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Semirigid malleable prostheses are the simplest and easiest to implant, but they can be difficult to conceal because the penis is always erect.

Inflatable prostheses typically consist of two tubes that replace the corpora cavernosa, plus a pump in the scrotum and an intra-abdominal reservoir ( eFigure A ) .

Mechanical failure goodrx coupon sildenafil or infection may require removal of the prosthesis.

Risks include scarring, penile shortening, and recurrent infections. Prostheses coated with antibiotics have been used to reduce the risk of infection.64. Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References.

Many men have ED that is predominantly or exclusively caused by psychological or interpersonal factors.65 Psychogenic ED occurs at all ages but is most common in men younger than 40 years. A thorough history can elicit potential causes such as performance anxiety and relationship conflicts, which distract attention and impair sexual arousal.

Problems such as premature ejaculation, genital pain, or dyspareunia can lead to psychogenic ED, as can cultural or religious taboos or a history of sexual abuse. Although men and their partners may resist a psychological explanation for ED, counseling can be effective.60.

ED of mixed organic and psychogenic origin is common. Psychogenic causes are more likely when the patient has normal erections with masturbation or when nocturnal penile tumescence is normal. Devices are available to measure the number, duration, and rigidity of erections during sleep.

However, normal nocturnal erections do not always correlate with sexually relevant erections, and this test may be unreliable in older or anxious patients.66.

When ED coexists with depression or anxiety, treatment of the mood disorder may be

the

If

antidepressants

PDE-5 inhibitors are effective in men with depression and can be used in combination with treatments for mood disorders.67.

This article updates previous articles on this topic by Heidelbaugh, 62 Miller, 70 and Viera, et al. HEIDELBAUGH, MD, University of Michigan, Ann Arbor, Michigan. Patient information: See related handout on erectile dysfunction, written by the author of this article.

Abstract Prevalence Pathophysiology Diagnosis and Evaluation Treatment Link to Cardiovascular Disease References. Abstract Prevalence Pathophysiology Diagnosis and Evaluation Treatment Link to Cardiovascular Disease References.

Erectile dysfunction (ED) is the most common sexual problem in men.

The incidence increases with age and affects up to one third of men throughout their lives.

It causes a substantial negative impact on intimate relationships, quality of life, and self-esteem. History and physical examination are sufficient to make a diagnosis of ED in most cases, because there is no preferred, first-line diagnostic test.

Initial diagnostic workup should usually be limited to a fasting serum glucose level and lipid panel, thyroid-stimulating hormone test, and morning total testosterone level. First-line therapy for ED consists of lifestyle changes, modifying drug therapy that may cause ED, and pharmacotherapy with phosphodiesterase type 5 inhibitors.

Obesity, sedentary lifestyle, and smoking greatly increase the risk of ED.

Phosphodiesterase type 5 inhibitors are the most effective oral drugs for treatment of ED, including ED associated with diabetes mellitus, spinal cord injury, and antidepressants.

Intraurethral and intracavernosal alprostadil, vacuum pump devices, and surgically implanted penile prostheses are alternative therapeutic options when phosphodiesterase type 5 inhibitors fail.

Testosterone supplementation in men with hypogonadism improves ED and libido, but requires interval monitoring of hemoglobin, serum transaminase, and prostate-specific antigen levels because of an increased risk of prostate adenocarcinoma. Cognitive behavior therapy and therapy aimed at improving relationships may help to improve ED.

Screening for cardiovascular risk factors should be considered in men with ED, because symptoms of ED present on average three years earlier than symptoms of coronary artery disease. Men with ED are at increased risk of coronary, cerebrovascular, and peripheral vascular diseases. Erectile dysfunction (ED) is defined by the National Institutes of Health as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.1 ED is the most common sexual problem in men; it often causes serious distress, prompting men to seek medical attention they may not otherwise seek.

It often has a profound effect on intimate relationships, quality of life, and overall self-esteem.

ED may also be the presenting symptom or harbinger of undetected cardiovascular disease.2

The

Diagnostic testing for erectile dysfunction should usually be limited to obtaining a fasting serum glucose level and lipid panel, thyroid-stimulating hormone test, and morning total testosterone level. First-line therapy for erectile dysfunction should consist of oral phosphodiesterase type 5 inhibitors. Phosphodiesterase type 5 inhibitors are most effective in the treatment of erectile dysfunction associated with diabetes mellitus and spinal cord injury, and of sexual dysfunction associated with antidepressants. Additional therapy for erectile dysfunction may consist of psychosocial therapy and testosterone supplementation in men with hypogonadism.

Testosterone supplementation in men with hypogonadism improves erectile dysfunction and libido.

Screening for cardiovascular risk factors should be considered in men with erectile dysfunction.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series.

For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml . Diagnostic testing for erectile dysfunction should usually be limited to obtaining a fasting serum glucose level and lipid panel, thyroid-stimulating hormone test, and morning total testosterone level.

