Erectile Dysfunction

Abstract

Erectile dysfunction is commonly defined as the inability to attain or maintain a penile erection sufficient for satisfactory sexual intercourse. The prevalence, as estimated in a cross-sectional national probability survey in the United States of America (men aged 40 years and more, May 2001–January 2002), was 22% with significant increase with aging (1). A similar prevalence of 19.2% was found in an urban area in Germany (30–80 years of age), with an increase from 2% among the youngest group to 53% in the oldest group (2). Twenty-six new cases per 1,000 men were the estimated annual incidence of erectile dysfunction determined in the Massachusetts Male Aging Study (40- to 69-year-old men) (3).

Key Points

• The majority of cases of erectile dysfunction are associated with a general vascular process including endothelial dysfunction and may be classified as vascular-type erectile dysfunction.

• Cardiovascular risk factors, such as smoking, dyslipidemia, diabetes mellitus, arterial hypertension, are very common among patients with erectile dysfunction.

• Erectile dysfunction might be an (early) harbinger of other vascular disease such as silent myocardial ischemia or cerebrovascular and peripheral arterial disease. Erectile dysfunction should initiate a cardiovascular work-up including a complete history and physical exam, an ECG, and in many cases also an exercise test. Referral to a cardiologist might be appropriate in certain patients.

• Reduction of cardiovascular risk factors, be it lifestyle change or medical intervention, should be the first step for treatment of erectile dysfunction due to vascular dysfunction.

• When cardiovascular medications, in particular antihypertensives, are prescribed, careful selection of appropriate drugs is prudent because many, in particular thiazide diuretics and β-blockers, may worsen erectile function.

• Before an appropriate treatment option is considered, patients, especially those with preexisting cardiovascular disease, should be evaluated for the issue of whether sexual intercourse can be safely recommended or whether further stabilization of the medical condition is mandatory.

• For evaluation of cardiovascular patients, recommendations of the first and second Princeton Consensus Conference may be applied.

• Oral treatment with inhibitors of phosphodiesterase-5, such as sildenafil, vardenafil, and tadalafil, is highly effective in a broad spectrum of patients presenting with erectile dysfunction.

• The use of drugs serving as nitric oxide donors, such as nitrates, is an absolute contraindication for the use of phosphodiesterase-5 inhibitors.

• A stable blood pressure (at least >90/60 mmHg) is a prerequisite for the use of phosphodiesterase-5 inhibitors. In general, concomitant use of antihypertensive therapy is well tolerated. Special caution is advisable when α(alpha)-receptor—antagonists are used simultaneously.

• Other treatment strategies, for instance testosterone replacement in hypogonadism or psychotherapy and antidepressants in major depression, are restricted to special indications and may in certain cases be combined with phosphodiesterase-5 inhibitors. Non-oral treatment strategies for erectile dysfunction, such as vacuum pumps, intracavernosal self-injection, or intraurethral application of alprostadil or penile prostheses, have become second- or third-line therapies.

• Dopamine agonists, such as sublingual apomorphine (available in Europe, but not FDA approved in the United States), are less effective than phosphodiesterase-5 inhibitors, but may be useful, in particular when contraindications do not allow use of phosphodiesterase-5 inhibitors.