ERECTILE DYSFUNCTION (ED)






penile erection


  • Reference [4]
Age (years) % of population reporting ED
< 40 1 - 10%
40 - 49 2 - 15%
50 - 59 6 - 35%
60 - 69 20 - 40%
≥ 70 50 - 100%




  • References [1,2,3,10]
NEUROLOGICAL
Causes Risk factors
Central nervous system dysfunction
  • Multiple sclerosis
  • Spinal cord injury
  • Stroke
  • Parkinson disease
  • Alzheimer's
Peripheral nervous system dysfunction
  • Diabetic neuropathy
  • Peripheral neuropathy
  • History of pelvic irradiation or surgery
  • Prostatectomy - occurs in 25 - 75% of men after surgery
VASCULAR
Causes Risk factors
Endothelial dysfunction (decreased nitric oxide release)
  • Advancing age
  • Atherosclerosis
  • High cholesterol
  • Diabetes
  • Hypertension
  • Obesity
  • Sedentary lifestyle
  • Benign prostatic hypertrophy
  • Smoking
PSYCHOLOGICAL
Causes Risk factors
Past issues
  • History of trauma
  • History of sexual abuse
  • Strict upbringing
  • Guilt
Current issues
  • Depression
  • Anxiety
  • Relationship problems
  • Major life event - childbirth, job loss, etc.
ENDOCRINOLOGICAL
  • Hypogonadism (low testosterone)
  • Hyperprolactinemia
  • Hyper- and hypocortisolism (Cushing's disease, Addison's disease)
  • Hypothyroidism
  • Diabetes
OTHER
  • Peyronie's disease
  • Hypospadias, epispadias
  • Cavernous fibrosis
  • Alcohol abuse
  • Illicit drug use (ex. cocaine, THC, amphetamines)




  • Reference [1,2,3,10]
MEDICATIONS ASSOCIATED WITH ED
Drug class Medication examples
Antiandrogens
  • Finasteride (Proscar®, Propecia®)
  • Flutamide
  • GnRH agonists - leuprorelin, triptorelin, goserelin
  • Ketoconazole
  • Spironolactone
  • H₂ blockers (famotidine, cimetidine, etc.)
Anticholinergic medications
Antidepressants
  • SSRIs (fluoxetine, paroxetine, etc.)
  • SNRIs (venlafaxine, etc.)
  • Tricyclic (amitriptyline, etc.)
Blood pressure medications
Butyrophenones
  • Haloperidol (Haldol®)
  • Droperidol
  • Domperidone
Cholesterol
medications
Cytotoxic
medications
Heart medications
  • Amiodarone (Cordarone®)
  • Digoxin
  • Disopyramide
Interferon
  • PegIntron®
  • Pegasys®
Phenothiazines
  • Promethazine
  • Prochlorperazine
  • Thioridazine
Steroids




Finding Considerations
Patient reports rigid erections in the morning, nighttime, or during sexual thoughts
  • Probable psychogenic ED
ED has sudden onset or is intermittent
  • Probable psychogenic ED
Patient reports lower urinary tract symptoms
  • Consider BPH
  • Examine prostate
  • PSA when indicated
Risk factors for vascular disease
  • Check lipid profile
  • Screen for diabetes
  • Measure blood pressure
Hypothyroid symptoms
  • Measure TSH
Low testosterone symptoms















Lifestyle therapy vs None for ED, JAMA (2004) [PubMed abstract]
  • A trial in the JAMA enrolled 110 obese men with erectile dysfunction
Main inclusion criteria
  • BMI ≥ 30
  • Age 35 - 55 years
  • ED defined as score ≤ 21 on IIEF scale
Main exclusion criteria
  • Diabetes or glucose intolerance
  • Hypertension
  • Cardiovascular disease
  • Prostate disease
  • Neuropathy
  • Psychiatric problems
  • Impaired renal function
Baseline characteristics
  • Average age 43 years
  • Average weight - 224 lbs (102 kg)
  • Average BMI - 37
  • Average IIEF score - 14
Randomized treatment groups
  • Group 1 (55 patients) - Intensive lifestyle therapy (detailed diet and exercise program)
  • Group 2 (55 patients) - Given general advice about weight loss (control group)
  • The intensive lifestyle therapy group met with a dietician and trainer monthly during the first year and bimonthly during the second year
Primary outcome: Erectile function measured with the International Index of Erectile Function (IIEF) scale (the IIEF scale runs from 5 - 25; a score of 17 - 21 indicates mild ED; 12 - 16 mild-to-moderate ED; 8 - 11 moderate ED; 5 - 7 severe ED), levels of cholesterol and triglycerides, circulating levels of interleukin 6, interleukin 8, and C-reactive protein, and endothelial function as assessed by vascular responses to L-arginine (a surrogate marker for penile vascular function)
Results

Duration: 2 years
Outcome Lifestyle therapy Control Comparisons
Average weight loss 33 lbs 4.4 lbs Diff 13 kg, 95%CI [-18 to -11], p=0.007
Average IIEF score 17 13.6 Diff 3, 95%CI [1.2 to 4.8], p=0.008
IIEF score ≥ 22 17 3 p=0.001
  • Response to L-arginine was significantly improved in the lifestyle group when compared to the control group (p=0.02)
  • All other outcomes (except interleukin 8) were significantly better in the lifestyle group

Findings: Lifestyle changes are associated with improvement in sexual function in about one third of obese men with erectile dysfunction at baseline.