Treatment of erectile dysfunction

A. Testosterone cypionate (200 mg IM q 2 weeks) or testosterone patches may be beneficial if the serum-free testosterone is low (<9 ng/dL). Older males (>50 years) are at risk for development of prostate cancer. A careful rectal examination and PSA testing is recommended prior to institution of, and during, testosterone therapy. Patients with elevated prolactin and a pituitary secreting tumor should be referred to an endocrinologist or neurosurgeon for bromocriptine treatment or surgical ablation.

B. Sildenafil (Viagra) is the only oral medication available for erectile dysfunction. A type-5-phosphodiesterase inhibitor, the drug potentiates the effects of nitrous oxide on sinusoidal smooth muscle. It comes in 25, 50, and 100 mg tablets which should be taken about 1-1.5 hours prior to intercourse. Initial dose is 50 mg at a maximum frequency of one per day. The dose can be increased up to 100 mg. The drug can potentiate the hypotensive effects of nitrates; therefore, nitrate us is an absolute contraindication. Adverse reactions include headache and changes in vision. Other oral medications awaiting FDA approval include phentolamine

(Vasomax) and apomorphine.

C. Vacuum constriction devices (VCD) are an effective treatment alternative for erectile dysfunction. The design involves a plastic cylinder that is placed on the penis with negative pressure created. A constriction band is placed at the base of the penis. Almost every patient can be a candidate for these devices. Contraindications include penile angulation deformity, prior history of priapism, and patients taking anticoagulants.

D. Pharmacologic injection therapies include papaverine, phentolamine, and prostaglandin E-1 (PGE-1), either as single agents or in combination therapy. The only FDA-approved medications for injection are Caverject and Edex.

E. Intraurethral prostaglandin suppositories (MUSE), have the advantage that penile injection is not necessary. MUSE comes in four dosages-125, 250, 500, and 1000 mcg. A condom should be used for intercourse with a pregnant female. The response rate of is 40-60%.

F. Surgical treatment of erectile dysfunction consists of placement of a penile prosthesis. This therapy should only be considered if all other options have been explored. Devices available include semirigid or inflatable prostheses. An occasionally indicated treatment option is vascular surgery.

References: See page 195.

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