine intracavernosal injection
- vacuum constriction device, Erectaid Pump
- penile prosthesis
- alprostadil
- androgens
- of little or no benefit[1]
- testosterone replacement if testosterone is low[2]
- testosterone replacement of no benefit when added to sildenafil[15]
- platelet-rich plasma injections of no benefit for erectile dysfunction[37]
- penile revascularization is not recommended (MKSAP19)[1][5]
- risk-stratified guidelines for treatment of ED
- low-risk
- criteria
- asymptomatic & < 3 major cardiac risk factors
- controlled hypertension
- mild stable angina
- s/p successful PCI
- s/p MI > 6-8 weeks prior
- mild valvular heart disease
- NYHA class 1 heart failure
- recommendation:
- sexual activity OK
- may treat with PDE-5 inhibitor unless using nitrate
- criteria
- intermediate risk
- criteria
- asymptomatic & >= 3 major cardiac risk factors
- moderate stable angina
- recent MI, 2-6 weeks prior
- LVEF < 40% or NYHA class 2 heart failure
- peripheral arterial disease
- history of TIA or stroke
- recommendation
- cardiac stress testing & restratification prior to further sexual activity or treatment for ED
- criteria
- high risk
- criteria
- unstable angina or refractory angina
- uncontrolled hypertension
- NYHA class 3 or 4 heart failure
- recent MI < 2 weeks prior
- high-risk arrhythmia
- obstructive cardiomyopathy
- moderate to severe vavlular heart disease, especially aortic stenosis
- recommendation
- defer sexual activity or ED treatment until after cardiac condition has stabilized & risk has diminished
- criteria
- low-risk
* major cardiac risk factors
- hypertension, diabetes mellitus, smoking, dyslipidemia, sedentary lifestyle, familty history of premature CAD
More general terms
More specific terms
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18. 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2022.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 2.0 2.1 2.2 2.3 2.4 Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 286
- ↑ 4.0 4.1 Journal Watch 24(15):119-120, 2004 Esposito K, Giugliano F, Di Palo C, Giugliano G, Marfella R, D'Andrea F, D'Armiento M, Giugliano D. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial. JAMA. 2004 Jun 23;291(24):2978-84. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15213209
Saigal CS. Obesity and erectile dysfunction: common problems, common solution? JAMA. 2004 Jun 23;291(24):3011-2. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15213216 - ↑ 5.0 5.1 Management of Erectile Dysfunction American Urologic Association http://www.auanet.org/guidelines/edmgmt.cfm
- ↑ 6.0 6.1 Internal Medicine News 20(8)2005 cites R Shabsigh & data form the Massachussets Male Aging Study
- ↑ 7.0 7.1 Thompson IM et al, Erectile dysfunction and subsequent cardiovascular disease JAMA 2005; 294:2996
- ↑ 8.0 8.1 Saigal CS et al, Predictors and prevalence of erectile dysfunction in the primary care setting: Importance of risk factors for diabetes and vascular disease Arch Intern Med 2006; 166:207 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16432090
Grover SA et al, T he prevalence of erectile dysfunction in the primary care setting: Importance of risk factors for diabetes and vascular disease. Arch Intern Med 2006; 166:213 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16432091
Min JK et al, Prediction of coronary heart disease by erectile dysfunction in men referred for nuclear stress testing Arch Intern Med 2006; 166:201 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16432089 - ↑ 9.0 9.1 Prescriber's Letter 13(9): 2006 FDA Warns Consumers About Dangerous Ingredients in 'Dietary Supplements' Promoted for Sexual Enhancement Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=220906&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Prescriber's Letter 13(9): 2006 Drugs That May Cause Male Sexual Dysfunction Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=220907&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 11.0 11.1 Kupelian V, Shabsigh R, Travison TG, Page ST, Araujo AB, McKinlay JB. Is there a relationship between sex hormones and erectile dysfunction? Results from the Massachusetts Male Aging Study. J Urol. 2006 Dec;176(6 Pt 1):2584-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17085164
- ↑ Qaseem A et al Hormonal Testing and Pharmacologic Treatment of Erectile Dysfunction: A Clinical Practice Guideline From the American College of Physicians Ann Intern Med. 2009 Nov 3;151(9):639-49 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19884625 <Internet> http://www.annals.org/content/151/9/639.full
