Erectile Dysfunction PDF

Erectile Dysfunction KARL T. REW, MD, and JOEL J. HEIDELBAUGH, MD, University of Michigan Medical School, Ann Arbor, Michigan Erectile dysfunction (ED) is the inability to achieve or maintain an erection sufficient for satisfactory sexual perfor- mance. It is common, affecting at least 12 million U...

Erectile Dysfunction KARL T. REW, MD, and JOEL J. HEIDELBAUGH, MD, University of Michigan Medical School, Ann Arbor, Michigan Erectile dysfunction (ED) is the inability to achieve or maintain an erection sufficient for satisfactory sexual perfor- mance. It is common, affecting at least 12 million U.S. men. The five-question International Index of Erectile Func- tion allows rapid clinical assessment of ED. The condition can be caused by vascular, neurologic, psychological, and hormonal factors. Common conditions related to ED include diabetes mellitus, hypertension, hyperlipidemia, obe- sity, testosterone deficiency, and prostate cancer treatment. Performance anxiety and relationship issues are common psychological causes. Medications and substance use can cause or exacerbate ED; antidepressants and tobacco use are the most common. ED is associated with an increased risk of cardiovascular disease, particularly in men with meta- bolic syndrome. Tobacco cessation, regular exercise, weight loss, and improved control of diabetes, hypertension, and hyperlipidemia are recommended initial lifestyle interventions. Oral phosphodiesterase-5 inhibitors are the first- line treatments for ED. Second-line treatments include alprostadil and vacuum devices. Surgically implanted penile prostheses are an option when other treatments have been ineffective. Counseling is recommended for men with psy- chogenic ED. (Am Fam Physician. 2016;94(10):820-827. Copyright © 2016 American Academy of Family Physicians.) E More online rectile dysfunction (ED) is the reuptake inhibitors citalopram (Celexa), at http://www. inability to achieve or maintain an fluoxetine (Prozac), paroxetine (Paxil), aafp.org/afp. erection sufficient for satisfactory and sertraline (Zoloft), and the serotonin- CME This clinical content sexual performance.1 ED becomes norepinephrine reuptake inhibitor venlafax- conforms to AAFP criteria for continuing medical more common as men age (Figure 1).2 At ine. Bupropion (Wellbutrin), mirtazapine education (CME). See least 12 million U.S. men 40 to 79 years of (Remeron), and fluvoxamine are less likely CME Quiz Questions on age have ED.3 to cause ED.11 Tobacco, alcohol, and illicit page 791. drugs can cause ED.13,14 Marijuana use may Author disclosure: No rel- Diagnosis cause ED, although further study is needed.15 evant financial affiliations. The five-question International Index of METABOLIC SYNDROME Patient information: Erectile Function (IIEF-5) allows rapid ▲ A handout on this topic, clinical assessment of ED and can mea- ED has been linked to each component of the written by the authors of sure the effectiveness of ED treatments (see metabolic syndrome (eTable A), including this article, is available at http://www.aafp.org/ http://www.aafp.org/afp/2010/0201/p305. increased fasting serum glucose levels, dia- afp/2016/1115/p820-s1. html#afp20100201p305-t3). Other diagnos- betes, hypertension, and abdominal obesity, html. tic options include a single-question self- as well as to an increased risk of cardiovascu- assessment (Table 1) 4 and the Brief Male lar disease (CVD).16-22 Sexual Function Inventory.5 Low serum testosterone levels are one fac- tor that may explain the relationship between Causes and Related Conditions metabolic syndrome and ED.23 The adipose ED has vascular, neurologic, psychologi- tissue enzyme aromatase prevalent in obese cal, and hormonal causes. Conditions com- men converts testosterone into estradiol, a monly associated with ED include diabetes significant cause of hypogonadism.24-26 Adi- mellitus, hypertension, hyperlipidemia, pocytes also generate inflammatory cyto- obesity, testosterone deficiency, and prostate kines associated with impaired