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For the Chapter in the Schwinghammer, Handbook (not Wells Handbook anymore) please go to Chapter 81, Erectile Dysfunction.



  • image 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 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 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 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 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 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 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 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 Testosterone supplementation should be reserved for patients with primary, secondary, or mixed hypogonadism who have erectile dysfunction. Testosterone supplementation should not be used by patients with erectile dysfunction who have normal serum testosterone levels.

  • image Although intracavernosal injections and intraurethral pellets of alprostadil are effective and 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.


Preclass Engaged Learning Activity

Many medications may cause or worsen erectile dysfunction. Based on the physiology of a normal erection, create a table in which you identify various classes of medications that interfere with the hormonal, vascular, neurologic, or psychogenic factors that are essential for a normal penile erection. In a separate column, identify medications that are less likely to interfere with those physiologic factors and therefore have a ...

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