Overview
This discussion covers the assessment, pathophysiology, diagnosis, and treatment strategies for erectile dysfunction (ED), with particular focus on differentiating psychogenic and organic causes, mechanisms of common medications, lifestyle interventions, and diagnostic protocols.
ED Diagnostic Criteria and Evaluation
- ED is present if a man cannot achieve or maintain an erection sufficient for penetration or orgasm, even if infrequent.
- The most common initial symptom is inability to maintain an erection, often indicating venous leak.
- Inability to ejaculate with normal erections and maintenance is a separate issue from ED.
- Psychogenic ED is more typical in younger patients and is distinguished by normal erections during masturbation and/or morning erections.
Etiologies and Mechanisms
- Major causes of ED include vascular, endocrine, neurologic, trauma, medication-induced, and psychogenic factors.
- Medications like beta blockers and anti-androgens can contribute to ED.
- Organic and psychogenic ED are treated differently, with psychogenic forms often responding well to sex therapy and daily low-dose Cialis.
Treatment Approaches
- Phosphodiesterase type 5 inhibitors (e.g., Viagra, Cialis) promote erection by blocking cyclic GMP breakdown, prolonging smooth muscle relaxation and blood inflow.
- Daily Cialis may offer preventative benefits by promoting smooth muscle hypertrophy and maintaining penile health.
- Newer agents like avanafil may have fewer side effects but are not yet available as generics.
- Mechanical approaches (e.g., penile bands) and procedural interventions (e.g., injections) can address venous leak.
- Lifestyle modifications—diet, exercise, sleep, and stress reduction—significantly impact erectile function.
Pathophysiology of Age-Related Changes
- Aging leads to atrophy and fibrosis of penile muscle, reducing the ability to sustain erections due to loss of venous occlusion.
- Lower testosterone also contributes to muscle atrophy and ED.
- Regular sexual activity and nocturnal erections help maintain muscle tone and tissue oxygenation.
Diagnostic Procedures
- Penile Doppler ultrasound, combined with intracavernosal injection, assesses arterial inflow (peak systolic velocity) and venous leak (end diastolic velocity).
- Peak systolic velocity under 30 mL/sec (especially below 25) suggests arterial insufficiency; end diastolic velocity above 5 mL/sec indicates venous leak.
Relationship with Cardiovascular Health
- ED and cardiovascular disease share similar risk factors, with ED often serving as an early indicator ("canary in the coal mine") for cardiovascular events.
- Improving metabolic parameters (e.g., lowering hemoglobin A1c) and lifestyle changes can reverse or improve ED.
Medication Use and Practical Considerations
- Generics for ED drugs are now widely available and affordable, with some concerns about consistency in efficacy.
- Daily Cialis is also FDA-approved for benign prostatic hyperplasia (BPH) and pulmonary hypertension, though mechanism for BPH remains unclear.
Decisions
- Daily low-dose Cialis is recommended both as therapy and a preventive measure for men noticing early or mild ED.
Recommendations / Advice
- Lifestyle modification—focusing on diet, exercise, sleep, and stress reduction—is strongly advised for all men with sexual dysfunction.
- Monitor for cardiovascular risk factors in men presenting with organic ED, as ED may precede overt cardiovascular disease.