endothelial cancer treatment (Table 2).6-8 Performance function, cardiovascular events, and ED.27-29 anxiety and relationship issues are common Patients with diabetes are three times more psychological causes. likely to develop ED, and a longer duration of diabetes is strongly associated with ED.18,30,31 MEDICATIONS AND SUBSTANCE USE Metabolic syndrome is associated with a 2.6- Many medications cause or exacerbate ED fold increase in the incidence of ED, and the (Table 3).9-12 Antidepressants are a com- fasting blood glucose level is the component mon cause, especially the selective serotonin associated with the highest risk of ED.32,33 820 American Downloaded Family from the Physician American www.aafp.org/afp Family Physician website at www.aafp.org/afp. Volume Copyright © 2016 American Academy 94, Number of Family 10 ForNovember Physicians. the private, 15, ◆ 2016 noncom- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.  Erectile Dysfunction BEST PRACTICES IN UROLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN Sponsoring Recommendation organization mass index, and waist circumference to assess abdomi- Do not prescribe testosterone to men American nal obesity; a genital examination; and an assessment of with erectile dysfunction who have Urological normal testosterone levels. Association male secondary sex characteristics. Source: For more information on the Choosing Wisely Campaign, Laboratory Evaluation see http://www.choosingwisely.org. For supporting citations and to The A1C or fasting glucose level can be used to assess for search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm. diabetes. A lipid panel can assess for hyperlipidemia. A thyroid-stimulating hormone level is recommended for men with signs or symptoms of hypothyroidism. The probability of having undiagnosed diabetes is one in 50 among men 40 to 59 years of age who do not have ED, but increases to one in 10 for those with ED.34 Low Median High 100 CVD 90 ED and CVD share similar risk factors, including older Prevalence of erectile dysfunction (%) age, hypertension, dyslipidemia, smoking, obesity, and 80 74 diabetes. ED is associated with an increased risk of CVD, 70 76 coronary artery disease (CAD), stroke, and all-cause mortality, and it is probably an independent risk factor 60 50 for CVD.35 50 44 ED typically occurs two to five years before CAD, pro- viding a potential window during which men diagnosed 40 32 with ED can make lifestyle changes to prevent CAD.36 30 29 Men with ED are at higher risk of angina, myocardial 26 infarction, stroke, transient ischemic attack, congestive 20 heart failure, and cardiac arrhythmias compared with 16 10 6 3 men who do not have ED.37 Men with ED have a 75% 1 7 increased risk of developing peripheral vascular disease.38 0 40 to 49 50 to 59 60 to 69 70 to 79 ED has a positive predictive value for the development of CVD that is equal to or greater than that for smoking, Age (years) hyperlipidemia, or a family history of myocardial infarc- Figure 1. The prevalence of erectile dysfunction increases tion.37,39 ED can accurately predict silent CAD.40-45 ED in with age. men 40 to 49 years of age is more predictive of CAD than Information from reference 2. in older men.36 In one study, the incidence of CAD in men younger than 40 years who had ED was seven times that in the control population.46 ED is a useful marker Table 1. Single-Question Assessment for assessing cardiovascular risk, particularly in younger of Erectile Dysfunction men and minorities, for whom global risk assessment calculators may underestimate actual risk.47,48 Impotence means not being able to get and keep an Management of cardiovascular risk factors is recom- erection that is rigid enough for satisfactory sexual activity. mended in men who have ED but no known CVD.49,50 How would you describe yourself? Because diagnosing ED can help identify men at higher A. N ot impotent: always able to get and keep an erection risk of CVD, use of the IIEF-5 is also recommended dur- good enough for sexual