The Faces of Erectile Dysfunction: Patient Care Strategies for Improved Sexual Health

Erectile dysfunction (ED), defined asa consistent or recurrent inability to achieve or maintain an erection sufficient for satisfactory sexual performance over a minimum period of three months, may be of physiological or psychological origins. The diagnostic requirement of three months’ duration is a recent addition to the definition intended to distinguish a chronic disorder from intermittent or transient bouts of erectile insufficiency attributable to acute stressors. The concept of satisfactory sexual performance has no quantitative standard; rather, each individual and partner has her/his own expectations.

Following a brief introduction to the etiology of and treatment options for ED, two faculty members presented four case studies designed to illustrate the diagnosis and treatment of ED associated with hypertension, diabetes, non-nerve-sparing radical prostatectomy, and psychological factors. Finally, a couple described in detail their experience with ED resulting from complications of a postoperative pelvic infection at the age of 12 years.

This program was supported by an unrestricted educational grant from Pfizer Inc.

Etiology and Treatment Options in ED

Christopher Forest, PA-C, who practices at the Male Clinic in Beverly Hills, CA and teaches in the Department of Family Practice at the Keck School of Medicine of the University of Southern California, chaired the symposium and lectured briefly on the etiology of ED and the current treatment options. He noted that because of the negative connotations associated with the word “impotence,” it is no longer used in medical discussion.

The principal risk factor for ED is arterial disease that decreases the normal blood flow to the corpus cavernosum, accounting for approximately 40% of cases. This category includes hypertension, hyperlipidemia, and all types of ischemic cardiovascular disease. Second in order of frequency is diabetes (30%) followed by prostatectomy and other pelvic surgical procedures (13%), and spinal cord injuries (8%). Deficiency of thyroid hormone is involved in a small portion of cases. Although hypogonadism, defined as an abnormally low testosterone production, is commonly thought to be a major cause of ED, it is seen infrequently. There is a strong correlation between depression and ED, and effective treatment of ED may significantly improve mild depression. Statistics on moderate to severe depression and other psychogenic causes of ED are unclear, but there is little doubt that they contribute to a significant fraction of cases, sometimes independently and sometimes as a comorbid condition.

First-line therapy for ED consists of sexual counseling and the treatment of any underlying pathology. Most cases require intervention, however, beginning with sildenafil, the only oral agent currently approved by the FDA for use in this disorder. Sildenafil citrate is a selective inhibitor of cyclic guanosine monophosphate-specific phosphodiesterase type 5 (PDE-5). The 50 mg dose is efficacious in approximately 77% of cases, and the 100 mg dose in approximately 84% of cases. Patients with diabetes and those who have undergone radical prostatectomy generally have lower success rates and may require other treatments. The principal side effects of sildenafil are headache (16%), which is successfully managed with standard analgesics taken prior to or concurrent with sildenafil, and clinically insignificant facial flushing (10%). Dyspepsia, usually relieved by antacids, occurs in approximately 7% of patients. Varying degrees of visual disturbance occur in 2.7% of men as the result of a crossover effect, namely, partial binding with PDE-6 receptors on the retina. Most often this is described as a blue coloration of white objects or unusual brightness of lights. Ophthalmologic studies have confirmed that there is no long-term effect on the patient’s vision.

Second-line therapy for ED may involve either mechanical or pharmacologic means. One common method, which yields modest results, is a vacuum-constriction device that fits over the penis and creates a vacuum with either a manual or electrical pump. The vacuum facilitates the flow of blood into the corpus cavernosum, and an elastic ring affixed to the base of the penis prevents outflow during sexual activity. The ring functions as a tourniquet and must not be left in place for more than 20 to 30 minutes. These devices, which cost approximately $400, are often regarded as undesirable “contraptions” by sexual partners. Thus counseling of both the patient and the partner prior to committing to the expense is advisable.

A more effective but more invasive second-line therapy for ED is injection of the corpus cavernosum with alprostadil, a synthetic prostaglandin E1. In most patients, this causes almost immediate vasodilation and an erectile response upon stimulation in 10 to 15 minutes lasting only as long as stimulation is continued, with efficacy for up to approximately 1 hour. Although the injection is not painful, many men reject it in favor of a pellet-like formulation of alprostadil that uses an applicator for direct deposit into the urethra. Although the package instructions urge the patient to stand or walk for 10 minutes while the erection is developing, because this agent is a vasodilator capable of inducing marked hypotension, standing is not advisable. Dose testing with blood pressure monitoring should be done in the office prior to prescribing this medication. The intraurethral form of alprostadil is not as effective as the injected formulation.

Patients who do not respond to first- or second-line therapies for ED may select more invasive methods such as penile implants. The simplest form involves placement of a flexible silicone rod in each of the corpora cavernosa that is used in erect position for sexual activity and bent downward at other times. The penis remains permanently elongated with this type of implant. An inflatable implant design includes two hollow silicone cylinders that are placed in the corpora cavernosa and a pump that is inserted in the scrotum. Prior to sexual activity, the pump is squeezed about 10 times to inflate the cylinders. Following intercourse, compression of the other end of the pump returns the penis to normal. Although the inflatable implant surgery is more expensive, it has the advantage of preserving the normal external appearance of the penis when flaccid. Patient satisfaction is generally high with both types of penile implant, provided that expectations are realistic.

