Sexual Dysfunction in Men
Men in May. Community based epidemiologic studies reveal that more than 50% of men age 40-70 have erectile dysfunction. Recognized risk factors include age, high cholesterol and low HDL, hypertension, diabetes, cigarette smoking, coronary artery disease, myocardial infarction and obesity. Several new studies involving approaching 30,000 subjects have shown that daily exercise burning 200 calories/day lowers the risk of erectile dysfunction.
Contemporary thinking about erectile dysfunction is that is it strongly predicted by factors that affect the health of the lining of the blood vessels (the endothelial cells). The diameter of the artery in the erection chamber is .5 mm (if this artery is blocked impotence would result) and the diameter of the artery in the heart is 3 mm (if this artery were blocked a heart attack would occur) and the diameter of the artery of the neck is 1 cm (if this artery were blocked a stroke would occur) and the diameter of the aorta is 2 cm (and if this artery were blocked it would lead to difficulty walking or claudication.) Should the process of atherosclerosis occur in the arteries of the body, one of the earliest signs of artery blockage even before the occurrence of a heart attack is the condition of erectile dysfunction.
Management of patients with erectile dysfunction is traditionally divided into first line, second line and third line therapies based on reversibility and cost and degree of invasiveness. First line therapies include sex therapy, vacuum constriction device therapy, and oral vasodilator agents such as Viagra, Levitra and Cialis. New head-to-head scientific trials have been performed with these 3 agents in placebo-controlled double-blind trials in PDE5 naïve patients. The bottom line of these studies is that not all patients with erectile dysfunction should choose a single drug in all situations. Certain patients prefer one drug over another. For patients who find long duration useful, Cialis is preferred. For patients who find rigidity and speed of erection useful, Levitra is preferred. For patients who want few side effects Viagra is preferred. In one study Cialis was selected for patients who were young with mild erectile dysfunction and psychogenic-based erectile dysfunction. In contrast, for older patients with more severe erectile dysfunction and/or physical-based erectile dysfunction, Levitra was preferred.
Second line therapies include intraurethral or self-injection therapies with vasoactive drugs. Such therapies are used frequently when the underlying pathology is venous leakage or where impotence follows radical prostatectomy surgery.
Third line therapies include penile prosthesis insertion or microvascular surgery, especially for young patients who have impotence after blunt trauma such as following bicycle riding.
Finally, androgen therapy is indicated for men with erectile dysfunction who have hypogonadism, defined by blood test values either below or in the lower quartile of the reference range. Such patients commonly have other symptoms including low interest, low energy, less efficient performance at work, fall asleep after dinner, and are sad and grumpy.
Men who have erectile dysfunction have many management options and should seek professional consultation, especially with physicians who are knowledgeable in sexual medicine.