intercourse. ing CVD risk assessment. B. Minimally impotent: usually able to get and keep an erection good enough for sexual intercourse. History and Physical Examination C. Moderately impotent: sometimes able to get and keep an erection good enough for sexual intercourse. Medical and surgical history, sexual history, use of medi- D. Completely impotent: never able to get and keep an cations and other substances, and an assessment of psy- erection good enough for sexual intercourse. chological and relationship health are key components of the patient history. Essential parts of the physical exami- Information from reference 4. nation include measurement of blood pressure, body November 15, 2016 ◆ Volume 94, Number 10 www.aafp.org/afp American Family Physician 821 Erectile Dysfunction Table 2. Erectile Dysfunction: Related Conditions and Approaches to Evaluation Related condition Approach to evaluation Routine measurement of testoster- Cardiovascular disease History and physical examination one levels is controversial. As part of the Diabetes mellitus A1C or fasting glucose level Choosing Wisely campaign, the Ameri- Endocrine disorders (e.g., hypo- History and physical examination; if can Urological Association recommends gonadism, hyperprolactinemia, an endocrine disorder is suspected, thyroid disorders) consider laboratory testing that physicians not prescribe testoster- Genital pain History one to men with ED who have normal Hyperlipidemia Lipid panel testosterone levels. A diagnosis of hypo- Hypertension Blood pressure gonadism must be based on more than Metabolic syndrome Blood pressure; fasting glucose, just an abnormal laboratory test result.51 high-density lipoprotein, Measurement of morning total testos- and triglyceride levels; waist terone may be considered for men with circumference small testes, lack of male secondary sex Neurologic conditions (e.g., multiple History and physical examination characteristics, significantly low libido, sclerosis, Parkinson disease, spinal or a history of inadequate response to cord injury, stroke) phosphodiesterase-5 (PDE-5) inhibi- Obesity Body mass index, waist circumference tors; if the initial result is abnormal, the Peyronie disease History and physical examination test should be repeated in a few months. Prostate cancer treatment History (e.g., surgery, radiation, hormone Free testosterone levels vary widely across therapy) laboratories and are not uniformly rec- Psychological conditions (e.g., anxiety, History ommended for screening. However, depression, guilt, history of sexual when hypogonadism is clinically sus- abuse, marital or relationship pected but the morning total testosterone problems, stress) level is repeatedly normal, bioavailable Sedentary lifestyle History testosterone or free testosterone may Tobacco use History account for the effects of sex hormone– Trauma History binding globulin levels on testosterone Venous leakage History and physical examination; activity. Levels of follicle-stimulating if venous leakage is suspected, consider urology consultation for hormone, luteinizing hormone, sex hor- venous flow testing mone–binding globulin, estradiol, and prolactin can help differentiate between Information from references 6 through 8. primary and secondary causes of testicu- lar hypogonadism.52 Table 3. Medications and Substances That May Cause or Contribute to Erectile Dysfunction Alcohol, nicotine, and illicit drugs (e.g., amphetamines, Antipsychotics (e.g., chlorpromazine, haloperidol, pimozide barbiturates, cocaine, marijuana, opiates) [Orap], thioridazine, thiothixene) Analgesics (e.g., opiates) Cardiovascular agents (e.g., digoxin, disopyramide Anticonvulsants (e.g., phenobarbital, phenytoin [Dilantin]) [Norpace], gemfibrozil [Lopid]) Antidepressants (e.g., lithium, monoamine oxidase inhibitors, Cytotoxic agents (e.g., methotrexate) selective serotonin reuptake inhibitors, serotonin- Diuretics (e.g., spironolactone, thiazides) norepinephrine reuptake inhibitors, tricyclic antidepressants) Hormones and hormone-active