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Additionally, the study found a decrease in sexual desire with increasing age.

Men in the oldest cohort (50 to 59) were more than 3 times as likely to experience erection problems and to report low sexual desire compared with men 18 to 29.

Experience of sexual dysfunction was more likely among buy professional viagra men in poor physical and emotional health. The study also concluded that sexual dysfunction is an important public health concern and that emotional issues are likely to contribute to the experience sexual dysfunction. The development of an erection is a complex event involving integration of psychologic, neurologic, endocrine, vascular, and local anatomic systems. Positron emission tomography scanning studies have suggested that sexual arousal is activated in higher cortical centers that then stimulate the medial preoptic and paraventricular nuclei of the hypothalamus.

5 These signals ultimately descend through a complex neural network involving the parasympathetic nervous system and eventually activate parasympathetic nerves in the sacral area (S2 to S4). The neurovascular events that ultimately occur result in the inhibition of adrenergic tone and the release of the nonadrenergic, noncholinergic neurotransmitter, nitric oxide.

Nitric oxide is believed to be released from nonadrenergic, noncholinergic nerves and endothelial cells.

It subsequently stimulates the guanylate cyclase enzyme system in penile smooth muscle.

This results in increased levels of cyclic guanosine monophosphate (cGMP) and ultimately in smooth muscle relaxation, enhancement of arterial inflow, and veno-occlusion, producing adequate firmness for sexual activity. Recognized risk factors for ED include cardiovascular disease (CVD) (hypertension, atherosclerosis, and hyperlipidemia), diabetes, depression, alcohol use, smoking, pelvic/perineal surgery or trauma, neurologic disease, obesity, pelvic radiation, and Peyronie’s disease. One study suggested that the relationship between arterial disease and ED is very strong, with 49% (147 of 300) of patients with coronary artery disease noted on cardiac catheterization reporting significant erectile dysfunction. 6 Endothelial dysfunction has been indicated as the pathophysiologic mechanism responsible for both CVD and ED.

7 The Boston Area Community Health survey demonstrated a dose-response between smoking and incidence of erectile dysfunction.

8 Animal studies have demonstrated both smooth-muscle disruption and decreased production of neural nitric oxide synthase in cigarette-exposed animals.

Some evidence exists to suggest that chronic inflammation associated with metabolic syndrome also plays a role in endothelial dysfunction and erectile function, possibly due to oxidative stress.

Examples of common neurologic conditions that can lead to ED include cerebral vascular accident, multiple sclerosis, Parkinson’s disease, and spinal cord injury. Microvascular disease associated with diabetes is thought to compound the endothelial and neural injuries associated with this disease. Pelvic surgery may disrupt both neural and vascular pathways, resulting in ED. Hormone deficiency or hypogonadism, whether primary or secondary, has been thought to impact erectile function.

Approximately a third of men in the European Male Aging Study demonstrated low testosterone, suggesting that hypogonadism is overrepresented among men with ED.

11 Hormone deficiency, however, is less frequently the cause of ED than diabetes or vascular disease.

Many entities with a strong relationship to ED also diminish bioavailable testosterone, including obesity, diabetes, and opioid use. Other hormones involved in testosterone metabolism or availability, like thyroid stimulating hormone and gonadotropins, also may impact erectile quality, presumably through regulating bioavailable testosterone. Understanding the relationship between testosterone and ED has been impaired by a lack of standardized measurement of this hormone and the cyclic nature of its release and consumption.

Some self-administered measures may be useful in the primary care setting to screen for and

evaluate

12 The most commonly used instrument is the International Index of Erectile Function, a 15-item questionnaire that has been validated in many populations and is considered the gold standard to evaluate patients for ED.