Tsertsvadze A et al Oral Phosphodiesterase-5 Inhibitors and Hormonal Treatments for Erectile Dysfunction: A Systematic Review and Meta-analysis Ann Intern Med. 2009 Nov 3;151(9):650-61 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19884626 <Internet> http://www.annals.org/content/151/9/650.full - ↑ Gupta BP et al The Effect of Lifestyle Modification and Cardiovascular Risk Factor Reduction on Erectile Dysfunction: A Systematic Review and Meta-analysis Arch Intern Med. Published online September 12, 2011 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21911624 <Internet> http://archinte.ama-assn.org/cgi/content/abstract/archinternmed.2011.440
- ↑ 14.0 14.1 Alemozaffar M et al. Prediction of erectile function following treatment for prostate cancer. JAMA 2011 Sep 21; 306:1205. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21934053
Barry MJ. Helping patients make better personal health decisions: The Promise of Patient-Centered Outcomes Research. JAMA 2011 Sep 21; 306:1258. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21934062 - ↑ 15.0 15.1 Spitzer M et al Effect of Testosterone Replacement on Response to Sildenafil Citrate in Men With Erectile Dysfunction: A Parallel, Randomized Trial Ann Intern Med. 20 November 2012;157(10):681-691 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23165659 <Internet> http://annals.org/article.aspx?articleid=1391696
Greco EA, Spera G, Aversa A. Combining testosterone and PDE5 inhibitors in erectile dysfunction: basic rationale and clinical evidences. Eur Urol. 2006 Nov;50(5):940-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16979814 - ↑ 16.0 16.1 Schwartz BG, Kloner RA Clinical cardiology: physician update: erectile dysfunction and cardiovascular disease. Circulation. 2011 Jan 4;123(1):98-101 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21200016
- ↑ Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Pena BM. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999 Dec;11(6):319-26. PMID: https://www.ncbi.nlm.nih.gov/pubmed/10637462
- ↑ Albersen M, Orabi H, Lue TF. Evaluation and treatment of erectile dysfunction in the aging male: a mini-review. Gerontology. 2012;58(1):3-14. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21912081
Albersen M, Mwamukonda KB, Shindel AW, Lue TF. Evaluation and treatment of erectile dysfunction. Med Clin North Am. 2011 Jan;95(1):201-12. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21095423 - ↑ Heidelbaugh JJ. Management of erectile dysfunction. Am Fam Physician. 2010 Feb 1;81(3):305-12. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20112889
- ↑ 20.0 20.1 Cassidy A, Franz M, Rimm EB Dietary flavonoid intake and incidence of erectile dysfunction. Am J Clin Nutrition Jan 13, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26762373 <Internet> http://ajcn.nutrition.org/content/early/2016/01/06/ajcn.115.122010.full.pdf+html
- ↑ Bacon CG, Mittleman MA, Kawachi I et al Sexual function in men older than 50 years of age: results from the health professionals follow-up study. Ann Intern Med. 2003 Aug 5;139(3):161-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/12899583
- ↑ Beckman TJ, Abu-Lebdeh HS, Mynderse LA. Evaluation and medical management of erectile dysfunction. Mayo Clin Proc. 2006 Mar;81(3):385-90. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16529142
- ↑ Nehra A, Jackson G, Miner M et al The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc. 2012 Aug;87(8):766-78. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22862865 Free PMC Article
- ↑ 24.0 24.1 Hagberg KW, Divan HA, Persson R, Nickel JC, Jick SS. Risk of erectile dysfunction associated with use of 5-alpha reductase inhibitors for benign prostatic hyperplasia or alopecia: population based studies using the Clinical Practice Research Datalink. BMJ 2016;354:i4823 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27659058 Free Article <Internet> http://www.bmj.com/content/354/bmj.i4823
Roehrborn CG, Manyak MJ, Palacios-Moreno JM, et al. A prospective randomised placebo-controlled study of the impact of dutasteride/tamsulosin combination therapy on sexual function domains in sexually active men with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). BJU Int. 2018;121(4):647-658 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29044968 https://bjui-journals.onlinelibrary.wiley.com/doi/10.1111/bju.14057 - ↑ 25.0 25.1 Davenport L Type 2 Diabetes Could Be a Cause of Erectile Dysfunction. Medscape - Dec 26, 2018. https://www.medscape.com/viewarticle/906979
- ↑ 26.0 26.1 Stridh A, Ponten M, Arver S et al. Placebo responses among men with erectile dysfunction enrolled in phosphodiesterase 5 inhibitor trials: A systematic review and meta-analysis. JAMA Netw Open 2020 Mar 2; 3:e201423. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32196105 Free PMC Article
- ↑ 27.0 27.1 Bauer SR et al. Association of diet with erectile dysfunction among men in the Health Professionals Follow-up study. JAMA Netw Open 2020 Nov 2; 3:e2021701 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33185675 PMCID: PMC7666422 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772916.