agents (e.g., 5-alpha- Antihistamines (e.g., dimenhydrinate, diphenhydramine reductase inhibitors, androgen receptor blockers, [Benadryl], hydroxyzine, meclizine [Antivert], promethazine) androgen synthesis inhibitors, corticosteroids, estrogens, Antihypertensives (e.g., alpha blockers, beta blockers, calcium gonadotropin-releasing hormone analogs, progesterones) channel blockers, clonidine, methyldopa, reserpine) Immunomodulators (e.g., interferon alfa) Antiparkinson agents (e.g., bromocriptine [Parlodel], levodopa, Tranquilizers (e.g., benzodiazepines) trihexyphenidyl) Information from references 9 through 12. 822 American Family Physician www.aafp.org/afp Volume 94, Number 10 ◆ November 15, 2016  Erectile Dysfunction Treatment of other agents are expected to be available in 2017 to 2019. An algorithm for the diagnosis and management of ED is Insurance coverage for these medications is limited, and shown in Figure 2.6-17,33,49-68 prescriptions may require prior authorization. LIFESTYLE MODIFICATIONS SURGICAL AND PROCEDURAL THERAPY Lifestyle modifications can improve IIEF-5 scores in Second-line treatments for ED include alprostadil men with ED.53 Regular exercise, weight loss in obese (Caverject) and vacuum devices. These treatments can or overweight men, and improved control of diabetes, hypertension, and hyperlipid- emia are recommended. Weight loss can Diagnosis and Management of Erectile Dysfunction modestly improve low testosterone levels, Have patient complete the five-item International although the extent of the benefit on ED is Index of Erectile Function questionnaire. unclear.54 Statin use seems to improve ED, as measured by IIEF-5 scores.55 Tobacco ces- Perform a focused history and physical examination: medical and surgical history, sation is highly recommended. Compared sexual history, use of medications and substances, psychological and relationship with men who have never smoked, the risk health. Measure blood pressure, body mass index, and waist circumference. of ED is increased by 51% in current smok- Perform a genital examination and assess for secondary sex characteristics. ers and 20% for ex-smokers.14 Obtain appropriate laboratory tests: fasting glucose or A1C, lipid panel. Consider MEDICATIONS morning total testosterone level and other laboratory tests if clinically indicated. Oral PDE-5 inhibitors are first-line treat- ments for ED.57 Sexual stimulation is needed Common causes present Common causes not present to produce an erection; the PDE-5 inhibitor helps to maintain the erection by enhancing the vasodilatory effects of endogenous nitric Optimize management of: Consider: oxide. Four PDE-5 inhibitors with similar Cardiovascular disease Stress test or cardiology consultation to effectiveness and safety profiles are currently Diabetes mellitus assess for undetected cardiovascular approved by the U.S. Food and Drug Admin- disease Hyperlipidemia Evaluation for possible endocrine, istration (FDA) for treatment of ED: avana- Hypertension neurologic, or psychological causes fil (Stendra), sildenafil (Viagra), tadalafil Hypogonadism (Table 2) (Cialis), and vardenafil (Levitra). Table 4 Metabolic syndrome Nocturnal penile tumescence testing summarizes these medications.56-58 All are Overweight or obesity Sexual health evaluation and counseling Psychogenic causes effective within about one hour of dosing Tobacco use cessation and are typically used on an as-needed basis. The effects may be delayed or decreased if the patient has recently eaten a fatty meal, First-line therapies: particularly for sildenafil and vardenafil.69 Lifestyle modifications PDE-5 inhibitors are ineffective in some Medication changes if needed (Table 3) men, particularly those with severe ED. Oral phosphodiesterase-5 inhibitor (if not contraindicated) Headache, flushing, and dyspepsia are com- mon adverse effects.58 PDE-5 inhibitors are contraindicated in men using nitroglycerin Second-line therapies: or other nitrates because of the risk of cata- Intraurethral or intracavernosal alprostadil (Caverject) strophic low blood pressure. Tadalafil has a Vacuum device longer half-life, which gives men the option of taking it up to 12 hours before sex or as a lower-dose, once-daily medication; however, Consider urology consultation for possible penile prosthesis implantation. adverse effects also last longer. Vardenafil is available as a 10-mg oral disintegrating tab- Figure 2. Algorithm for the diagnosis and management of erectile let. Sildenafil is the only PDE-5 inhibitor that dysfunction. is available generically; generic formulations Information from references 6 through 17, 33, and 49 through 68. November 15, 2016 ◆ Volume 94, Number 10 www.aafp.org/afp American Family Physician 823 Erectile Dysfunction Table 4. PDE-5 Inhibitors for Treatment of Erectile Dysfunction Minimum time from dosing to Medication* Dosage sexual activity Elimination half-time Cost for 10 tablets† Avanafil (Stendra) 50, 100, or 200 mg once daily 15 minutes Five to 10 hours NA ($350) as needed Sildenafil (Viagra) 20, 25, 50, or 100 mg once daily 30 minutes Three to five hours $10 ($475) as needed Tadalafil (Cialis) 10 or 20 mg once daily as needed 30 minutes 17.5 hours NA ($525) 2.5 or 5 mg once daily NA NA NA ($280 for 30 tablets) Vardenafil (Levitra) 10 or 20 mg once daily as needed 60 minutes Four to five hours NA ($465) NOTE: Contraindications include concomitant use of nitrates, stroke or myocardial infarction in the past six to eight weeks, significantly low blood pressure, uncontrolled high blood pressure, unstable angina, severe cardiac failure, severe liver impairment, and end-stage kidney disease requiring dialysis. Lower doses should be used in patients with chronic kidney disease or moderate liver impairment. NA = not available or not applicable; PDE-5 = phosphodiesterase-5. *—Other PDE-5 inhibitors not currently approved by the U.S. Food and Drug Administration include lodenafil, mirodenafil, and udenafil. †—Estimated retail cost based on information from http://www.goodrx.com (accessed July 27, 2016). Generic price listed first; brand price in parentheses. Information from references 56 through 58. be used to establish an erection before sexual stimula- left in place for more than 30 minutes. Vacuum devices tion. They should be avoided in men who are receiving can be cumbersome, require several minutes to produce anticoagulants or who have sickle cell disease or other an erection, may lead to bending at the base of the penis bleeding or clotting disorders. Alprostadil causes penile vasodilation by relaxing arterial smooth muscle; it is available in injectable and intraurethral forms and can be used in combination with PDE-5 inhibitors. Injectable alprostadil is adminis- tered intracavernosally into one side of the penis. Intra- urethral alprostadil is a dissolvable pellet that is placed into the urethra with an applicator.59 The injectable form is more effective.60 The lowest effective dose should be used, and the patient should be instructed on proper technique by administering a test dose in the physician’s office. Fear of needles or pain can limit patient accep- tance of alprostadil. Patients should be warned to seek emergency urologic treatment if an erection lasts four hours or longer. Penile fibrosis is another possible adverse effect; in one study, persistent fibrotic changes occurred in 4.9% of patients using intracavernosal alprostadil for four years.61 A similar ED treatment that has not been approved by the FDA is intracavernosal injection of compounded mixtures of alprostadil, papaverine, and phentolamine.60 Vacuum devices consist of a tube that is placed over the penis and sealed at the base with lubricant (Figure 3).62 A vacuum pump removes air from the tube, pulling blood into the penis and creating an erection. A constricting ring is then slid off the base of the tube onto Figure 3. Erec-Tech vacuum therapy system. the penis to maintain the erection. To prevent ischemic Reprinted with permission from Heidelbaugh JJ. Management of erectile damage, the constricting ring should generally not be dysfunction. Am Fam Physician. 