SOAP. – Sexual Dysfunction, Male—Erectile Dysfunction

Cheryl A. Glass and Nancy Pesta Walsh

Definition

A.Erectile dysfunction (ED), also known as impotence, is the persistent inability to achieve or maintain penile erection sufficient for satisfactory sexual performance. ED occurs with reduced blood flow to the penis or nerve damage, as well as psychological triggers. Low self-esteem, performance anxiety, depression, stress, and effects to quality of life occur secondary to ED. ED is noted to be a precursor to symptomatic coronary artery disease (CAD).

B.Age-associated changes in sexual function in men include delay in erection, diminished intensity and duration of orgasm, and decreased force of seminal emission. ED lasting 3 months or longer should have further evaluation and consideration of treatment.

C.Multiple male sexual dysfunction questionnaires are available for order through the Pfizer Patient-Reported Outcomes website located at www.pfizerpatientreportedoutcomes.com/order-measures, sponsored by Pfizer, Inc. Charges may apply for commercial use. The questionnaires are available in several translations. Questionnaires include the following:

1.Erectile dysfunction inventory of treatment satisfaction (EDITS) used in the evaluation of satisfaction with medical treatment modalities for ED.

2.Erectile Hardness Scale (EHS) was developed to assess erection hardness in men with erectile dysfunction.

3.International Index of Erectile Function (IIEF) is available in two versions. Version 1 is applicable to heterosexual men. Version 2 is edited so that it is applicable to heterosexual and homosexual men. The IIEF assesses five dimensions relevant to sexual function:

a.Erectile function (six items).

b.Orgasmic function (two items).

c.Sexual desire (two items).

d.Intercourse satisfaction (three items).

e.Overall satisfaction (two items).

4.Index of Premature Ejaculation (IPE) assesses control over ejaculation, sexual satisfaction, and distress.

5.Premature Ejaculation Diagnostic Tool (PEDT) was developed to screen for premature ejaculation (PE), including control, frequency, minimal sexual stimulation, distress, and interpersonal difficulty.

6.Quality of Erection Questionnaire (QEQ) evaluates satisfaction with the quality of erections, including hardness, onset, and duration.

7.Self-Esteem and Relationship (SEAR) questionnaire assesses confidence.

8.Sexual Health Inventory for Men (SHIM) is a fiveitem abridged version of the 15-item IIEF.

9.Sexual Quality of Life-Men (SQOL-M) was developed to assess sexual confidence, emotional well-being, and relationship issues. This questionnaire has been validated for men with ED and premature ejaculation.

Incidence

A.ED can occur at any age; however, it is more common in men older than 60 years.

B.It is estimated that 15 to 30 million American men have ED.

C.By 2025 it is estimated that 322 million men worldwide will have ED.

D.Men with ED have a 65% to 85% increased risk of subsequent CAD.

E.Reduced libido is estimated as affecting 5% to 15% of men.

Pathogenesis

A.Normal pathology: The dorsal nerve of the penis provides innervation, the dorsal somatic nerve provides sensation, and the autonomic nervous system, via the cavernosal nerves, regulates blood flow to the penis, allowing for erection to occur. The ability to maintain an erection relies on the dorsal nerve, the peripheral nerves, penile vasculature, and biochemical releases within the corpora.

B.Multiple factors may contribute to ED:

1.Vascular (most common):

a.This system is responsible for delivering and trapping the blood in the corporal sinusoids. Usually the blood flowing in is not the problem; rather, the ED is the result of venous leaking from the corporal sinusoids.

b.Arterial insufficiency contributes to decreased blood flow to the cavernosal sinuses. The cavernosal dysfunction causes difficulty with retaining blood in the penis and sustaining an erection.

i.Chronic diseases such as cardiovascular (CV) disease, hypertension (HTN), dyslipidemia, and obesity affect blood flow.

ii.Certain medications can contribute to this physiological effect.

iii.Smoking is also a contributing factor, especially in the presence of existing CV disease, because of the vasoconstrictive effects it causes.

2.Psychological:

a.Direct inhibition of the spinal erection center and/or excessive sympathetic nervous system biochemical release occurs, which increases the smooth muscle tone of the penis, preventing erection because of:

i.Age-related decline.

ii.Lack of sexual response.

iii.Personal intimacy-related issues.

iv.Partner-specific intimacy issues.

v.Performance anxiety.

vi.Depression or life stress related.

3.Neurologic:

a.Any disease affecting the brain, spinal cord, and cavernous and penile nerves can impair the ability to achieve erection, such as spinal cord injury, stroke, or diabetes.

b.Surgery in the pelvic region, including prostatectomy, perineal resection, and sphincterotomy, may also be causes.

