Current diagnosis and management of erectile dysfunction

McMahon, Christopher G

doi:10.5694/mja2.50167

ARTICLE
AUTHORS
REFERENCES

Topics

Sexual health

Summary

Erectile dysfunction (ED) is a common male sexual dysfunction associated with a reduced quality of life for patients and their partners.
ED is associated with increasing age, depression, obesity, lack of exercise, diabetes mellitus, hypertension, dyslipidaemia, cardiovascular disease and lower urinary tract symptoms related to benign prostatic hyperplasia.
The evaluation of men with ED requires a full medical and personally and culturally sensitive sexual history, a focused clinical examination, fasting glucose levels, a fasting lipid profile and, in select cases, a total testosterone level and a prostate‐specific antigen test.
Treatment of ED requires lifestyle modification, reduction of comorbid vascular risk factors, and treatment of organic or psychosexual dysfunction with either pharmacotherapy alone or in combination with psychosexual therapy.
Between 60% and 65% of men with ED, including those with hypertension, diabetes mellitus, spinal cord injury and other comorbid medical conditions, can successfully complete intercourse in response to the phosphodiesterase type 5 inhibitors (PDE5i) sildenafil, tadalafil, vardenafil and avanafil.
Patient‐administered intracorporal injection therapy using vasodilator drugs such as alprostadil is an effective treatment and is useful in men who fail to respond to oral pharmacological agents.
Surgical treatment of ED with multicomponent inflatable penile implants is associated with high satisfaction rates.
Penile arterial revascularisation and venous ligation surgery are associated with relatively poor outcome results in men with penile atherosclerotic disease or corporal veno‐occlusive dysfunction.

The full article is accessible to AMA
members and paid subscribers.
Login to MJA or subscribe now.

LOGIN TO MJA TO DOWNLOAD

SUBSCRIBE NOW

ACCESS VIA WILEY ONLINE

Australian Centre for Sexual Health, Sydney, NSW

Correspondence: cmcmahon@acsh.com.au

Competing interests:

Christopher McMahon is a paid investigator, member of an advisory board and speaker's panel for Pfizer, Eli Lilly and Menarini.