2010;81(3):310. 824 American Family Physician www.aafp.org/afp Volume 94, Number 10 ◆ November 15, 2016  Erectile Dysfunction history can elicit potential causes such as SORT: KEY RECOMMENDATIONS FOR PRACTICE performance anxiety and relationship con- flicts, which distract attention and impair Evidence Clinical recommendation rating References sexual arousal. Problems such as premature ejaculation, genital pain, or dyspareunia can Current smoking is significantly associated with A 13, 14 lead to psychogenic ED, as can cultural or ED, and smoking cessation has a beneficial religious taboos or a history of sexual abuse. effect on the restoration of erectile function. Although men and their partners may resist Men with metabolic syndrome should be B 33 counseled to make lifestyle modifications to a psychological explanation for ED, coun- reduce the risk of cardiovascular events and ED. seling can be effective.60 Phosphodiesterase-5 inhibitors are the first-line A 57 ED of mixed organic and psychogenic ori- treatment for ED. gin is common. Psychogenic causes are more likely when the patient has normal erections ED = erectile dysfunction. with masturbation or when nocturnal penile A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited- tumescence is normal. Devices are available quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence to measure the number, duration, and rigid- rating system, go to http://www.aafp.org/afpsort. ity of erections during sleep. However, normal nocturnal erections do not always correlate with sexually relevant erections, and this test where the ring is in place, and will cause the erect penis may be unreliable in older or anxious patients.66 to seem cool or cold because of restricted blood flow. When ED coexists with depression or anxiety, treat- However, success and satisfaction rates are fairly high.63 ment of the mood disorder may be the most appropri- Vacuum devices can be used in combination with an ate first step. If antidepressants are used, the specific oral PDE-5 inhibitor or with alprostadil for men who agent should be one that is less likely to worsen ED (e.g., have not had success with single-component treat- bupropion, mirtazapine, fluvoxamine). PDE-5 inhibi- ment. These devices are also useful in men receiving tors are effective in men with depression and can be used daily nitroglycerin or other long-term nitrate therapy, in combination with treatments for mood disorders.67 in whom PDE-5 inhibitors are contraindicated. Patients This article updates previous articles on this topic by Heidelbaugh,62 can obtain vacuum devices at medical supply compa- Miller,70 and Viera, et al.71 nies by presenting a physician’s prescription. Insurance Data Sources: A computerized literature search was performed using the coverage varies. PubMed Clinical Query function to identify publications using the follow- ing terms: erectile dysfunction, male sexual dysfunction, cause/etiology, PROSTHESES treatment, phosphodiesterase type-5 inhibitors, metabolic syndrome. Surgically implanted penile prostheses are a third-line The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Additional sources searched included the Agency for treatment option for ED when other treatments have Healthcare Research and Quality, Cochrane database, Essential Evidence, been ineffective. Semirigid malleable prostheses are the National Guideline Clearinghouse, and U.S. Preventive Services Task Force. simplest and easiest to implant, but they can be difficult The search was limited to English-language studies involving human to conceal because the penis is always erect. Inflatable subjects. Abstracts, book chapters, and case studies were excluded. Bibli- ographies from index citations were also reviewed for additional relevant prostheses typically consist of two tubes that replace the studies. Search dates: March 27, 2016, and June 20, 2016. corpora cavernosa, plus a pump in the scrotum and an intra-abdominal reservoir (eFigure A). Mechanical