4.Endocrine:

a.Decreased testosterone level.

b.Increased prolactin level.

c.Hyperthyroidism.

d.Hypothyroidism.

Predisposing Factors

A.Cardiovascular disease.

B.Diabetes (neurological and vascular problems).

C.Hypertension (HTN).

D.Hyperlipidemia.

E.Advanced age (over 60 years).

F.Peripheral neuropathy.

G.Obesity.

H.Neurologic disorders:

1.Spinal cord injuries.

2.Brain injuries.

3.Multiple sclerosis (MS).

4.Parkinson’s disease.

I.Alcohol abuse.

J.Drug abuse:

1.Heroin.

2.Cocaine.

3.Marijuana.

K.Side effect of medication (e.g., serotonin reuptake inhibitors, antihypertensives, antihistamines, diuretics, nonsteroidal anti-inflammatories, muscle relaxants).

L.Surgical/radiation therapy for cancers of the pelvis.

M.Hypogonadism (hypoandrogenism/hypoestrogenism).

N.Psychological and psychiatric disorders.

O.Peyronie’s disease (deformity of the penis).

P.Obstructive sleep apnea (OSA).

Q.Physical inactivity.

Common Complaints

A.Inability to achieve an erection.

B.Erection is not firm enough for penetration.

C.Inability to maintain an erection.

Other Signs and Symptoms

A.Diminished self-esteem.

B.Depression.

C.Anxiety.

D.Reduced libido.

E.Relationship difficulties.

F.PE.

Subjective Data

History taking for ED includes sexual, medical, surgical, emotional, and medication evaluations.

A.Sexual history:

1.Did the onset of ED coincide with a specific event?

2.How long has the patient had trouble attaining or maintaining an erection?

3.Is he able to obtain an erection in order to penetrate? On a scale of 0 to 10, how hard is the erection?

4.Is the ED getting worse?

5.Does he come close to achieving orgasm and ejaculating?

6.How long is the patient able to have intercourse prior to ejaculation?

7.Is there pain or discomfort with ejaculation?

8.Does the patient have nocturnal or morning erections?

9.How frequently does the patient have sexual activity?

a.Is the activity planned, or does it occur spontaneously?

b.How much foreplay occurs?

c.Do the patient and partner agree on the frequency of intercourse?

d.Is the patient’s partner satisfied?

10.Has the patient tried any treatment(s) for ED?

a.What treatments have been tried?

b.Inquire about his desire to try any particular therapy. Is he opposed to try any particular therapy?

B.Medical history:

1.Does the patient have HTN? When was HTN diagnosed? What is his usual BP?

2.Does the patient have diabetes?

a.Is he insulin dependent?

b.Does he have any peripheral neuropathy?

3.Does the patient have heart disease? When was his heart disease diagnosed?

4.Has the patient ever had cancer, including any surgery, chemotherapy, and radiation?

5.Does the patient have dyslipidemia? What were the results of his last laboratory tests?

6.Does the patient smoke? How much, including the number of pack-years?

7.Does the patient drink? How much, how often?

8.Does the patient have penile curvature (Peyronie’s disease)?

9.Does the patient have any neurological disorders?

C.Surgical history:

1.Has the patient had any prior surgeries, including pelvic or prostate, or experienced trauma?

2.Has the patient had any invasive cardiac procedures or surgery?

D.Emotional history:

1.Has the patient ever had any traumatic sexual experience?

2.Has the patient had a loss of libido?

3.Does the patient have a history of depression or mood disorders?

4.Is the patient experiencing any problems related to work and/or family?

5.Does the patient have any intrapartner problems such as separation or divorce?

E.Medication history: Ask the patient to list all medications currently being taken, particularly substances not prescribed, including herbal products and illicit drugs. Multiple drug classifications include medications that contribute to ED. Review medications from these drug classes:

1.Nitrates.

2.Antihypertensives (particularly alpha-blockers).

3.Antiulcer medications.

4.Lipid-lowering medications.

5.5-Alpha reductase inhibitors (e.g., finasteride or dutasteride).

6.Antidepressants.

7.Herbal products.

8.Illicit drugs.

9.Caffeine.

Physical Examination

A.Check BP, height, and weight. Calculate body mass index (BMI).

B.Inspect:

1.Inspect general appearance, noting dyspnea and weakness.

2.Inspect skin for jaundice, pallor, and diaphoresis.

3.Inspect legs for edema, cyanosis, and venous stasis.

4.Perform a fundoscopic examination.

5.Evaluate visual field defects (present in hypogonadal men with pituitary tumors).

6.Inspect for penile plaques (indicates Peyronie’s disease).

