- 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.
- 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.
- 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.
- Specific treatments for erectile dysfunction include vacuum erection devices (VEDs), pharmacologic treatments, psychotherapy, and surgery. Of these, phosphodiesterase inhibitors are the medications of first choice.
- 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.
- Specific treatment is first initiated with the least invasive forms of treatment, including VEDs or oral phosphodiesterase inhibitors, followed by intracavernosal injections or intraurethral inserts, and finally by surgical insertion of a penile prosthesis.
- VEDs can have a slow onset of action (30 minutes) and are not discreet; therefore, they are most effective for a couple in a stable relationship.
- Although phosphodiesterase inhibitors are convenient and effective regardless of the etiology of erectile dysfunction, they fail in 30% to 40% of patients. Also, phosphodiesterase inhibitors are contraindicated in patients taking any dosage formulation of nitrate.
- Testosterone supplementation should be reserved for patients with primary or secondary 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.
- Although intracavernosal injections and intraurethral pellets of alprostadil are effective independent of the etiology of erectile dysfunction, they fail in one third of patients. To self-administer medication by these routes, patients require training to minimize administration-related adverse effects.
On completion of the chapter, the reader will be able to:
Explain the pathophysiology of erectile dysfunction.
Compare and contrast the mechanism of action, indications, and side effect profile of various medical treatments for erectile dysfunction.
List the factors that guide selection of a specific treatment for an individual patient.
Recommend an appropriate phosphodiesterase inhibitor based on a patient’s symptoms and history of erectile dysfunction.
List common reasons for phosphodiesterase inhibitor failure and strategies to optimize treatment response.
Identify the most common drug interactions of phosphodiesterase inhibitors and how to minimize clinically significant drug interactions in patients.
Differentiate among testosterone supplements according to their route of administration, advantages, and disadvantages.
Describe a monitoring plan for a patient who will receive a testosterone supplement in terms ...