Treatment of Erectile Dysfunction (ED)

Basic definition and background of Erectile Dysfunction:

Erectile Dysfunction is the inability to achieve and/or maintain an erection satisfactorily for sexual intercourse. It is an incredibly common problem in the United States; there are an estimated 30 million men who suffer from ED, with up to 52% of men aged 40 to 70 experiencing some degree of ED and increasing rates with age. Causes of ED are divided into organic (ie vascular, neurologic, hormonal, or structural), psychogenic, or mixed etiologies, with roughly 80% of men with ED having an organic cause.

Relevance of ED to primary care:

The relevance of ED to primary care is profound, as ED adversely affects patients’ quality of life, relationships, and personal self-esteem. ED is also seen a variety of common medical conditions (see table). ED can also be a sign of an underlying illness such as those named above; in fact, up to 60% of healthy patients presenting with ED were found to have abnormal cholesterol levels, and 15% of healthy patients with ED had elevated blood glucose levels.

Treatment of ED as a primary care physician:

Firstly, as with any encounter, a thorough medical and sexual history, and physical examination should be conducted. Many patients will not volunteer information about their ED; directed questions such as “Are you satisfied with your sexual function and relationship?” should be asked. Standard questionnaires, such as the International Index of Erectile Function (IIEF) or the abbreviated Sexual Health Inventory for Men (SHIM, see chart below), can be used to effectively screen for ED or to elucidate the nature of sexual dysfunction. Relevant lab studies (CBC, Chemistry panel, UA, Lipid profile, Thyroid function, and Testosterone level) should also be examined.

Once ED has been established and discussed with the patient, initial management should follow along the following steps:

1. Etiology should be assessed and addressed – Possible underlying medical, hormonal, or other problems should be optimally managed and relevant medications should be changed or discontinued.

2. Lifestyle modification – diet, exercise, stress reduction, eliminating alcohol and drug intake, and smoking cessation.

3. First-line therapy – oral pharmologic agents (1st line oral agents are phosphodiesterase-5 inhibitors, which have reported success rates of 69%, other oral agents include Yohimbine, Phentolamine, L-arginine, Apo-morphine), vacuum constriction devices, and sexual or couples therapy.

4. Second line therapy – intraurethral alprostadil (MUSE), intracavernosal self-injection of alprostadil; Referral to a specialist.

5. Third-line therapy – surgical prosthesis or other necessary surgery.

Adverse effects of Phosphodiesterase-5 Inhibitors:

Important considerations for the primary care physicians to remember when prescribing phosphodiesterase-5 inhibitors, such as Viagra, Cialis, and Levitra, include side-effect profile. The most common side effects are headache (15%), facial flushing (14%), nasal congestion (4%), dizziness (2%), and visual disturbances (2%). These adverse reactions are generally not severe enough to cause discontinuation.

Response rate to Phosphodiesterase-5 Inhibitors:

Response rate to the drug should occur within 3-4 uses. If there is inadequate response, the dose should be titrated upwards, or additional uses up to 6-8 times should be considered. If failure of therapy persists, referral to a specialist should be considered.

When to refer to a specialist?

Primary care physicians should consider referral to a specialist at any point where they feel lack of comfort with treatment/management. In general, indications for referral include failure of oral pharmacologic therapy/1st line therapy as aforementioned, patients with complex etiologies (such as Peyronie’s disease, history of pelvic/perineal trauma), or young patients who have never achieved erection, which suggests primary ED.

Tables:

SHIM Score: >22 no ED, 17-21 Mild ED, 12-16 Mild-Moderate ED, 8-11 Moderate, <7>

References:

Category: Medicine Notes , Psychiatry Notes , Surgery Notes