Erectile Dysfunction

H&P

• Check for psych factors, medications that may cause ED, and possible medical contributions to ED (DM2, obesity, CAD). Do physical exam to check for hypogonadism, peyronie’s disease, or other possible causes of ED.

Labs

• Total testosterone level (deficient if <300), TSH, lipid panel, A1C. Remember, ED can be a sentinel marker for CAD.

First-Line Treatment

• Phosphodiesterase-5 Inhibitors – all have equal efficacy. AE headache. Stop nitros!
  • Sildenafil (Viagra, 50-100mg) – take 1 hr prior, lasts up to 4 hrs
  • Tadalafil (Cialis, 10-20mg) – take 1-12 hrs prior, lasts up to 36 hrs
  • Vardenafil (Levitra, 10-20mg) – take 1 hr prior, lasts up to 4 hrs
• If ED 2/2 hypogonadism, treat with testosterone. Transdermal better than IM or PO. Check CBC, LFT, PSA regularly when on testosterone replacement therapy, due to AE of erythrocytosis, transaminitis, BPH, prostate cancer.
• If ED 2/2 libido, meds won’t help. Treat with behavioral therapy.

Second-Line Treatment

• Vacuum Pump
• Alprostadil – inject into corpus cavernosum. Better tolerated than intraurethral injection. AE priapism – ice bag. If doesn’t work, then go to EC to drain blood from corpus cavernosum. If this doesn’t work, inject phenylephrine.

Third-Line Treatment

• Refer to urology to consider inflatable penile implants.

Natural/Complementary Treatments

• Panax Ginseng 900mg TID has been shown in some studies to be effective.