7.Inspect the testicles:

a.Check for presence of atrophy.

b.Assess asymmetry.

c.Evaluate the cremasteric reflex by stroking the inner thighs and observe ipsilateral contraction of the scrotum.

C.Palpate:

1.Palpate abdomen for masses, tenderness, bounding pulses, and organomegaly.

2.Palpate peripheral pulses in legs.

3.Palpate femoral pulses.

4.Examine breasts to detect gynecomastia.

5.Palpate the testicles for masses.

6.Perform a rectal exam to evaluate the prostate.

D.Auscultate:

1.Auscultate carotid arteries for bruits.

2.Auscultate abdomen for bruits and bowel sounds.

3.Auscultate heart for murmurs, rubs, clicks, irregularities, or extra sounds.

4.Auscultate for femoral bruits (possible pelvic blood occlusion).

5.Auscultate all lung fields.

E.Mental status: Assess for depression.

F.Perform a neurologic examination if neurologic etiology is suspected.

Diagnostic Tests

Hormonal testing and treatment of ED should be individualized based on clinical presentation, including libido, premature ejaculation, fatigue, testicular atrophy, and muscle atrophy that suggests a hormonal abnormality.

A.Laboratory tests:

1.Lipid profile.

2.Triglycerides.

3.Glucose or hemoglobin (Hgb) A1c.

4.Prostate-specific antigen (PSA) testing (if on testosterone replacement).

5.Hematocrit (if on testosterone replacement).

6.Testosterone (performed in the morning) and other hormone levels, such as prolactin level, if high index of suspicion for prolactinoma including visual disturbance or headache. Free testosterone is considered more reliable according to the Endocrine Society.

B.Urinalysis for protein and glucose.

C.Duplex ultrasound of the cavernous arteries and other vascular testing as indicated. Penile perfusion ultrasound may be done to evaluate arterial perfusion of the penis. (Not commonly used.)

D.Nocturnal penile tumescence (NPT) as indicated. This determines the quality and number of nighttime erections. This test is not routinely used and is typically used in younger, more complicated patients.

E.Other tests as indicated for abnormal findings on physical examination.

Differential Diagnoses

A.Erectile dysfunction.

B.Testosterone deficiency.

C.Decreased libido.

D.Anorgasmia.

E.Peyronie’s disease.

Plan

A.General interventions:

1.Lifestyle modification to include weight loss, increased physical activity, limited alcohol consumption, and smoking cessation.

2.Control of comorbidities, including CV disease, diabetes, and HTN, is desired.

B.Patient teaching:

1.Educate patient about modifying controllable risk factors such as keeping diabetes and HTN under control, diet, exercise, and stopping smoking.

2.Failure to respond to phosphodiesterase-5 (PDE-5) inhibitor treatment may be from improper instructions or an inadequate dosage of medication (see Table 15.6 for dosing and side effects).

3.The initial administration of an alprostadil intraurethral suppository should be done in the office in order to demonstrate correct administration.

4.The initial intrapenile administration of alprostadil should be done in the office in order to demonstrate correct administration.

5.Stepwise therapy for ED includes pharmaceuticals and surgery.

C.Stepwise therapy for ED includes the following treatment modalities:

1.First-line therapy: Pharmaceutical treatment with PDE-5 inhibitors is the first-line therapy for the treatment of ED. PDE-5 inhibitors are not initiators of erection and require sexual stimulation for an erection to occur. The evidence shows that the PDE-5 inhibitors improve erections and successful intercourse with an approximately 80% success rate. The use of PDE-5 inhibitors has been extensively studied; however, they are not without side effects (see Table 15.6 for dosing and side effects).

a.Contraindications to PDE-5 inhibitors include high-risk conditions and the concomitant use of nitrites. If the patient develops angina while using a PDE-5 Inhibitor, other antianginal agents should be used instead of nitroglycerin.

b.High-risk patients/conditions are defined as:

i.Unstable or refractory angina.

ii.Refractory angina.

iii.Uncontrolled HTN.

iv.Congestive heart failure (CHF; (New York Heart Association classes III and IV).

v.Myocardial infarction (MI) or a cardiovascular accident within the previous 2 weeks.

vi.High-risk arrhythmias.

vii.Hypertrophic obstructive and other cardiomyopathies.

c.Before proceeding to other ED therapies, patients reporting failure of PDE-5 inhibitors should be evaluated to determine whether the medication trial was adequate:

i.Evaluate food/drug interactions.

ii.Timing and frequency of dosing.

iii.Lack of adequate sexual stimulation.

iv.Heavy alcohol use.

v.Relationship issues.

vi.Using a licensed PDE-5 inhibitor medication.

d.After evaluation, reeducation, and counseling on the medications, and partner–partner expectations, a different PDE-5 inhibitor may be needed, or titrate the patient’s current dosing for a change if needed.

e.Discuss other options for ED if the patient has a contraindication to, or an unsuccessful trial of, PDE-5 inhibitors.