- ↑ 28.0 28.1 Wilson FP Could Taking Viagra Come With an Extra Perk? Medscape - Mar 24, 2021. https://www.medscape.com/viewarticle/947851
Wendling P Better Survival With PDE5 Inhibitors for ED in Stable CAD Medscape - Mar 23, 2021 https://www.medscape.com/viewarticle/947982
Andersson DP, Landucci L, Lagerros YT et al Association of Phosphodiesterase-5 Inhibitors Versus Alprostadil With Survival in Men With Coronary Artery Disease. J Am Coll Cardiol. 2021 Mar, 77 (12) 1535-1550 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33766260 https://www.jacc.org/doi/10.1016/j.jacc.2021.01.045 - ↑ 29.0 29.1 Monoco K 'Modest' Erectile Dysfunction Benefit With GLP-1 Agonist. Dulaglutide didn't improve pre-existing symptoms, but did prevent some new cases. MedPage Today June 23, 2021 https://www.medpagetoday.com/endocrinology/diabetes/93250
Bajaj HS, Gerstein HC, Rao-Melacini P et al Erectile function in men with type 2 diabetes treated with dulaglutide: an exploratory analysis of the REWIND placebo-controlled randomised trial. Lancet Diabetes Endocrinol 2021. June 18 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34153269 https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00115-7/fulltext
Madsbad S Dulaglutide for erectile dysfunction in type 2 diabetes. Lancet Diabetes Endocrinol 2021. June 18 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34153270 https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00142-X/fulltext - ↑ Kim ED Erectile Dysfunction Medscape. Nov 2, 2020 https://emedicine.medscape.com/article/444220-overview#showall
- ↑ 31.0 31.1 Medical Knowledge Self Assessment Program (MKSAP) 18, American College of Physicians, Philadelphia 2018
Prescriber's Letter 20(3): 2013 Persistent Sexual Dysfunction with Finasteride and Dutasteride Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=290308&pb=PRL (subscription needed) http://www.prescribersletter.com - ↑ Burnett AL, Nehra A, Breau RH et al. Erectile Dysfunction: AUA Guideline. J Urol. 2018;200(3):633-641 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29746858 https://www.auajournals.org/doi/10.1016/j.juro.2018.05.004
- ↑ Irwin GM. Erectile dysfunction. Prim Care. 2019;46(2):249-255 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31030826 https://www.sciencedirect.com/science/article/abs/pii/S0095454319300090
- ↑ 34.0 34.1 NEJM Knowledge+ Gastroenterology
- ↑ 35.0 35.1 NEJM Knowledge+ Psychiatry
- ↑ 36.0 36.1 O'Mary L FDA Approves First-Ever OTC Erectile Dysfunction Gel. Medscape. June 13, 2023 https://www.medscape.com/s/viewarticle/993181
- ↑ 37.0 37.1 Masterson TA et al. Platelet-rich plasma for the treatment of erectile dysfunction: A prospective, randomized, double-blind, placebo-controlled clinical trial. J Urol 2023 Jul; 210:154. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37120727 PMCID: PMC10330773 (available on 2024-07-01) https://www.auajournals.org/doi/10.1097/JU.0000000000003481
- ↑ Erectile Dysfunction http://kidney.niddk.nih.gov/kudiseases/pubs/impotence/index.htm