1. Consensus development conference statement. National Institutes of Health. Impotence. December 7–9, 1992. Int J Impot Res 1993; 5: 181–284.
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed, DSM‐5. Arlington, VA: American Psychiatric Association Publishing, 2013.
3. ICD10data.com. International Classification of Diseases, 10th ed, Male erectile dysfunction, unspecified. http://www.icd10data.com/ICD10CM/Codes/N00-N99/N40-N53/N52-/N52.9 (viewed Feb 2018).
4. Jensen J, Lendorf A, Stimpel H, et al. The prevalence and etiology of impotence in 101 male hypertensive outpatients. Am J Hypertens 1999; 12: 271–275.
5. Saenz de Tejada I, Goldstein I, Azadzoi K, et al. Impaired neurogenic and endothelium‐mediated relaxation of penile smooth muscle from diabetic men with impotence. N Engl J Med 1989; 320: 1025–1030.
6. Kirby M, Jackson G, Betteridge J, Friedli K. Is erectile dysfunction a marker for cardiovascular disease? Int J Clin Pract 2001; 55: 614–618.
7. Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994; 151: 54–61.
8. Seftel AD, de la Rosette J, Birt J, et al. Coexisting lower urinary tract symptoms and erectile dysfunction: a systematic review of epidemiological data. Int J Clin Pract 2013; 67: 32–45.
9. Rosen R, Altwein J, Boyle P, et al. Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the aging.male (MSAM‐7). Prog Urol 2004; 14: 332–344.
10. Jackson G, Rosen RC, Kloner RA, et al. The second Princeton consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine. J Sex Med 2006; 3: 28–36.
11. Hatzimouratidis K, Amar E, Eardley I, et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Eur Urol 2010; 57: 804–814.
12. Bella AJ, Lee JC, Carrier S, et al. 2015 CUA Practice guidelines for erectile dysfunction. Can Urol Assoc J 2015; 9: 23–29.
13. Ryu JK, Cho KS, Kim SJ, et al. Korean Society for Sexual Medicine and Andrology (KSSMA) guideline on erectile dysfunction. World J Mens Health 2013; 31: 83–102.
14. American Urological Association. Erectile dysfunction: AUA guidelines. https://www.auanet.org/guidelines/erectile-dysfunction-(ed)-guideline (viewed Jan 2018).
15. Hatzimouratidis K, Salonia A, Adaikan G, et al. Pharmacotherapy for erectile dysfunction: recommendations from the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2016; 13: 465–488.
16. Levine LA, Becher E, Bella A, et al. Penile prosthesis surgery: current recommendations from the International Consultation on Sexual Medicine. J Sex Med 2016; 13: 489–518.
17. Trost LW, Munarriz R, Wang R, et al. External mechanical devices and vascular surgery for erectile dysfunction. J Sex Med 2016; 13: 1579–1617.
18. Montorsi F, Adaikan G, Becher E, et al. Summary of the recommendations on sexual dysfunctions in men. J Sex Med 2010; 7: 3572–3588.
19. Qaseem A, Snow V, Denberg TD, et al. Hormonal testing and pharmacologic treatment of erectile dysfunction: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2009; 151: 639–649.
20. Hackett G, Kirby M, Wylie K, et al. British Society for Sexual Medicine guidelines on the management of erectile dysfunction in men — 2017. J Sex Med 2018; 15: 430–457.
21. Kimoto Y, Nagao K, Sasaki H, et al. JSSM guidelines for erectile dysfunction. Int J Urol 2008; 15: 564–576.
22. Cappelleri JC, Rosen RC, Smith MD, et al. Diagnostic evaluation of the erectile function domain of the International Index of Erectile Function. Urology 1999; 54: 346–351.
23. Ghanem HM, Salonia A, Martin‐Morales A. SOP: physical examination and laboratory testing for men with erectile dysfunction. J Sex Med 2013; 10: 108–110.
24. Greene KL, Albertsen PC, Babaian RJ, et al. Prostate specific antigen best practice statement: 2009 update. J Urol 2013; 189 (Suppl): S2–S11.
25. McKinlay JB. The worldwide prevalence and epidemiology of erectile dysfunction. Int J Impot Res 2000; 12 (Suppl): S6–S11.
26. De Berardis G, Franciosi M, Belfiglio M, et al. Erectile dysfunction and quality of life in type 2 diabetic patients: a serious problem too often overlooked. Diabetes Care 2002; 25: 284–291.
27. American Diabetes Association. Classification and diagnosis of diabetes: standards of medical care in diabetes, 2018. Diabetes Care 2018; 41 (Suppl): S13–S27.