fail- The Authors ure or infection may require removal of the prosthesis. Risks include scarring, penile shortening, and recurrent KARL T. REW, MD, is an assistant professor in the Departments of Family Medicine and Urology at the University of Michigan Medical School, Ann infections. Prostheses coated with antibiotics have been Arbor. used to reduce the risk of infection.64 JOEL J. HEIDELBAUGH, MD, FAAFP, FACG, is a professor in the Depart- Managing Psychogenic ED ments of Family Medicine and Urology at the University of Michigan Medi- cal School. Many men have ED that is predominantly or exclu- Address correspondence to Karl T. Rew, MD, University of Michigan sively caused by psychological or interpersonal fac- Medical School, 24 Frank Lloyd Wright Dr., Lobby H, Ann Arbor, MI tors.65 Psychogenic ED occurs at all ages but is most 48105 (e-mail: [email protected]). Reprints are not available from common in men younger than 40 years. A thorough the authors. November 15, 2016 ◆ Volume 94, Number 10 www.aafp.org/afp American Family Physician 825 Erectile Dysfunction ment in patients with erectile dysfunction? 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Vlachopoulos C, Rokkas K, Ioakeimidis N, et al. Prevalence of asymptom- 21. Tomada N, Tomada I, Botelho F, Cruz F, Vendeira P. Are all metabolic atic coronary artery disease in men with vasculogenic erectile dysfunc- syndrome components responsible for penile hemodynamics impair- tion: a prospective angiographic study. Eur Urol. 2005;48(6):996-1002. 826 American Family Physician www.aafp.org/afp Volume 94, Number 10 ◆ November 15, 2016  Erectile Dysfunction 43. Montorsi P, Ravagnani PM, Galli S, et al. Association between erectile 57. Yuan J, Zhang R, Yang Z, et al. Comparative effectiveness and safety of dysfunction and coronary artery disease. Role of coronary clinical pre- oral phosphodiesterase type 5 inhibitors for erectile dysfunction: a system- sentation and extent of coronary vessels involvement: the COBRA trial. atic review and network meta-analysis. Eur Urol. 2013;63(5): 902-912. Eur Heart J. 2006;27(22):2632-2639. 58. Ückert S, Kuczyk MA, Oelke M. 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Erectile dysfunction as a predictor alprostadil alfadex—an effective and well tolerated treatment for erec- for subsequent atherosclerotic cardiovascular events: findings from a tile dysfunction. Results of a long-term European study. Int J Impot Res. linked-data study. J Sex Med. 2010;7(1 pt 1):192-202. 1998;10(4):225-231. 47. Marma AK, Berry JD, Ning H, Persell SD, Lloyd-Jones DM. Distribution 62. Heidelbaugh JJ. Management of erectile dysfunction. Am Fam Physi- of 10-year and lifetime predicted risks for cardiovascular disease in US cian. 2010;81(3):305-312. adults: findings from the National Health and Nutrition Examination 63. Pahlajani G, Raina R, Jones S, Ali M, Zippe C. Vacuum erection devices Survey 2003 to 2006. Circ Cardiovasc Qual Outcomes. 2010;3(1):8-14. revisited: its emerging role in the treatment of erectile dysfunction and 48. Billups KL, Bank AJ, Padma-Nathan H, Katz S, Williams R. Erectile dys- early penile rehabilitation following prostate cancer therapy. J Sex Med. function is a marker for cardiovascular disease: results of the Minority 2012;9(4):1182-1189. Health Institute expert advisory panel. J Sex Med. 2005;2(1):40-50. 64. Gurtner K, Saltzman A, Hebert K, Laborde E. Erectile dysfunction: a review 49. Kostis JB, Jackson G, Rosen R, et al. Sexual dysfunction and cardiac risk of historical treatments with a focus on the development of the inflatable (the Second Princeton Consensus Conference). Am J Cardiol. 2005; penile prosthesis. Am J Mens Health. Published online ahead of print July 96(2):313-321. 23, 2015. http://jmh.sagepub.com/content/early/2015/07/21/155798831 50. Nehra A, Jackson G, Miner M, et al. The Princeton III Consensus recom- 5596566.long [subscription required]. Accessed March 26, 2016. mendations for the management of erectile dysfunction and cardiovas- 65. Rosen RC. Psychogenic erectile dysfunction. Classification and manage- cular disease. Mayo Clin Proc. 2012;87(8):766-778. ment. Urol Clin North Am. 2001;28(2):269-278. 