Erectile Dysfunction

Question 1

Diagnostic Evaluation of ED

Answer 1

The goal of the diagnostic evaluation is to define the problem, to clearly distinguish ED from complaints about ejaculation and/or orgasm, and to establish the chronology and severity of symptoms.

The initial evaluation is conducted in person and should include thorough medical, sexual and psychosocial histories. An assessment of the patient’s needs and his expectations of therapy are equally important.

• Perform a medical history to determine:
• causes or comorbidities such as cardiovascular disease (e.g., hypertension, artherosclerosis or hyperlipidemia), diabetes mellitus, depression and alcoholism
• related dysfunctions
• premature ejaculations
• increased latency time associated with age
• psychosexual relationship problems
• contraindications for drug therapy
• additional risk factors (e.g., smoking, pelvic, perineal or penile trauma or surgery, neurologic disease, endocrinopathy, obesity, pelvic radiation therapy, Peyronie’s disease, prescription or recreational drug use)
• other critical elements
• alterations of sexual desire, ejaculation and orgasm
• presence of genital pain
• presence of genital deformity
• lifestyle factors (e.g., sexual orientation, presence of spouse or partner and quality of the relationship with the partner)
• history of partner’s sexual function

• Perform a physical evaluation except in established patients with a new complaint of ED. Include:

• a focused examination of the abdomen, penis, testicles, secondary sexual characteristics and lower extremity pulses
• a digital rectal examination and a serum PSA measurement in men >50 years of age with an estimated life expectancy of more than 10 years and
• additional assessments in select patients including
• testosterone levels,
• vascular and/or neurological,
• nocturnal erections.

Question 2

Initial management and discussin of treatment options with the patient

Answer 2

Begin management by identifying organic comorbidities and psychosexual dysfunctions, and appropriately treating them or triaging care. Consider non-surgical or surgical therapies (Table 1).

• Inform patient (and partner) of risks and benefits of available treatments.
• Consider comorbid conditions. Patients at intermediate and high risk for cardiovascular disease should be referred to a cardiologist.
• Choose treatment jointly with the patient and the partner, taking into consideration patient preferences and expectations.
• Initiate treatment in a step-wise fashion, with increasing invasiveness and risk balanced against the likelihood of efficacy.

Question 3

Non surgical therpies

Answer 3

Non-surgical Therapies
• Oral phosphodiesterase type 5 (PDE5) inhibitors (e.g., sildenafil, tadalafil, vardenafil) are first-line therapies unless contraindicated.
• Monitor patients for efficacy, side effects and change in health status or medication.
• If a patient fails to respond, determine adequacy of PDE5 inhibition before proceeding to other therapies. Recommend a different PDE5 inhibitor, or proceed with more invasive therapies.
• Use caution if the patient is taking alpha blockers.
• PDE5 inhibitors are contraindicated in patients taking organic nitrates or in whom sexual activity is unsafe.

• Alprostadil intra-urethral suppositories
• Consider using for a patient who has failed therapy with or is not a candidate for PDE5 inhibitors.
• Supervise initial dose due to risk of syncope.
• Can be used in combination with other treatment modalities, such as penile constriction devices or oral PDE5 inhibitors.

• Intracavernous vasoactive drug injection therapy
• Supervise initial injection to determine dose, monitor for prolonged erection and instruct patient on proper technique.
• Schedule periodic follow-ups to check for corporal fibrosis, review injection technique, and adjust therapy as necessary.
• Choose either monotherapy with alprostadil and papaverine or combination therapy with other vasoactive drugs (e.g., bimix and trimix) which can increase efficacy or reduce side effects (Note: bimix and trimix are available only in pharmacies offering compounding services).
• Inform the patient of potential for prolonged erection (lasting four hours), have a plan for the urgent treatment and inform the patient of the plan.
• Vacuum constriction devices
• Recommend only those devices that contain a vacuum limiter.
• Other treatment modalities
• Trazodone, yohimbine and herbal therapies are not recommended.
• Testosterone is not indicated for treatment of ED in patients with a normal serum testosterone level.
• Topical therapies do not appear to have significant efficacy beyond intra-urethral administration of alprostadil.

Question 4

Surgical Therapies

Answer 4

Surgical Therapies

• Penile prosthesis implantation

• Inform the patient (and, when possible, his partner) of the:
• types of prostheses available
• possibility and consequences of infection and erosion, mechanical failure and resulting reoperation
• differences from the normal flaccid and erect penis including penile shortening
• possible reduction in effectiveness of other therapies if the device is subsequently removed
• Do not perform prosthetic surgery in the presence of a systemic, cutaneous or urinary tract infection.
• Administer preoperative antibiotics that provide Gram-negative and Gram-positive coverage.
• Magnetic resonance imaging to evaluate status of a penile implant or for other indications is safe with all currently available prosthetics.

• Vascular surgery

• Penile vascular surgeries intended to limit the venous outflow of the penis are not recommended.
• Arterial reconstructive surgery is a treatment option only in healthy individuals 55 years old or younger who recently acquired ED secondary to focal arterial occlusive disease and do not have any evidence of generalized vascular disease.

Question 5

Treatment options for ED list

Answer 5