Erectile Dysfunction

Discussion in 'Men's Health Forum' started by Michael Scally MD, Nov 10, 2017.

  1. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Nguyen HMT, Gabrielson AT, Hellstrom WJG. Erectile Dysfunction in Young Men - A Review of the Prevalence and Risk Factors. Sexual Medicine Reviews 2017;5(4):508-20.

    Introduction - Erectile dysfunction (ED) is an important health concern that can significantly affect a man's psychosocial well-being. ED has traditionally been considered a disease of old age; however, contemporary evidence suggests a growing incidence of ED in men younger than 40 years.

    The process of achieving an erection is multifaceted; there are many potential mechanisms that can be disrupted. It is critical to identify the specific causes of ED before proceeding with potentially costly and invasive therapeutic options. Advances in diagnostic and treatment modalities offer opportunities to identify and manage young men with ED.

    Aim - To provide an update on the prevalence and risk factors of ED in young men and to provide a framework to guide clinicians in identifying and managing the affected young man.

    Methods - Comprehensive review of the literature pertaining to ED in young men.

    Main Outcome Measures - ED in young men was assessed by outlining the prevalence according to recent epidemiologic studies. The pathophysiology, diagnostic considerations, risk factors, and etiologies were reviewed.

    Results - Large multinational studies have estimated the prevalence of ED in young men to be as high as 30%. Several studies have stratified the etiologies of ED into psychogenic and organic causes.

    Psychogenic etiologies of ED include depression, anxiety, and partner-related difficulties. These patients tend to experience sudden onset of symptoms, with decreased libido and good quality of spontaneous or self-stimulated erections.

    Organic etiologies include vasculogenic, endocrinologic, neurogenic, iatrogenic, and structural components. These patients usually experience gradual onset of symptoms and a low to normal libido. Conservative treatments such as phosphodiesterase type 5 inhibitors continue to be the mainstay treatment.

    Conclusions - ED in young men is an increasingly common condition. A careful diagnostic evaluation should focus on the identification of any underlying etiology to ensure appropriate management of patients.

    Attached Files:

  2. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Erectile Dysfunction: AUA Guideline

    Purpose - The purpose of this guideline is to provide a clinical strategy for the diagnosis and treatment of erectile dysfunction.

    Materials & Methods - A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1965 to 7/29/17) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of erectile dysfunction.

    Evidence-based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions.

    Results - The American Urological Association has developed an evidence-based guideline on the management of erectile dysfunction. This document is designed to be used in conjunction with the associated treatment algorithm.

    Conclusions - Using the shared decision-making process as a cornerstone for care, all patients should be informed of all treatment modalities that are not contraindicated, regardless of invasiveness or irreversibility, as potential first-line treatments. For each treatment, the clinician should ensure that the man and his partner have a full understanding of the benefits and risk/burdens associated with that choice.

    Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. The Journal of urology. Erectile Dysfunction: AUA Guideline

    Attached Files:

  3. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    [OA] Dehydroepiandrosterone and Erectile Function

    To review the contemporary knowledge regarding the dehydroepiandrosterone and erectile function. Medline was reviewed for English-language journal articles spanning the time between January 1990 and December 2017, using the terms 'erectile function', 'dehydroepiandrosterone'.

    We used Journal Articles and review articles that found to be relevant to the purpose of this review. Criteria included all pertinent review articles, randomized controlled trials with tight methodological design, cohort studies and retrospective analyses. We also manually revised references from selected articles.

    Several interesting studies have addressed the age-related decline in dehydroepiandrosterone levels with many age-related phenomena or deterioration in various physiological functions. Particularly, aging; neurological functions including decreased well-being, cognition, and memory; increased depression, decreased bone mineral density, obesity, diabetes, increased cardiovascular morbidity, erectile dysfunction (ED), and decreased libido.

    Supporting this result, some trials of dehydroepiandrosterone supplementation in healthy, middle-aged, and elderly subjects have reported improvements in different aspects of well-being. Several studies had demonstrated that dehydroepiandrosterone level is declined as a part of aging.

    Large-scale well-designed prospective studies are warranted to better define indications and therapeutic implications of dehydroepiandrosterone in men with ED.