51. Paduch DA, Brannigan RE, Fuchs EF, et al. The laboratory diagnosis of testos- 66. Papagiannopoulos D, Khare N, Nehra A. Evaluation of young men with terone deficiency. Urology. 2014; 83(5):980-988. organic erectile dysfunction. Asian J Androl. 2015;17(1):11-16. 52. Shabsigh R, Kaufman JM, Steidle C, Padma-Nathan H. Randomized study 67. Makhlouf A, Kparker A, Niederberger CS. Depression and erectile dys- of testosterone gel as adjunctive therapy to sildenafil in hypogonadal function. Urol Clin North Am. 2007;34(4):565-574, vii. men with erectile dysfunction who do not respond to sildenafil alone. 68. Rosen RC, Cappelleri JC, Smith MD, et al. Development and evaluation of an J Urol. 2004;172(2):658-663. abridged, 5-item version of the International Index of Erectile Function as a 53. Gupta BP, Murad MH, Clifton MM, Prokop L, Nehra A, Kopecky SL. The diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11(6):319-326. effect of lifestyle modification and cardiovascular risk factor reduction 69. Hawksworth DJ, Burnett AL. Pharmacotherapeutic management of on erectile dysfunction: a systematic review and meta-analysis. Arch erectile dysfunction. Clin Pharmacol Ther. 2015;98(6):602-610. Intern Med. 2011;171(20):1797-1803. 70. Miller TA. Diagnostic evaluation of erectile dysfunction. Am Fam Physi- 54. Corona G, Rastrelli G, Monami M, et al. Body weight loss reverts obesity- cian. 2000;61(1):95-104. associated hypogonadotropic hypogonadism: a systematic review and 71. Viera AJ, Clenney TL, Shenenberger DW, Green GF. Newer pharma- meta-analysis. Eur J Endocrinol. 2013;168(6):829-843. cologic alternatives for erectile dysfunction [published correction 55. Kostis JB, Dobrzynski JM. The effect of statins on erectile dysfunction: a appears in Am Fam Physician. 2000;61(8):2344]. Am Fam Physician. meta-analysis of randomized trials. J Sex Med. 2014;11(7):1626-1635. 1999;60(4):1159-1166. 56. Brant WO, Bella AJ, Lue TF. Treatment options for erectile dysfunction. Endocrinol Metab Clin North Am. 2007;36(2):465-479. November 15, 2016 ◆ Volume 94, Number 10 www.aafp.org/afp American Family Physician 827  Erectile Dysfunction eTable A. Diagnostic Criteria for Metabolic Syndrome Clinical measure Criteria* Blood pressure† Systolic ≥ 130 mm Hg or diastolic ≥ 85 mm Hg Fasting blood glucose level ≥ 100 mg per dL (5.6 mmol per L) High-density lipoprotein level† Men < 40 mg per dL (1.04 mmol per L); women < 50 mg per dL (1.29 mmol per L) Triglyceride level† ≥ 150 mg per dL (1.7 mmol per L) Waist circumference‡ Asians: men ≥ 35.5 inches (90 cm); women ≥ 31.5 inches (80 cm) Blacks: men ≥ 37 inches (94 cm); women ≥ 31.5 inches Hispanics: men ≥ 35.5 inches; women ≥ 31.5 inches Whites: men ≥ 37 inches; women ≥ 31.5 inches§ *—Criteria listed are the harmonized criteria proposed by the joint statement from the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. At least three criteria must be present to diagnose metabolic syndrome. †—Patients currently receiving drugs to manage lipid disorders or high blood pressure are considered positive for these criteria. ‡—Thresholds according to International Diabetes Federation recommendations. §—Thresholds for white patients differ significantly according to the recommending organization. Thresholds listed are from the International Diabe- tes Federation. However, the American Heart Association and National Heart, Lung, and Blood Institute set thresholds of 40 inches (102 cm) for U.S. men and 34.5 inches (88 cm) for U.S. women, noting that there is increased risk at the lower International Diabetes Federation values. Adapted with permission from Mayans L. Metabolic syndrome: insulin resistance and prediabetes. FP Essent. 2015;435:12. eFigure A. Coloplast Alpha-1 inflatable penile prosthesis. Reprinted with permission from Heidelbaugh JJ. Management of erectile dysfunction. 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