The remaining alternative is revascularization surgery, used principally for young men who have suffered pelvic trauma. The technique is essentially an arterial bypass in which the inferior epigastric artery or similar artery is grafted to the pudendal vessels to enhance the blood supply to the penis. This is an uncommon and expensive procedure performed at only a few medical centers. In carefully selected patients, the success rate is approximately 50%. Patients over 45 years of age and those with diabetes respond poorly to revascularization.

In summarizing his presentation, Mr. Forest emphasized the importance of individualizing treatment for ED to both the patient and his partner after assessment of their treatment goals and expectations. Treatment should also be appropriate to the patient’s age and medical condition.

The Link between Hypertension and ED: A Case Study

Richard Sadovsky, MD (State University of New York Medical Center at Brooklyn) presented the case of a 55-year-old man who, consistent with JNC-VI guidelines, is taking beta-blockers and diuretics for hypertension. His hypertension is well controlled. During a follow-up visit, however, he complained of moderately progressive ED but denied having symptoms other than increased fatigue and decreased exercise tolerance. A physical examination and laboratory work-up revealed a weight gain of 12 pounds in 5 months and gradually rising cholesterol. During a stress test, ST- segment depressions were observed and he was referred for cardiac catheterization. A lesion of greater than 90% was found in the patient’s left anterior descending coronary artery leading to angioplasty and stenting. Four months later, following an apparently good result, he sought approval to resume sexual activity and help in improving his erections and his overall sex life.

The several issues involved in this case included the patient’s hypertension, which may cause ED, and the fact that he was taking beta-blockers and diuretics, both of which are among the many medications implicated in ED. The critical issue, however, was the advisability of resuming sexual activity despite his stable condition. Clinical studies indicate that healthy men have a slightly elevated risk of myocardial infarction for 2 hours following sexual activity, but it is extremely low. Sexual activity with a known partner expends three to four metabolic equivalents of oxygen, somewhat less than normal walking, golfing on foot, gardening and running. All of these place more stress on the heart than sexual activity. Because the patient had no active angina, a useful measure of his risk was his ability to walk up two flights of stairs without chest pain or shortness of breath. The Princeton Guidelines include this test among multiple criteria for assessing cardiovascular risk when contemplating the resumption of sexual activity. (Men with active angina, class 3 or 4 congestive heart failure, obstructive aortic valvular heart disease, or unstable arrhythmias are at high risk for acute events, and should be evaluated by cardiologists prior to resuming sexual activity.)

Because this patient was in the low-risk stratum, he was given sildenafil for ED. This medication is very safe for low-risk patients, with little probability of myocardial infarction during or following sexual activity with a known partner. Patients taking nitrate medications should not be given sildenafil, however, as the combination may result in decreases of as much as 50 mmHg and 30 mmHg in systolic and diastolic blood pressures, respectively, in a minority of patients.

Sildenafil is available in sample packets containing six 50 mg tablets and detailed instructions for use. Although sildenafil may be effective for some men in less than 30 minutes, to prevent patients from being discouraged, they should be instructed to wait one hour before attempting intercourse. Because anxiety may interfere with its efficacy during the first few attempts, patients should be counseled to make multiple attempts at sexual activity before evaluating this agent.

Dr. Sadovsky concluded by characterizing an erection as “a neurovascular event.” ED may be a sign of coronary artery disease or of arterial disease elsewhere. Progressive ED may indicate more diffuse vascular disease and should trigger consideration of a cardiovascular work-up.

ED in the Patient with Diabetes: A Case Study

Mr. Forest presented the case of a 44-year-old individual with insulin-dependent diabetes of 8 years’ duration and a 10-year history of worsening ED. (This is a commonly observed combination, because diabetes is frequently associated with “venous leak,” a phenomenon by which the corpus carvernosum fills with blood normally, but is unable to retain it.) Because of his inability to maintain erections, he avoided sexual relations for fear of an embarrassing failure. Laboratory tests indicated that his glycosylated hemoglobin (HbA1c) was slightly elevated, indicating only fair control of his diabetes. His hematology and chemistry including lipids were normal, and his testosterone was at the low border of the normal range. A RigiScan evaluation, conducted to determine the quality of spontaneous erections during REM sleep, indicated poor nocturnal erections consistent with vascular ED.

Following diagnosis, treatment options were presented to the patient together with advice that patients with venous insufficiency typically require higher doses of medications, including injected alprostadil. The patient opted for initial treatment with sildenafil 50 mg, with which he had a partial response. When the dose was doubled, he had a fully satisfactory response.