    El-Sakka AI. Dehydroepiandrosterone and Erectile Function: A Review. World J Mens Health 2018.
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  4. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    An Update on Emerging Drugs for The Treatment of Erectile Dysfunction

    INTRODUCTION: Erectile dysfunction is an extremely frequent and extensively studied condition, currently affecting the lives of tens of millions of men around the globe. The extensive knowledge of its pathophysiology has led to the development of phosphodiesterase 5-inhibitors, which can facilitate sexual intercourse in a large number of patients. However, an ever-increasing number of patients is unresponsive to these drugs due to underlying comorbidities or previous surgery. Different molecular pathways need to be addressed to provide treatment for a larger patient population.

    AREAS COVERED: In this paper we will review the underlying molecular pathways, discuss already available treatment options and their limitations and provide an overview of the newest therapeutics in development. Centrally and peripherally acting agents will be discussed separately. Additionally, newest advances in regenerative medicine options will be discussed.

    EXPERT OPINION: Even though novel drugs have not been tested in a phase III setting, several phase II clinical trial results are eagerly awaited. These newest therapeutics could be applied as monotherapy or combination therapy in the subset of patients unresponsive to traditional treatment options.

    Milenkovic U, Campbell J, Roussel E, Albersen M. An update on emerging drugs for the treatment of erectile dysfunction. Expert opinion on emerging drugs 2018.
  5. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Sanches BC, Laranja WW, Alonso JC, Rejowski RF, Simoes FA, Reis LO. Does underestimated penile size impact erectile function in healthy men? International journal of impotence research 2018;30:158-62. Does underestimated penile size impact erectile function in healthy men?

    The aim of this study is to assess the impact of objective (stretched) and subjective penile size in the erectile function in a urological check-up program on a cross-sectional study including 689 men aged 35-70 years. IIEF-5 questionnaire, physical examination (penile length, prostate volume, blood pressure, body mass index-BMI), metabolic syndrome (MS), comorbidities, habits (sexual intercourse frequency, physical activity, alcohol, and tobacco use), level of education, serum glucose, total testosterone, estradiol, PSA, lipid profile, and self-perceptions (ejaculation time and subjective penile size) were examined in multivariate models using logistic and linear regressions.

    Penile objective mean length was 13.08 cm +/- 2.32 and 67 (9.72%) patients referred small penis self-perception. Seventy-six (11.03%) participants had severe erectile dysfunction (ED), 75 (10.88%) had mild to moderate and moderate ED, 112 (16.25%) had mild ED and 426 (61.83%) had no ED.

    Risk factors for ED that held statistical significance were
    · self-perceived small penis (OR = 2.23, 95% CI 1.35-3.69, p = .0017),
    · sexual intercourse frequency (per week) (OR = 0.45, 95% CI 0.38-0.52, p < .0001),
    · satisfactory ejaculation time (no vs. yes, OR = 2.06, 95% CI 1.46-2.92, p < .0001),
    · comorbidity (yes vs. no, OR = 2.01, 95% CI 1.46-2.76, p < .0001),
    · age >65 years (OR = 2.93, 95% CI 1.53-5.61, p < .0001),
    · tobacco use (yes vs. no, OR = 1.41, 95% CI 1.02-1.96, p < .0375),
    · regular physical activity (no vs. yes, OR = 1.59, 95% CI 1.13-2.23, p < .0083),
    · serum total testosterone < 200 ng/dl (OR = 3.48, 95% CI 1.69-7.16, p = 0.0009),
    · serum glucose > 100 mg/dl (OR = 1.69, 95% CI 1.18-2.43, p = 0.0044) and
    · systolic blood pressure > 130 mmHg (OR = 1.60, 95% CI 1.16-2.19, p = 0.0037).

    Results suggest that in addition to previously reported risk factors, patient's subjective impressions of penile size negatively impacts sexual life in about 10% of men considered healthy, while objective penile length does not play significant role in erectile function.
  6. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Erectile Dysfunction: An Umbrella Review of Meta-Analyses of Risk-Factors, Treatment, and Prevalence Outcomes

    INTRODUCTION: Erectile dysfunction (ED) is a major health care problem that has implications for quality of life. AIM: This umbrella review sought to synthesize all meta-analytic research on risk factors, treatment, and prevalence of ED.

