Outpatient / Cardiology
Erectile Dysfunction
#Erectile Dysfunction
Intake
-- History: *** age, sex, and health of partner; onset, difficulty achieving, maintaining erections, AM erections, prev trauma, prostate surgeryPeyronies, loss of libido, premature ejaculation, anorgasmia, h/o vascular disease (CAD, PAD) or diabetes
-- Meds: *** spironolactone, finasteride, SSRI (paroxetine, sertraline), B-blockers,
-- Clinical: *** secondary sexual characteristics (body hair, facial hair, habitus), peripheral pulses, breast exam, testicular volume, varicocele
-- Etiology: *** psychogenic, drug-induced, vascular, hormonal, neurologic
Plan
-- Labs (only if c/f non-psychogenic etiology): *** A1c, lipids, CBC, CMP, AM (before 10am) serum total testosterone (then LH/FSH if testosterone low)
-- Lifestyle: *** weight loss, exercise, smoking cessation, management of HTN, diabetes, OSA
-- Tx: *** sildenafil - 50-100mg taken on an empty stomach one hour before sex and effective up to four hours (do not use with nitrates); tadalafil - up to 36 hours - can take 5mg daily (get to steady state) or 10-20mg PRN around 1 hour before sex, trazodone - 25-100mg daily at bedtime for psychogenic ED
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Patient Guidance and Information
Prescribing Sildenafil
For erectile dysfunction, we can prescribe a medication called ***.
Please take *** 1 hour prior to sexual activity. Do not take more than one dose per day.
Side effects can include headaches, upset stomach, , diarrhea, blue tinge to your vision, or other visual disturbances. Please let us know if you experience any of these side effects, or experience an erection for longer than 4 hours, or a painful erection.
Never take *** with nitrates for chest pain - you should wait at least 48 hours after taking nitrates.
Prescribing Tadalafil
For erectile dysfunction, we can prescribe a medication called ***.
Please take *** at the same time each day regardless of when you plan to have sex. This medicine lasts up to 36 hours. Do not take more than one dose per day.
Side effects can include headaches, upset stomach, diarrhea, blue tinge to your vision, or other visual disturbances. Please let us know if you experience any of these side effects, or experience an erection for longer than 4 hours, or a painful erection.
Never take with nitrates for chest pain - you should wait at least 48 hours after taking nitrates.
If You Remember Nothing Else
Erectile dysfunction (ED) is a common issue defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual activity. Normalize talking about sex and asking male patients about ED. The majority of care for ED patients can be done by PCP. Lifestyle modifications, such as weight loss, exercise, smoking cessation, and management of hypertension, diabetes, and obstructive sleep apnea, can improve ED. Treatment options include medications like sildenafil or tadalafil, which are phosphodiesterase type 5 inhibitors (PDE5i). Sildenafil, taken in doses of 50-100mg on an empty stomach one hour before sexual activity and is effective for up to four hours. Tadalafil can be taken daily (5mg) or as needed (10-20mg) about one hour before sexual activity, and its effects last up to 36 hours. For psychogenic ED, trazodone (25-100mg daily) can be taken at bedtime. Side effects of sildenafil may include headaches, dyspepsia, vasodilation, diarrhea, rhinitis, epistaxis, and visual disturbances. It is essential to avoid taking PDE5i with nitrates, as this may cause a significant drop in blood pressure. These medications require sexual stimulation to work and do not cause dependence. If ED treatments are not effective, referral to a urologist may be necessary to discuss alternative options, such as vacuum pumps, injections, or penile implants. Remember that the severity of ED may correlate with the risk of cardiovascular events, so it is crucial to consider undiagnosed cardiac risk factors in these patients.
Clinical Pearls
- When to Refer: send to urology if no efficacy after trialing PDE4i - to discuss vacuum pumps, injections (papaverine, phentolamine, alprostadil), penile implants
- ED is defined as the inability to get or maintain an erection sufficient for penetration to the point of sexual satisfaction or orgasm
- Intake can be standardized using the SHIM (Standardized Health in Men) - link
- Testosterone reference range based on AM draw - variation more significant in young men
- Degree of ED correlates with risk of cardiovascular events - should consider if these patients have cardiac risk factors that are undiagnosed
- PDE5i Pearls - don’t give with nitrates within same 24 hour period (may drop BP due to vasodilation); tadalafil is longer acting but same potency as sildenafil; tadalafil is also approved for BPH - can help with both (better option then finasteride); sildenafil needs to be taken on an empty stomach - guidance to take before dinner on date night, will last ~8 hours; sildenafil will not have increased potency for erections above 100mg, but will lead to more side effects - need to counsel patients not to take more than needed; these meds do not cause priapism despite the ads everyone sees; they will NOT get a spontaneous erection - still need to have stimulation; these drugs will not cause dependence and you may not need it forever
- Often not covered by insurance - options are CostPlusDrugs and GoodRx, and patients can ask for the cash price which since sildenafil is generic isn’t always that bad
- The benefit of injections is no systemic symptoms
- L-Arginine supplementation can be considered if patients are interested in that realm
Other Resources
- Curbsiders: #317 Erectile Dysfunction
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