TOC |  Kidney
Erectile Dysfunctions (ED)            REF: PIER ACP Online 2005  |  ED2007.pdf  

Determine the severity of ED as being mild, moderate, or severe/complete:

• Mild: a minimally decreased ability to attain and/or maintain an erection with intermittent satisfactory sexual performance
• Moderate: an intermediately decreased ability to attain and/or maintain an erection with infrequent satisfactory sexual performance
• Severe: a substantially decreased ability to attain and/or maintain an erection with rare or absent satisfactory performance

Categorize the cause according to whether there is

• a presumed psychological or interpersonal determinant (psychogenic);
• a specific endocrinologic, neurologic, or vascular cause (organic); or
• coexistence of psychological or relationship factors and organic causes (mixed).     

History and Physical Examination Elements for Erectile Dysfunction

History

1. ED history - Inquire about onset, duration, evolution, severity, cause, stimulus required for achievable erections; simple, patient-administered, validated questionnaires recently have been developed for easy use by physicians in clinical settings (4; 8)
2. Cardiovascular disorders  - Look for hypertension, hyperlipidemia, diabetes mellitus, atherosclerosis, peripheral vascular disease, and cigarette use
3. Neurogenic disorders  - Look for diabetes mellitus, cerebrovascular accidents, Parkinson's disease, and multiple sclerosis
4. Endocrine disorders - Look for hypogonadism, hyperprolactinemia, hyperthyroidism, and hypothyroidism
5. Penile disorders - Peyronie's disease, priapism
6. Injuries  - Particularly perineal, pelvic, or nervous system trauma and radiation or surgery to the pelvis or retroperitoneum
7. Psychosocial elements - Ask about potential stresses, interpersonal relationship problems, and affective disorders
8. Medications - Look for antihypertensives, antidepressants, antiandrogens, and NSAIDs. (See table Medication Associated in the Literature with Erectile Dysfunction). Medications are estimated to play a role in up to 25% of cases of ED (10)
9. Substances of abuse - Ask about alcohol, tobacco, and recreational drugs; drugs like cocaine, opiates, and marijuana have CNS depressant effects and vasoconstrictor actions that can decrease local blood flow to the penis

Physical exam

1. Height and weight - May be helpful in identifying congenital disorders that may be accompanied by ED
2. BP - Looking for hypertension as a risk factor for vascular disease
3. Vascular exam - Palpate femoral and pedal pulses to look for evidence of vascular disease
4. Neurological exam - Evaluate genital and perineal sensation and bulbocavernosus reflex
5. Endocrine exam - Evaluate thyroid gland for masses or other abnormalities, breasts for gynecomastia, general masculine development, and hair distribution
6. Genital exam - Look for penile deformities, such as micropenis, chordee, and Peyronie's disease (fibrous plaques in the corpora cavernosa); evaluate position, size, and consistency of the testes
7. Prostate exam - Evaluate size, consistency, and presence of nodules or induration; this portion of the exam is performed as needed based on the patient's age and relative risk status for prostate disease (e.g., prostate cancer) that might be stimulated by exogenously administered testosterone

Medications Associated with Erectile Dysfunciton

• Anxiolytic drugs: Clonazepam, Oxazepam, Oxazolam, Secobarbital, Butabarbital, Phenobarbital, Pentobarbital, Diazepam, Temazepam, Lorazepam, Fenfluramine, Triazolam, Meprobamate, Alprazolam , Chlordiazepoxide, Amoxapine , Flurazepam
• Anti-depressants: Imipramine, Nortriptyline, Paroxetine (Paxil), Fluoxetine,  Lithium, Doxepin ,Trazodone, Amitriptyline, Desipramins (Norpramin)  
• Anti-psychotics: Perphenazine, Trifluoperazine, Chlorpromazine  (Thorazine), Clomipramine (Anafranil),  Fluphenazine, Haloperidol  
• Diiuretics: Bumetanide, Chlorthalidone, Hydrochlorothiazide,  Indapamide, Spironolactone ,Acetazolamide ,Amiloride
• Beta-blockers: Atenolol, Acebutolol, Nadolol, Propranolol ,Sotalol, Labetalol ,Timolol, Acebutolol ,Bisoprolol, Pindolol , Metoprolol  
• Alpha-blockers: Hydralazine, Reserpine, Terazosin, Prazosin
• Anti-adrenergic agents: Clonidine, doxazosin, guanabenz, guanfacine, methyldopa, prazosin, reserpine, terazosin  
• Calcium blockers: Nifedipine, Felodipine, Verapamil
• ACE Inhibitors: Captopril, Ramipril, Lisinopril ,Enalapril
• BP Meds: Methyldopa Minoxidil Guanidine
• Cholesterol meds: Simvastatin, Fenofibrate, Clofibrate, Gemfibrozil  
• Anti-arrhythmics: Flecainide, Amiodarone, Digoxin, Mexiletine
• Anti-Histamine blockers: Phenergan/Promethazine, Hydroxyzine , cimetidine, ranitidine, Famotidine
• Proton Pump Inhibitors: Omeprazole
• NSAIDs: Naproxen. Indometacin Diclofenac
• Analgesics & Narcotics : Hydromorphone, Oxycodone , Methadone ,Morphine
• Decongestants: Pseudophedrine, Oxymetazoline, Ephedrine
• Anticholinergics: Hyoscyamine, Scopolamine, Oxybutynin, Atropine
• Muscle Relaxants: Orphenadrine (Norflex), Cyclobenzaprine (Flexeril) , Baclofen  
• Anti-fungal meds: Itraconazole ,Ketoconazole
• Migraine meds: Dihydroergotamine, Ergotamine Methysergide
• Seizure meds: Carbamazepine (Tegretol),  Phenytoin
• Others: Allopurinol , Busulfan , Cortisol, Tamoxifen  Disulfiram Testosterone  Medroxyprogesterone, Finasteride

Republished with permission from Meinhardt W, Kropman RF, Vermeij P, Lycklama A, Nijehold AAB, and Zaartendiijk J. The influence of medication on erectile function. Int J Impot Res. 1997;9:17-26.

