Erectile Dysfunction

Overview: Erectile Dysfunction

• Erectile dysfunction (ED), the most common sexual problem in men, affects up to one third of men at some point in their lives. ED is defined as the inability to achieve or maintain a sufficient erection for satisfactory sex.

• The prevalence of ED increases with age. and ED is associated with poor cardiovascular health, psychosocial factors, hormonal dis-orders, recreational drug abuse, and adverse effects from prescribed medications.

• Less common are anatomic, traumatic, or infectious causes. Normally, an erection is stimulated by a combination of neurovascular, hormonal, and environmental factors beginning with sexual interest and desire.

• Through parasympathetic activation, endothelial cells are directly activated to produce nitric oxide (NO), which is the major hormonal mediator needed to initiate and main tainan erection.

• With NO present, the corpus cavernosum is engorged with arterial blood as a result of smooth muscle endothelial relaxation while venous return is simultaneously restricted.

Important points to consider

• Presentation of erectile dysfunction is a window of opportunity to improve health and reverse the development of cardiovascular disease.

• The most important recommendation to prevent erectile dysfunction is to encourage overall healthy behaviors to improve well-being and reduce the incidence of chronic disease.

Prevention Prescription

• Obtain regular vigorous exercise most days of the week for 30 to 60 continuous minutes.

• Follow a healthy calorie-controlled antiinflammatory or Mediterranean diet rich in phytonutrients and antioxidants (organic fruits and vegetables), omega-3 fatty acids, whole grains, nuts, seeds, legumes, filtered water, green or rooibos tea, and lean or organic meats.

• Reduce stress through rest, vacation, meditation, breathing exercises, yoga, journaling, sauna, and selected manual therapies.

• Maintain healthy sexual relationships, good communication, and regular erections and ejaculations (three times/week).

• Avoid tobacco, marijuana, and other illegal or recreational drugs.

• Be moderate with alcohol consumption (2 drinks or less per day on average).

• Avoid antinutrients such as high-fructose corn syrup, trans fats, artificial sweeteners, colors, or preservatives, and processed foods. Avoid pesticides, herbicides, and overuse of chemical or cleaning products.

• Avoid heating or storing food in plastics (e.g., bisphenol-A endocrine and hormone disruptor).

Integrative therapeutics review

Workup and Evaluation

• History with International Index of Erectile Function-5 (IIEF-5) short survey and medication review

• Physical examination with blood pressure, body mass index, and genitourinary examination

• Laboratory tests (complete blood count, fasting glucose and lipids, electrolytes, creatinine, liver function tests, thyroid-stimulating hormone, prostate-specific antigen, morning total serum testosterone)

Lifestyle

• Antiinflammatory diet

• Weight loss

• Regular exercise 30 to 60 minutes daily

• Stress reduction

• Smoking cessation"

• Alcohol reduction

First-Line Pharmaceuticals

• Trial of phosphodiesterase type 5 inhibitor

• Sildenafil (Viagra): 25 to 100 mg orally daily as needed or

• Vardenafil (Levitra): 5 to 20 mg orally daily as needed or

• Tadalafil (Cialis): 5 to 20 mg orally every 72 hours as needed

Nutraceuticals

• Yohimbine: 5 to 10 mg three times daily

• Panax ginseng: 900 mg three times daily

• Pycnogenol: 40 mg three times daily with or without 500 to 1000 mg of L-arginine three times daily

• L-Arginine: 1000 to 2000 mg three times daily

• Saffron: 200 mg daily (particularly in erectile dysfunction with depression)

• Propionyl-1-carnitine: 1000 mg twice daily (to improve sildenafil response)

• Avoidance of proprietary or low-quality brands

Mind-Body Therapy

• Psychotherapy for patients with mood disorder, posttraumatic stress disorder, sex abuse history, relationship strain, or performance anxiety

• Stress reduction through yoga, meditation, breathing, massage, journaling, psychotherapy, and rest

Second- and Third-Line Therapies

• Vacuum erection or constriction devices with training or

• Alprostadil (Muse) urethral suppositories: 125- to 1000-mcg pellet intraurethrally daily as needed or

• Alprostadil (Caverject) injections: 2.5 to 7.5 mcg intracavernosal injection three times weekly as needed or

• Surgery with urology referral

Hormone Replacement

• Hypogonadism or testosterone deficiency diagnosis, low total serum testosterone less than 300 ng/dL..

• Topical testosterone: 12.5 to 100 mg every morning titrated to normal laboratory levels checked every 4 weeks until stable

• Compounded bioidentical testosterone

• Serum total testosterone laboratory test every 4 weeks until stable and then every 6 to 12 months

• Initial and annual serum total testosterone, complete blood count, liver function tests, and prostate-specific antigen laboratory tests with genitourinary examination

Key Web Sources

• http://www.cornellurology.com/sexualmedicine/ed

• http://www.titanhealthcare.co.uk/index.cfm/go/home

• http://www.nlm.nih.gov/medlineplus/erectiledysfunction.html

• http://www.aasect.org

• http://www.mayoclinic.com/health/erectile-Patientdysfunction-herbs/MC00064/METHOD=print

• http://www.pennmedi cine.org/encyclopedia/em PrintArticle.aspx?cid=003339&ptid=1