    METHODS: 8 electronic databases were searched for relevant meta-analyses in June 2018. The evidence was graded with 2 measures that use quantitative criteria to establish the quality of report writing and confidence in the effect size reported.

    MAIN OUTCOME MEASURES: Lifestyle factors, genetic markers, medical conditions, treatments.

    RESULTS: In total, 98 meta-analyses were identified that included 421 meta-analytic effects, 4,188 primary-effects, and 3,971,122 participants. Pooled estimates showed that an unhealthy lifestyle, genetic markers, and medical conditions were associated with an increased risk of ED. testosterone therapy and phosphodiesterase type 5 inhibitors showed the greatest treatment efficacy, with mild adverse events observed across treatments.

    Psychological and behavior change interventions produced effect sizes that were comparable to medication but had greater imprecision in effect sizes. There was little evidence that combined treatments were more efficacious than single treatments. Meta-analyses of prevalence estimates showed consistent age trends but were limited to particular regions or clinical samples, meaning that global estimates of ED are difficult to determine.

    CLINICAL IMPLICATIONS: The umbrella review synthesized findings for many treatment options that might aid evidence-based clinical decision-making. Based on prevalence estimates, we recommend that primary care physicians take a proactive approach and enquire about erectile problems in all men over age 40 displaying any health-related issue (eg, overweight, cigarette smoking).

    STRENGTHS & LIMITATIONS: Strengths include the calculation and comparison of summary estimates across multiple meta-analyses. Limitations include heterogeneity in research quality across research themes limiting effect size comparisons.

    CONCLUSION: The review provides summary estimates for 37 risk factors and 28 treatments. Meta-analyses of risk factors often did not control for important confounders, and meta-analyses of randomized trials were not exclusive to double-blinded trials, active placebo controls, or tests of long-term effects. We recommend further meta-analyses that eliminate lower quality studies and further primary research on behavioral and combined treatments.

    Allen MS, Walter EE. Erectile Dysfunction: An Umbrella Review of Meta-Analyses of Risk-Factors, Treatment, and Prevalence Outcomes. J Sex Med 2019.
  7. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Current Diagnosis and Management of Erectile Dysfunction


    · 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.

    McMahon CG. Current diagnosis and management of erectile dysfunction. The Medical journal of Australia 2019.
  8. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Diagnostic and Therapeutic Workup of Erectile Dysfunction

    Introduction Erectile dysfunction is a highly prevalent condition. Existing guidelines provide recommendations for diagnosis and treatment, but they are often disregarded in clinical practice in favor of a “patient-tailored” approach. Objectives We planned a Delphi consensus method to bridge the gap between evidence-based medicine and the real-life approach in daily practice.

    Materials and Methods The Advisory Board prepared 15 statements on debated topics in andrology, each including 4–6 items designed as a 5-point Likert scale. After a validation phase, the questionnaire was sent by e-mail to a panel of experts for a first round of voting; members of the panel were later invited to a second round of voting, preceded by discussion of the “hot topics” identified in the first round.

    Results The first round of the Delphi consensus involved 101 experts; 71 (70%) also took part in the second round of voting. The Advisory Board deemed 22 items to be worthy of debate, and these underwent the second round of voting. “Real-life” results from the survey proved quite different from evidence-based recommendations.

    Conclusion Although guidelines suggest the best approach for a “standard” patient, real-life settings require flexibility. Diagnostic and therapeutic approaches should be tailored to the patients’ needs. Phosphodiesterase type 5 inhibitors are recognized as the first-line therapy in both settings, including the newly introduced sildenafil orodispersible film. Indications from the panel might help close the gap between recommendations from guidelines and real-life practice in relation to the diagnosis and treatment of erectile dysfunction.