28. Dean JD, McMahon CG, Guay AT, et al. The International Society for Sexual Medicine's process of care for the assessment and management of testosterone deficiency in adult men. J Sex Med 2015; 12: 1660–1686.
29. Yeap BB, Grossmann M, McLachlan RI, et al. Endocrine Society of Australia position statement on male hypogonadism (part 1): assessment and indications for testosterone therapy. Med J Aust 2016; 205: 173–178. https://www.mja.com.au/journal/2016/205/4/endocrine-society-australia-position-statement-male-hypogonadism-part-1
30. Hackett G, Kell P, Ralph D, et al. British Society for Sexual Medicine guidelines on the management of erectile dysfunction. J Sex Med 2008; 5: 1841–1865.
31. Capogrosso P, Colicchia M, Ventimiglia E, et al. One patient out of four with newly diagnosed erectile dysfunction is a young man–worrisome picture from the everyday clinical practice. J Sex Med 2013; 10: 1833–1841.
32. Elhanbly S, Elkholy A. Nocturnal penile erections: the role of RigiScan in the diagnosis of vascular erectile dysfunction. J Sex Med 2012; 9: 3219–3226.
33. Meuleman EJ, Diemont WL. Investigation of erectile dysfunction. Diagnostic testing for vascular factors in erectile dysfunction. Urol Clin North Am 1995; 22: 803–819.
34. Hatzichristou DG, Hatzimouratidis K, Apostolidis A, et al. Hemodynamic characterization of a functional erection. Arterial and corporeal veno‐occlusive function in patients with a positive intracavernosal injection test. Eur Urol 1999; 36: 60–67.
35. Sikka SC, Hellstrom WJ, Brock G, et al. Standardization of vascular assessment of erectile dysfunction: standard operating procedures for duplex ultrasound. J Sex Med 2013; 10: 120–129.
36. Giuliano F, Rowland DL. Standard operating procedures for neurophysiologic assessment of male sexual dysfunction. J Sex Med 2013; 10: 1205–1211.
37. Tsertsvadze A, Fink HA, Yazdi F, et al. Oral phosphodiesterase‐5 inhibitors and hormonal treatments for erectile dysfunction: a systematic review and meta‐analysis. Ann Intern Med 2009; 151: 650–661.
38. Eardley I, Donatucci C, Corbin J, et al. Pharmacotherapy for erectile dysfunction. J Sex Med 2010; 7: 524–540.
39. Atiemo HO, Szostak MJ, Sklar GN. Salvage of sildenafil failures referred from primary care physicians. J Urol 2003; 170: 2356–2358.
40. Alhathal N, Elshal AM, Carrier S. Synergetic effect of testosterone and phophodiesterase‐5 inhibitors in hypogonadal men with erectile dysfunction: a systematic review. Can Urol Assoc J 2012; 6: 269–274.
41. Coombs PG, Heck M, Guhring P, et al. A review of outcomes of an intracavernosal injection therapy programme. BJU Int 2012; 110: 1787–1791.
42. Brock G, Harper W. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Erectile dysfunction. Can J Diabetes 2013; 37 (Suppl): S150–S152.
43. Thompson IM, Tangen CM, Goodman PJ, et al. Erectile dysfunction and subsequent cardiovascular disease. JAMA 2005; 294: 2996–3002.
44. Jackson G, Betteridge J, Dean J, et al. A systematic approach to erectile dysfunction in the cardiovascular patient: a consensus statement — update 2002. Int J Clin Pract 2002; 56: 663–671.
45. Gupta BP, Murad MH, Clifton MM, et al. The effect of lifestyle modification and cardiovascular risk factor reduction on erectile dysfunction: a systematic review and meta‐analysis. Arch Intern Med 2011; 171: 1797–1803.
46. Bacon CG, Mittleman MA, Kawachi I, et al. Sexual function in men older than 50 years of age: results from the health professionals follow‐up study. Ann Intern Med 2003; 139: 161–168.
47. Esposito K, Giugliano F, Di Palo C, et al. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial. JAMA 2004; 291: 2978–2984.
48. Derby CA, Mohr BA, Goldstein I, et al. Modifiable risk factors and erectile dysfunction: can lifestyle changes modify risk? Urology 2000; 56: 302–306.
49. Saltzman EA, Guay AT, Jacobson J. Improvement in erectile function in men with organic erectile dysfunction by correction of elevated cholesterol levels: a clinical observation. J Urol 2004; 172: 255–258.
50. Melnik T, Althof S, Atallah AN, et al. Psychosocial interventions for premature ejaculation. Cochrane Database Syst Rev 2011; (8): CD008195.