First-line therapy for erectile dysfunction should consist of oral phosphodiesterase type 5 inhibitors. Phosphodiesterase type 5 inhibitors are most effective in the treatment of erectile dysfunction associated with diabetes mellitus and spinal cord injury, and of sexual dysfunction associated with antidepressants. Additional therapy for erectile dysfunction may consist of psychosocial therapy and testosterone supplementation in men with hypogonadism.

Testosterone supplementation in men with hypogonadism improves erectile dysfunction and libido. Screening for cardiovascular risk factors should be considered in men with erectile dysfunction. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml . Abstract Prevalence Pathophysiology Diagnosis and Evaluation Treatment Link to Cardiovascular Disease References.

Many men associate advancing age with declining sexual function and an overall decreased quality of life.

ED affects up to one third of men throughout their lives, and the incidence increases with age.

health professionals found the prevalence of sexual dysfunction in men to be 12 percent in those younger than 59 years, 22 percent in those 60 to 69 years of age, and 30 percent in those older than 69 years.3 Persons with type 2 diabetes mellitus have a threefold greater risk of ED compared with the general population.4 Depression increases the risk of ED, but it is not clear if this relationship is causal.5.

Abstract Prevalence Pathophysiology Diagnosis and Evaluation Treatment Link to Cardiovascular Disease References.

ED may result from organic causes (e.g., vascular, neurogenic, hormonal, anatomic, drug-induced), psychological causes, or a combination of both. A normal sexual erectile response results from the interaction between neurotransmitter, biochemical, and vascular smooth muscle responses initiated by parasympathetic and sympathetic neuronal triggers that integrate physiologic stimuli of the penis with sexual perception and desire. Nitric oxide produced from endothelial cells after parasympathetic stimuli triggers a molecular cascade that results in smooth muscle relaxation and arterial influx of blood into the corpus cavernosum.

This is followed by compression of venous return, which produces an erection.6.

History of pelvic irradiation or surgery, including radical prostatectomy. Hormonal disorders (e.g., hypogonadism, hypothyroidism, hyperprolactinemia) Illicit drug use (e.g., cocaine, methamphetamine) Medications (e.g., antihistamines, benzodiazepines, selective serotonin reuptake inhibitors) Neurologic conditions (e.g., Alzheimer disease, multiple sclerosis, Parkinson disease, paraplegia, quadriplegia, stroke) Psychological conditions (e.g., anxiety, depression, guilt, history of sexual abuse, marital or relationship problems, stress) Information from reference 9 . History of pelvic irradiation or surgery, including radical prostatectomy. Hormonal disorders (e.g., hypogonadism, hypothyroidism, hyperprolactinemia) Illicit drug use (e.g., cocaine, methamphetamine) Medications (e.g., antihistamines, benzodiazepines, selective serotonin reuptake inhibitors) Neurologic

conditions

Abstract Prevalence Pathophysiology Diagnosis and Evaluation Treatment Link to Cardiovascular Disease References. There is no preferred, first-line diagnostic test for ED, and routine screening is not recommended.

History and physical examination are sufficient in making an accurate diagnosis of ED in most cases.

Penile duplex ultrasonography is not a useful diagnostic test for ED.7 The American Urological Association (AUA) recommends that the initial evaluation of ED include a complete medical, sexual, and psychosocial history.8 The medical history may reveal comorbid conditions, risk factors related to ED ( Table 1 ),9 or medications that contribute to ED ( Table 2 ).6 Sexual history should focus on erection adequacy, altered libido, quality and timing of orgasm, volume and appearance of ejaculate, presence of sexually-induced genital pain or penile curvature (Peyronie disease), and partner sexual function. The five-item version of the International Index of Erectile Function Questionnaire is a validated survey instrument that can be used to assess the severity of ED symptoms ( Table 3 ).10.

Medications and Substances That May Cause or Contribute to Erectile Dysfunction. Lithium, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, tricyclic antidepressants. Dimenhydrinate, diphenhydramine (Benadryl), hydroxyzine (Vistaril), meclizine (Antivert), promethazine (Phenergan) Alpha blockers, beta blockers, calcium channel blockers, clonidine (Catapres), methyldopa, reserpine. Bromocriptine (Parlodel), levodopa, trihexyphenidyl.

Digoxin, disopyramide (Norpace), gemfibrozil (Lopid) Spironolactone (Aldactone), thiazides.

5-alpha reductase inhibitors, corticosteroids, estrogens, luteinizing hormone-releasing hormone agonists, progesterone.

Amphetamines, barbiturates, cocaine, heroin, marijuana.

Medications and Substances That May Cause or Contribute to Erectile Dysfunction. Lithium, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, tricyclic antidepressants.

Dimenhydrinate, diphenhydramine (Benadryl), hydroxyzine (Vistaril), meclizine (Antivert), promethazine (Phenergan) Alpha blockers, beta blockers, calcium channel blockers, clonidine (Catapres), methyldopa, reserpine.

Bromocriptine (Parlodel), levodopa, trihexyphenidyl.