2.Second-line therapy: Pharmaceutical therapy with intracavernous injection is the second-line therapy for the treatment of ED. Penile injection therapy involves injection of alprostadil, a vasoactive drug, into the corpora cavernosa of the penis to expand the blood vessels and increase the blood flow to produce an erection. The most common side effects of alprostadil are burning and a prolonged erection lasting more than 4 hours. Prolonged erections require medical intervention to reverse the erection.

3.Third-line therapy: A penile implant is the third-line therapy for the treatment of ED. Penile prostheses (implants) are surgically implanted, semirigid rods or a hydraulic device to ensure a rigid erection. The prosthesis does not usually affect urination, sex drive, orgasm, or ejaculation. Pain and/or reduced sensation, infection, or mechanical failure may occur from the prosthesis.

4.Vacuum erection devices are external cylinders used to pump the penis into the cylinder and produce an erection by drawing blood into the penis. An occluding band is then placed at the base of the penis in order to prevent the blood from leaving with subsequent loss of the erection. Only vacuum constrictor devices containing a vacuum limiter should be used. The occluding band to maintain the erection should be limited to 30 minutes.

5.Penile arterial revascularization is indicated for young men (younger than 45 years) with no known risk factors for atherosclerosis. The goal of the surgery is to correct injury by rerouting the blood vessel around a blockage or injured blood vessel. Men with insulin-dependent diabetes or widespread atherosclerosis are not candidates for this surgery.

6.Venous ligation surgery is rarely used. Men with insulin-dependent diabetes or widespread atherosclerosis are also not candidates for venous surgery.

Follow-Up

A.Follow up in 1 to 3 weeks after treatments are initiated to monitor patient satisfaction and quality of erections.

B.At the time of prescription renewal, patients prescribed PDE-5 inhibitors should have a review of the effectiveness, side effects, and any significant change in health status, including all medications.

C.A mild prolongation of the QT interval has been observed with vardenafil. The product labeling for vardenafil recommends that caution be used in patients with a known history of QT prolongation or in patients who are on current medications that prolong the QT interval.

D.Testosterone therapy is not indicated in the treatment of ED if the patient has a normal serum testosterone level.

E.Men who present with sleep disorders should also be questioned about the presence of ED.

Emergent Issues/Instructions

A.A prolonged erection (priapism) lasting more than 4 hours is a medical emergency often requiring immediate urologic attention.

Consultation/Referral

A.Patients whose risk is undetermined for PDE-5 inhibitors should undergo further evaluation by a cardiologist before receiving therapies for sexual dysfunction.

B.Surgical consultation: Men with penile deformities may require surgical correction.

C.Urologist consultation.

D.Endocrinology consultation for complex endocrine disorders.

E.Psychosexual counseling.

Individual Considerations

A.Adults:

1.A mild prolongation of the QT interval has been observed with vardenafil. The product labeling for vardenafil recommends that caution be used in patients with known history of QT prolongation or in patients who are on current medications that prolong the QT interval.

2.Testosterone therapy is not indicated in the treatment of ED if the patient has a normal serum testosterone level.

3.Men who present with sleep disorders should also be questioned about the presence of ED.

4.In patients with diabetes, PDE-5 inhibitors may fail.

5.PDE-5 inhibitors are contraindicated in patients with high CV risk and for patients on nitrates.

6.Men with ED are associated with a higher incidence of CV events.

B.Geriatric population: After age 70, ED prevalence is nearly 70% and is strongly related to poor health.

1.Dose medications on the lower end for elderly patients:

a.Sildenafil: Dose at 25 mg for age greater than 65 years. Renal and hepatic dosing required.

b.Vardenafil: Dose at 5 mg for age greater than 65 years. Renal and hepatic dosing required.

c.Tadalafil: Renal and hepatic dosing required.

2.Atherosclerosis in feeder vessels to the penis and vessel damage from diabetes mellitus (DM) are commonly associated with the development of ED.

3.Polypharmacy is associated with ED as many medications interfere with libido or are linked with ED, including thiazide diuretics, clonidine, ketoconazole, and cimetidine. Others are linked with loss of libido (clonidine selective serotinin reuptake inhibitors (SSRIs), opioids, anti-androgens, and 5-alpha reductase inhibitors).

4.Geriatric syndrome assessment: Falls. Discuss the risk of dizziness or lightheadedness when standing up because of orthostatic hypotension for men receiving treatment for ED. Older men taking PDE-5 inhibitors have an increased risk for falls related to orthostatic hypotension, especially with concomitant use of alpha-blockers.