Jama 2004;291:2994; Nejm 2000;342:1802; male and female—Jama 1999;281:537

Cause:Drugs including thiazides, -blockers, clonidine, alpha-methyldopa (Aldomet), cimetidine, SSRI and other psychiatric medications, chemotherapy of cancer, and a long list of others that occasionally cause it (Med Let 1987;29:65); diabetes (Nejm 1989;320:1025); prolactin tumors, male menopause, hypogonadism (high FSH and LH, low testosterone); endothelial dysfunction, prostatectomy, prostate irradiation

Prevalence = 39% at age 40 yr, 67% at age 70 yr (J Urol 1994;151:54); vs 7% at age 25 yr, 11% at age 45 yr, 18% at 55 yr (Jama 1999;281:537). In healthy thin men, <5% at age 50 yr, 10% at 60 yr, 20% at 70 yr, 60% at 80 yr (Ann IM 2003;139:161)

Si:Rectal exam for prostate nodules, neurologic and vascular exams

r/o ejaculatory dysfunction, decreased libido

Lab: Chem:Testosterone total and free, prolactin, LH, FSH, FBS, PSA

Rx:

(Jama 1997;277:7)

Testosterone 200 mg

• im q 2 wk;
• patch (Nejm 1996;334:710, Med Let 1996;38:49) as scrotal (Testoderm) 4-6 mg, or nonscrotal (Androderm) 2.5- to 5-mg patch q 24 h;
• topical gels like Testim (Med Let 2003;45:70) 50 mg qd, or Androgel (Med Let 2000;42:49); or
• buccal Striant (Med Let 2003;45:70) 30 mg bid. Above for men if testosterone deficient, but also help women w post-BSOO sexual dysfunction at 300 µgm/d? at least short term (Nejm 2000;343:682, 730). Adv effects poorly studied (Nejm 2004;350:482)

Bupropion 150 mg po qd-bid helps 30% including women; often used w antidepressants that decr sexual function

Vasoactive drugs:

• Alprostadil (MUSE) (prostaglandin E) 250-1000 µgm intraurethral pill, works 2/3 of the time (Nejm 1997;336:1) or less; or 5-40 µgm intracaverously, or w papaverine and phentolamine (Trimix); cmplc: local pain (33%), hypotension (3%); $20/dose
• Papaverine up to 60 µgm intracavernous, along with phentolamine, or alprostadil (prostaglandin E₁) (Nejm 1996;334:873; Med Let 1995;37:83) at 1.25 µgm if neurogenic, 5-10 µgm usually enough except higher doses to 60 µgm needed often in vascular impotence, erections should last <60 min, 1/d, <3/wk; $20/shot (10 or 20 µgm/cc), help 86%; self-administered with insulin syringe; cmplc: priapism (Med Let 1987;29:95) and penile fibrotic nodules, which are less common with alprostadil, but transient testicular pain is common; costly (Med Let 1990;32:116)
• Selective phosphodiesterase inhibitors: block enzyme that metabolizes vasodilating nitric oxide via cyclic quanosine monophosphate (cCMP); adverse effects: transient visual changes, severe hypotension if given w nitrates, -blockers, or HIV protease inhibitors, mild headache, facial flushing, indigestion, ok w other (non-nitrate) antianginal and HT meds (Nejm 2000;342:1622) and in pts w ASHD if not on nitrates (Jama 2002;287:719)
• Sildenafil (Viagra) (Med Let 1998;40:51; Nejm 1998;338:1397) 50-100 mg po (25 mg if on erythromycin, ketoconazole, or itraconazole, or in renal or hepatic failure) 1 h before anticipate intercourse, onset 25 min, duration 4 h; helps at least 70% (50-60% of diabetics—Jama 1999;281:421); also women on SSRI and other antidepressants (Jama 2008;300:395); avoid w/i 4 h of -blocker meds; adv effects: angina, MI and shock esp in pts on nitrates, ischemic optic neuropathy (Med Let 2005;47:49); $10/tab but all 3 strengths cost same so can buy 100-mg pills and break in half
• Vardenafil (Levitra) 2.5-20 mg po prn; onset 25 min, duration 4 h; don’t use w -blocker meds; $9/pill no matter size
• Tadalafil (Cialis) (Med Let 2003;45:101) 5-20 mg po prn; onset 45 min, duration 36 h; $9/pill no matter size

Vacuum/constriction devices: vacuum devices (Erecaid), or adjustable bands (Actis or Rejoyn) work but are clumsier

Prostheses, permanent or inflatable, surgically implanted