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KEY CONCEPTS

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KEY CONCEPTS

  • Image not available. The incidence of erectile dysfunction is low in men younger than 40 years of age. The incidence increases as men age likely as a result of concurrent medical conditions that impair the vascular, neurologic, psychogenic, and hormonal systems necessary for a normal penile erection.

  • Image not available. Many commonly used drugs have sympatholytic, anticholinergic, sedative, or antiandrogenic effects that may exacerbate or contribute to the development of erectile dysfunction. Clinicians should be familiar with these agents and be prepared to make adjustments in drug regimens to minimize adverse effects of these drugs on a patient’s erectile function.

  • Image not available. The first step in clinical management of erectile dysfunction is to identify and, if possible, reverse the underlying causes. Risk factors for erectile dysfunction, including hypertension, diabetes mellitus, smoking, and chronic ethanol abuse, should be addressed and minimized.

  • Image not available. Specific treatments for erectile dysfunction include vacuum erection devices (VEDs), pharmacologic treatments, psychotherapy, and surgery. Of these, phosphodiesterase type 5 inhibitors are the medications of first choice.

  • Image not available. The ideal treatment of erectile dysfunction should have a fast onset, be effective, be convenient to administer, be cost effective, have a low incidence of serious adverse effects, and be free of serious drug interactions.

  • Image not available. Specific treatment is first initiated with the least invasive forms of treatment, including VEDs or oral phosphodiesterase type 5 inhibitors, followed by intracavernosal injections or intraurethral inserts, and finally by surgical insertion of a penile prosthesis.

  • Image not available. Vacuum erection devices can have a slow onset of action (up to 20 minutes) during initial use and are not discreet; therefore, they are most effective for a couple in a stable relationship.

  • Image not available. Although phosphodiesterase type 5 inhibitors are convenient and effective regardless of the etiology of erectile dysfunction, they fail in 30% to 40% of patients. Also, phosphodiesterase type 5 inhibitors are contraindicated in patients taking any dosage formulation of nitrate.

  • Image not available. Testosterone supplementation should be reserved for patients with primary, secondary, or mixed hypogonadism who have erectile dysfunction as a consequence of a decreased libido. Testosterone supplementation should not be used by patients with erectile dysfunction who have normal serum testosterone levels.

  • Image not available. Although intracavernosal injections and intraurethral pellets of alprostadil are effective independent of the etiology of erectile dysfunction, they fail in up to one third of patients. To self-administer medication by these routes, patients require training to minimize administration-related adverse effects.

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The National Institutes of Health Consensus Development Panel on Impotence defines erectile dysfunction as the persistent failure to achieve a penile erection to allow for satisfactory sexual intercourse.1 A persistent failure refers to erectile dysfunction for a minimum of3 months.2 Patients may refer to it as impotence.

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Erectile dysfunction must be distinguished from disorders of libido or ejaculation, and infertility, which are caused by different pathophysiologic mechanisms and are treated with alternative agents (Table 83-1). A patient may suffer from one or more disorders of sexual dysfunction. For example, an elderly man with primary hypogonadism may ...

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