51. Althof SE, Seftel AD. The evaluation and management of erectile dysfunction. Psychiatr Clin North Am 1995; 18: 171–192.
52. Goldstein I, Lue TF, Padma‐Nathan H, et al. Oral sildenafil in the treatment of erectile dysfunction. Sildenafil Study Group. N Engl J Med 1998; 338: 1397–1404.
53. Porst H, Rosen R, Padma‐Nathan H, et al. The efficacy and tolerability of vardenafil, a new, oral, selective phosphodiesterase type 5 inhibitor, in patients with erectile dysfunction: the first at‐home clinical trial. Int J Impotence Res 2001; 13: 192–199.
54. Brock GB, McMahon CG, Chen KK, et al. Efficacy and safety of tadalafil for the treatment of erectile dysfunction: results of integrated analyses. J Urol 2002; 168: 1332–1336.
55. Goldstein I, Jones LA, Belkoff LH, et al. Avanafil for the treatment of erectile dysfunction: a multicenter, randomized, double‐blind study in men with diabetes mellitus. Mayo Clin Proc 2012; 87: 843–852.
56. Porst H, Giuliano F, Glina S, et al. Evaluation of the efficacy and safety of once‐a‐day dosing of tadalafil 5 mg and 10 mg in the treatment of erectile dysfunction: results of a multicenter, randomized, double‐blind, placebo‐controlled trial. Eur Urol 2006; 50: 351–359.
57. McMahon C. Efficacy and safety of daily tadalafil in men with erectile dysfunction previously unresponsive to on‐demand tadalafil. J Sex Med 2004; 1: 292–300.
58. Margo CE, French DD. Ischemic optic neuropathy in male veterans prescribed phosphodiesterase‐5 inhibitors. Am J Ophthalmol 2007; 143: 538–539.
59. Porst H. The rationale for prostaglandin E1 in erectile failure: a survey of worldwide experience. J Urol 1996; 55: 802–815.
60. McMahon CG. Comparison of the response to the intracavernosal injection of a combination of papaverine and phentolamine, Prostaglandin E1 alone and a combination of all three in the management of impotence. Int J Impotence Res 1991; 3: 133–142.
61. McMahon CG, Samali R, Johnson H. Treatment of intracorporeal injection nonresponse with sildenafil alone or in combination with triple agent intracorporeal injection therapy. J Urol 1999; 162: 1992–1997; discussion 7‐8.
62. Carson CC, Mulcahy JJ, Govier FE. Efficacy, safety and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: results of a long‐term multicenter study. AMS 700CX Study Group. J Urol 2000; 164: 376–380.
63. Montorsi F, Briganti A, Salonia A, et al. Current and future strategies for preventing and managing erectile dysfunction following radical prostatectomy. Eur Urol 2004; 45: 123–133.
64. Incrocci L. Sexual function after external‐beam radiotherapy for prostate cancer: what do we know? Crit Rev Oncol Hematol 2006; 57: 165–173.
65. Montorsi F, Guazzoni G, Strambi LF, et al. Recovery of spontaneous erectile function after nerve‐sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomized trial. J Urol 1997; 158: 1408–1410.
66. Hong EK, Lepor H, McCullough AR. Time dependent patient satisfaction with sildenafil for erectile dysfunction (ED) after nerve‐sparing radical retropubic prostatectomy (RRP). Int J Impot Res 1999; 11 (Suppl): S15–S22.
67. Padma‐Nathan H, McCullough AR, Levine LA, et al. Randomized, double‐blind, placebo‐controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve‐sparing radical prostatectomy. Int J Impot Res 2008; 20: 479–486.
68. Incrocci L, Koper PC, Hop WC, Slob AK. Sildenafil citrate (Viagra) and erectile dysfunction following external beam radiotherapy for prostate cancer: a randomized, double‐blind, placebo‐controlled, cross‐over study. Int J Radiat Oncol Biol Phys 2001; 51: 1190–1195.
69. Schroder FH, Collette L, de Reijke TM, et al. Prostate cancer treated by anti‐androgens: is sexual function preserved? EORTC Genitourinary Group. European Organization for Research and Treatment of Cancer. Br J Cancer 2000; 82: 283–290.

Online responses are no longer available. Please refer to our instructions for authors page for more information.

Current diagnosis and management of erectile dysfunction

Topics

Summary

The full article is accessible to AMA members and paid subscribers. Login to MJA or subscribe now.

Author

Comment

Do you have any competing interests to declare? *

The full article is accessible to AMA
members and paid subscribers.
Login to MJA or subscribe now.