    Isidori AM, Giammusso B, Corona G, Verze P. Diagnostic and Therapeutic Workup of Erectile Dysfunction: Results From a Delphi Consensus of Andrology Experts. Sexual medicine 2019. Diagnostic and Therapeutic Workup of Erectile Dysfunction: Results From a Delphi Consensus of Andrology Experts - ScienceDirect
  9. Michael Scally MD

    Michael Scally MD Doctor of Medicine

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  11. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Erectile Dysfunction Predicts Cardiovascular Events as an Independent Risk Factor

    Introduction - Previous studies demonstrating that erectile dysfunction (ED) predicts the risk of further cardiovascular events (CV) events are insufficient to make recommendations for cardiologists, diabetologists, urologists, and more, and the association between CV events and ED degree is unclear.

    Aim - To assess whether ED was a risk factor for CV events in a comprehensive literature review and meta-analysis.

    Methods - PubMed, EMBASE, the Cochrane Library, Medline, and the Web of Science were searched for eligible studies. The protocol for this meta-analysis is available from PROSPERO (CRD42018086138).

    Main Outcome Measures - The main outcomes included cardiovascular disease (CVD), coronary heart disease (CHD), stroke, and all-cause mortality. Subgroup and sensitivity analyses were conducted to detect potential bias.

    Results - 25 eligible studies involving 154,794 individuals were included in our meta-analysis. Compared with those of men without ED, the CVD risk of ED patients was significantly increased by 43% (relative risk [RR] =1.43; P < .001), CHD was increased by 59% (RR = 1.59; P < .001), stroke was increased by 34% (RR = 1.34; P < .001), and all-cause mortality was increased by 33% (RR = 1.33; P < .001). Older individuals with ED (≥55 years), those with ED of a shorter duration (<7 years), and those with higher rates of diabetes (≥20%) and smoking (≥40%) were more prone to develop CVD. Additionally, severe ED was proven to predict higher CVD and all-cause mortality risk. The standardized model proposed here can be properly applied for screening early CV events.

    Clinical Implications - The evidence prompts the diligent observation of at-risk men and reinforces the importance of early treatment to prevent CV events.

    Strengths & Limitations - Larger sample sizes from recent prospective cohort studies were included to provide more up-to-date, reliable, and comprehensive results. Moreover, the results were robust regarding consistency across sensitivity and subgroup analyses and remained consistent; even pre-excluded retrospective or cross-sectional studies were included. We constructed a standardized model that addresses the study’s innovations and implications for the first time. However, not all included studies were randomized controlled trials, which might downgrade this evidence.

    Conclusions - Risk of total CVD, CHD, stroke, and all-cause mortality was significantly increased in populations with ED, and severe ED is of particular concern. The evidence suggests the need for diligent observation of at-risk men and reinforces the importance of early treatment to prevent CV events.

    Zhao B, Hong Z, Wei Y, et al. Erectile Dysfunction Predicts Cardiovascular Events as an Independent Risk Factor: A Systematic Review and Meta-Analysis. J Sex Med 2019;16:1005–1017.
  12. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Erectile Dysfunction, Physical Activity and Physical Exercise

    Erectile dysfunction could be an early sign of endothelial dysfunction and, therefore, of cardiovascular disease, with which it shares many risk factors. Among reversible risk factors, physical inactivity is one of the most important.

    Regular physical exercise has been shown to improve erectile function through different mechanisms involving glucose and lipid metabolism, regulation of arterial pressure, production of nitric oxide and hormonal modulation. Furthermore, exercise shows a synergistic effect with the drugs commonly used in the treatment of impotence.

    Since many patients with erectile dysfunction may have underlying cardiovascular disease, the evaluation of individual cardiovascular risk is mandatory before prescribing physical exercise. When exercise is not contraindicated, the most appropriate protocol must be chosen, considering the individual characteristics of the patient. Both aerobic and anaerobic/resistance protocols have proven effective.

    However, meta-analytic studies show that aerobic exercise with moderate-to-vigorous intensity is the most effective in improving erection. testosterone is an important modulator of physical performance, and its blood levels must always be evaluated in patients with erectile dysfunction.

    Duca Y, Calogero AE, Cannarella R, et al. Erectile dysfunction, physical activity and physical exercise: Recommendations for clinical practice. Andrologia 2019;51:e13264.