Laboratory and Other Studies for Erectile Dysfunction

1. Serum chemistries  - May be useful in confirming clinical suspicion of underlying chronic diseases (e.g., diabetes, renal insufficiency, liver disease)
2. CBC - May be useful in confirming clinical suspicion of underlying chronic disease
3. Testosterone (total) - A fasting morning level is recommended to screen androgenic status;
   if the level is low (suspected of hypogonadism), measure serum free (or bioavailable) testosterone, prolactin, and leuteinizing hormone (LH);
   If the prolactin level is elevated and/or the LH level is not elevated, then Brain MRI should be obtained to rule out a pituitary adenoma.
4. Thyroid function tests - To confirm clinical suspicion of thyroid dysfunction, which may underlie ED
5. Lipid profile - Looking for hyperlipidemia in suspected cardiovascular disease
6. PSA - Serum PSA testing is performed as needed if prostate pathology is suspected, which may be stimulated by exogenously administered testosterone
7. Urinalysis - Dipstick analysis may reveal glucosuria, suggesting diabetes mellitus

Treatment:

Non drug therapy: Offer psychosexual therapy or counseling (optimally, for the patient and his partner) for both organic and psychogenic presentations of dysfunction.

Drug Treatment for Erectile Dysfunction

Sildenafil citrate (Viagra)

• Phosphodiesterase  (PDE) Type 5 inhibition that preserves cGMP-induced corporal smooth muscle relaxant effects 2
• 5, 50, 100 mg po 1 hour before sexual activity
• Headaches (16%), flushing (10%), dyspepsia (7%), nasal congestion (4%), visual disturbances (3%)
• Presence of sexual stimulation is required for efficacy; first-line therapy; FDA-approved oral therapy (22);
• Contraindicated in men who receive nitrate therapy in any form that, in combination, may produce severe hypotension

Vardenafil hydrochloride (Levitra)

• Type 5 phosphodiesterase inhibition that preserves cGMP-induced corporal smooth muscle relaxant effects
• 5, 10, 20 mg po 1 hour before sexual activity
• Headaches (15%), flushing (11%), rhinitis (9%), dyspepsia (4%)
• Presence of sexual stimulation is required for efficacy; first-line therapy; FDA-approved oral therapy (26);
• Contraindicated in men who receive nitrate therapy in any form & alpha-blockers that, in combination, may produce severe hypotension

Tadalafil (Cialis)

• Type 5 phosphodiesterase inhibition that preserves cGMP-induced corporal smooth muscle relaxant effects
• 2.5, 5, 10, 20 mg po 1 hour before sexual activity
• Headaches (14%), dyspepsia (10%), back pain (6%), rhinitis (5%), myalgia (5%), flushing (4%)
• Presence of sexual stimulation is required for efficacy; first-line therapy; FDA-approved oral therapy;
• Contraindicated in men who receive nitrate therapy in any form & alpha-blockers that, in combination, may produce severe hypotension

Alprostadil (MUSE) Prostaglandin E1

• Stimulates production of cAMP, which induces corporal smooth muscle relaxant effects
• 125, 250, 500, 1000 µg, intraurethrally
• On-demand use; limited systemic effects
• Local urogenital pain (29%), minor urethral bleeding (5%), dizziness (4%), hypotension (3%)
• In-office instruction and titration are highly recommended; second-line therapy; contraindicated for patients with history of priapism

Alprostadil (Prostin VR, Caverject, Edex)  Prostaglandin E1  

• Stimulates production of cAMP, which induces corporal smooth muscle relaxant effects
• 5-60 µg, intracavernously
• On-demand use; limited systemic effects
• Priapism (1%), penile fibrosis (5%-10%), penile pain (10%)
• In-office instruction and titration are highly recommended; intracavernous drug mixtures also contain papaverine and phentolamine in varying combinations with alprostadil; second-line therapy; FDA-approved for penile injection; contraindicated for patients with history of priapism severe coagulopathy

Testosterone Replacement  

• In hypogonadal men, combining PDE-5 inhibitor Rx with testosterone is often effective.
• Moreover, testosterone replacement alone increases sexual interest, nocturnal erections, & fequency of sexual intercourse.
• Nevereless, testosterone replacement has not been shown to improve erectile function in men with normal serum testosterone levels.
• Does testosterone have a role in the treatment of Erectile Dysfunction?    

Drug therapy for Premature Ejaculation:

Consider Prazac (Fluoxetine) 10-40 mg/d, max 80 mg/d, Paxil (Paroxetine) 10-40 mg/d, max 50 mg/d, Dapoxetine ?

2008