Erectile Dysfunction

Abstract

Erectile dysfunction (ED) afflicts more than 50 % of men over 40 years of age. Its causes are often linked to vascular disease, and ED may be the first symptom of vascular disease often preceding an acute vascular event by 3–5 years. ED can also be associated with radical pelvic surgery, diabetes, testosterone deficiency, ­neurological disorders, and depression. Lifestyle associations include obesity, sleep apnea, tobacco use and drug abuse.

Evaluation for ED includes use of standard questionnaires such as the Sexual Health Inventory for Men (SHIM), a careful history, and a physical examination focused on the genitourinary system. Laboratory studies should include glucose, lipid profile, and serum testosterone.

Treatment of ED should begin with lifestyle modification such as diet, exercise, and smoking cessation. The treatment of ED has been enhanced by the introduction of the phosphodiesterase type 5 inhibitors (PDE5i). These drugs have a success rate of greater than 70 % with an excellent safety profile. PDE5i drugs should be taken 1 h before sexual stimulation and have a half-life of 4–17 h. These agents’ efficacy is enhanced by normalizing testosterone in hypogonadal men.

Should PDE5i drugs fail, second-line treatment can be considered. These options include vacuum erection device, pharmacoactive agents injected into the corpora cavernosa, and urethral prostaglandin suppositories. Surgical implantation of a penile prosthesis provides excellent function for men who fail less invasive alternatives or who desire a surgical solution to their ED.