Digoxin, disopyramide (Norpace), gemfibrozil (Lopid) Spironolactone (Aldactone), thiazides.

5-alpha reductase inhibitors, corticosteroids, estrogens, luteinizing hormone-releasing hormone agonists, progesterone. Amphetamines, barbiturates, cocaine, heroin, marijuana.

Five-Item Version of the International Index of Erectile Function Questionnaire.

How do you rate your confidence that you could get and keep an erection?

When you had erections with sexual stimulation, how often were your erections hard enough for penetration?

During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? When you attempted sexual intercourse, how often was it satisfactory for you? note : The score is the sum of the above five question responses.

Erectile dysfunction is classified based on these scores: 17 to 21 = mild; 12 to 16 = mild to moderate; 8 to 11 = moderate; 5 to 7 = severe . Adapted with permission from Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Pena BM.

Development and evaluation of an abridged, 5-item goodrx coupon sildenafil version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction .

Five-Item Version of the International Index of Erectile Function Questionnaire. How do you rate your confidence that you could get and keep an erection?

When you had erections with sexual stimulation, how often were your erections hard enough for penetration?

During sexual intercourse, how

often

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

When you attempted sexual intercourse, how often was it satisfactory for you? note : The score is the sum of the above five question responses.

Erectile dysfunction is classified based on these scores: 17 to 21 = mild; 12 to 16 = mild to moderate; 8 to 11 = moderate; 5 to 7 = severe . Adapted with permission from Rosen RC, Cappelleri goodrx coupon sildenafil JC, Smith MD, Lipsky J, Pena BM.

Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction .

The physical examination should assess blood pressure and heart rate; body habitus, for central obesity; and cardiovascular, neurologic, and genitourinary systems, including penile, testicular, and digital rectal examinations ( Figure 1 ).8 , 9 , 11 – 14 The AUA and World Health Organization recommend limited diagnostic testing in men with ED.

This may include a fasting serum glucose level and lipid panel, thyroid-stimulating hormone test, and morning total testosterone level.8 , 11 Additional diagnostic testing and urologic evaluation may be warranted in cases of ED refractory to standard therapies ( Table 4 ).11 Clues to the diagnosis of ED are listed in Table 5 .

Algorithm for the diagnosis and treatment of erectile dysfunction. Algorithm for the diagnosis and treatment of erectile dysfunction. Additional Testing in the Workup of Erectile Dysfunction. Laboratory investigations (complete blood count; free testosterone, luteinizing hormone, and prolactin levels; sex hormone-binding globulin test; urinalysis) Psychological or psychiatric consultation. Neurophysiologic testing (vibrometry; bulbocavernosus reflex latency; cavernosal electromyography; somatosensory evoked potential test; pudendal and sphincter electromyography) Nocturnal penile tumescence and rigidity assessment.

Specialized goodrx coupon sildenafil endocrinologic testing (hypothalamic-pituitary-gonadal function studies; magnetic resonance imaging of the sella turcica) Vascular diagnostics (duplex ultrasonography; penile pharmacocavernosometry and pharmacocavernosography; penile arteriography; computed tomography or magnetic resonance imaging; nuclear imaging) Adapted with permission from Jardin A, Wagner G, Khoury S, et al.

Recommendations of the 1st International Consultation on Erectile Dysfunction. Plymouth, U.K.: Health Publication Ltd, 2000:718–719 .

Additional Testing in the Workup of Erectile Dysfunction.

Laboratory investigations (complete blood count; free testosterone, luteinizing hormone, and prolactin levels; sex hormone-binding globulin test; urinalysis) Psychological or psychiatric consultation.

Neurophysiologic testing (vibrometry; bulbocavernosus reflex latency; cavernosal electromyography; somatosensory evoked potential test; pudendal and sphincter electromyography) Nocturnal penile tumescence and rigidity assessment. Specialized endocrinologic testing (hypothalamic-pituitary-gonadal function studies; magnetic resonance imaging of the sella turcica) Vascular diagnostics (duplex ultrasonography; penile pharmacocavernosometry and pharmacocavernosography; penile arteriography; computed tomography or magnetic resonance imaging; nuclear imaging) Adapted with permission from Jardin A, Wagner G, Khoury S, et al.

Recommendations of the 1st International Consultation on Erectile Dysfunction.

Plymouth, U.K.: Health

Publication

First-line therapy for ED is aimed at lifestyle changes and modifying pharmacotherapy that may contribute to ED8 ( Table 2 6). Sedentary lifestyle, a significant risk factor for cardiovascular disease, may also be a modifiable risk factor for ED.15 Obesity nearly doubles the risk of ED3; one study determined that one third of men who were obese improved their ED with moderate weight loss and an increase in the amount and duration of regular exercise.14 The risk of moderate or total ED is almost double in men who smoke compared with nonsmokers.16 Patient education should be aimed at increasing exercise, losing weight to achieve a body mass index (BMI) less than 30 kg per m 2 , and stopping smoking.