Diabetes is one of the most common causes of ED, and it presents a number of treatment challenges. At age 30, non-diabetic males have almost no ED, but at that age the prevalence among men with diabetes may be as high as 20%. At age 50, the prevalence is 5 to 7% in healthy males, but 40 to 50% in men with diabetes. With time, as diabetes-related arterial disease progresses, so, too, does ED, often requiring third-line therapy. Moreover, because patients withdiabetes may have silent myocardial infarctions and silent angina, evaluation of risk for acute events is essential prior to initiating pharmacologic therapy.

A third case study, also presented by Mr. Forest, involved a 65-year-old man with a prostate-specific antigen (PSA) level of 7.5 ng/ml. Following confirmation of a diagnosis of prostate cancer by transrectal ultrasound-guided biopsy, the patient underwent a bilateral nerve-sparing radical prostatectomy, which reduces the incidence of postoperative ED by approximately half. Following his surgery, however, he was unable to achieve erections when stimulated. His hematologic and chemical lab parameters were normal, and he had no evidence of significant cardiovascular or peripheral vascular disease. As would be expected in a case of organic ED, RigiScan revealed poor nocturnal erections. Thus he was diagnosed with neurogenic ED secondary to radical bilateral nerve-sparing prostatectomy.

After a discussion of treatment alternatives, the patient declined alprostadil injection and opted for sildenafil 50 mg. Although he had a good response, he requested an increased dose of 100 mg. Because the improvement was only minimal, he returned to regular use of sildenafil 50 mg, which is generally safe and efficacious in men who have had nerve-sparing prostate surgery. For men whose pudendal nerves have not been preserved, treatment of ED typically consists of alprostadil 20 µg ICI with in-office instruction, titrated upward or downward until either an adequate result or an intolerable side effect is reached. As the dose increases, some patients complain of a generalized ache in the penis unassociated with the injection site. If this occurs, either the dose should be reduced or the patient should be referred to a urologist for consideration of alprostadil combinations (e.g., phentolamine or phentolamine/papaverine), providing efficacy at a lower dose. If there is no improvement with a bimix or trimix, the possibility of penile implant is considered.

The case of a 41-year-old man was presented by Dr. Sadovsky. The patient had recently lost his job and appeared for a check-up complaining of difficulty sleeping and loss of appetite. Upon the urging of the clinician, he admitted a diminution of his libido and difficulty achieving and maintaining erections. His affect was muted and he admitted to depression. He was given a selective serotonin reuptake inhibitor (SSRI) to improve his mood while his sexual difficulties were being evaluated, even though these agents may cause delayed ejaculation and may contribute to ED.

This patient’s ED was attributed to loss of his job, one of many psychosocial stressors that may cause sexual difficulties. Several studies have indicated that sildenafil may be successful in the treatment of ED in patients taking antidepressants, although shifting from SSRIs to bupropion, which is less associated with ED, may be useful. In young patients with loss of libido, testosterone quantitation may be useful along with PDE-5 inhibitors such as sildenafil. Supportive counseling that includes the sexual partner, whether female or male, is also an important aspect of therapy.

When Sharon Ellis, JD, and Mark Henne, MS, JD, began to date seriously, Mark cautioned almost jokingly that he “might not be good in bed.” Because of his athletic appearance and good general health, Sharon brushed his comment off only to find later that Mark had severe chronic ED. The effort to concentrate on resolving the issue led to complex emotions of anger, abandonment, aloneness, and selfishness for Sharon, and failure, depression, and diminished self-esteem for Mark. Both were suffering and unfulfilled, though both acknowledged that the problem was no one’s fault. Ten years of individual and joint psychotherapy failed to resolve the ED problem despite the prevailing assumption at the time that 90% of ED had a psychologic origin.

The concept of a medical consultation was never raised during a decade of psychotherapy; but Sharon’s candid story of an unfulfilled marital life in response to a casual inquiry by her gynecologist resulted in Mark’s first visit to a urologist. Disappointingly, the diagnosis was that “it’s all in your head,” although Mark had reported that at the age of 12 years, he had had a ruptured appendix followed by peritonitis and an infected testis that grew to the size of a plum.

Subsequently, Sharon happened upon a televised program involving penile revascularization in a man with ED attributed to pelvic trauma from a bicycle accident. From this she learned something quite different: 90% of ED is of physiologic origin. With this information, Mark consulted a second urologist who, by ultrasound and arteriogram, determined that Mark’s left pudendal artery was completely occluded and his right pudendal artery was 50% occluded, presumably from infection 30 years earlier. After failing several drug therapies, Mark underwent penile revascularization and woke up the following morning with a nocturnal erection. Two months later, however, advancing scar tissue began to close the arteries again, and ED problems resumed. When sildenafil was approved by the FDA for the treatment of ED, Mark began to take it with fully satisfactory results for both parties. They testified that sildenafil has improved both their sex life together and the quality of their marriage. ED-related emotions are no longer barriers to their happiness.

The symposium concluded with a discussion, in which the audience participated, on communicating with patients with ED. The principal emphasis was on the difficulties of initiating a discussion about sexual health for both the patient and the clinician. Dr. Sadovsky urged the audience to minimize this problem by having copies of the Sexual Health Inventory for Men (SHIM) questionnaire available for men to read and complete during office visits.