13 The Sexual Health Inventory for Men is a short-form, 5-item questionnaire developed to monitor treatment progress. 12 It is important to recognize that short-form questionnaire does not evaluate specific areas of the sexual cycle, such as sexual desire, ejaculation, and orgasm; however, it may be useful in discussing ED with patients and evaluating treatment results over time. If it is determined that ED is a problem, the patient evaluation should include a detailed sexual and medical history and a physical exam. In particular, it is important to evaluate the ED within the context of ejaculatory problems. There is a strong interplay between premature ejaculation (PE) and ED, with about a third of ED patients reporting PE.

The relationship between the PE and ED is bidirectional and successful treatment of one often requires treatment of the other.

A number of specific questions relating to sexual function can help the clinician evaluate the complaint of ED.

Questions should focus on the following: How long has ED been a problem, and did it start gradually or suddenly?

How frequently do you have intercourse currently, and how frequent was it in the past?

Do you have difficulty with penetration and/or loss of the erection during intercourse in the absence of premature ejaculation? How firm are your erections (use a scale of 1 to 10)? Do your erections vary under different circumstances, such as with different partners, oral stimulation, or masturbation?

Do you have morning or evening erections and, if so, what is the quality of these erections? Is there any new curve or bend to your penis to suggest Peyronie’s disease? What are the location and severity of the curvature?

Are you having any difficulties with sexual desire, arousal, ejaculation, or orgasm? If so, did these difficulties occur with the onset of the erectile dysfunction or are they separate issues?

Once

questions

Following a review of the medical history, the salient features of the physical examination should include the following: An assessment of the patient's general health and affect, as well as secondary sexual characteristics, noting in particular gynecomastia and hair loss (axillary or pubic). Careful peripheral vascular examination that includes palpation of the lower extremity pulses as well as auscultation for bruits in the abdominal and femoral regions. Detailed neurologic examination to include gait and postural instability, with blood pressure changes, distal extremity and saddle sensation, and reflexes, including cremasterics and bulbocavernosus. Careful genital examination, noting testicular size (to screen for hypogonadism) and palpating the penis for Peyronie’s plaques.

Rectal examination to assess sphincter tone and evaluate the prostate.

Careful abdominal examination looking for organomegaly masses or other signs of liver or kidney disease.

Cardiopulmonary examination to help evaluate the patient's fitness for future treatment options.

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and

For example, serum testosterone (and sometimes prolactin) is typically only useful when the patient demonstrates hypogonadal features or testicular atrophy, or when clinical history is suggestive.

Additional hormonal evaluation may include thyroid stimulating hormone in those with a clinical suspicion of hypothyroidism or appropriate diabetes screening in those presenting with a concern for impaired glucose metabolism.

If the patient has not been evaluated with a lipid panel and hyperlipidemia is suspected, measurement and appropriate referral to internal medicine or cardiology is recommended.

In most cases, a tentative diagnosis can be established with a complete sexual and medical history, physical examination, and limited or no laboratory testing. The 2018 American Urological Association Guidelines for the treatment of Erectile Dysfunction recommend a complete history and physical and lifestyle modifications followed by a shared-decision-making approach for the existing medical treatments (Figure 1). Erectile dysfunction is known to be associated with general health status, thus, lifestyle modification improves erectile function and decreases the rate of decline of function with aging. One year after discontinuation of smoking, patients were found to have a 25% improvement in erectile quality. 16 In addition, multivariate analysis found obesity is associated with erectile dysfunction with an approximately 50% increase in ED in obese men as compared with normal weight men.

Over a 2-year period, a third of the men randomized to a weight loss program demonstrated resolution of erectile dysfunction.

10 A Mediterranean diet and nutritional counseling reported increased erectile quality. 18 Little evidence supports that increased physical activity alone improves erectile quality; however, the strong association between physical activity and lower BMI is well described, and therefore recommended for men with erectile dysfunction and without a contraindication to physical activity. The Massachusetts Male Aging Study demonstrated increased risk of ED among heavy alcohol users though the impact of alcohol use on erection quality is not well understood.

Although there are numerous options for nonsurgical treatment, oral phosphodiesterase-5 (PDE5) inhibitors should be offered as first-line treatment of patients with ED unless contraindicated. 19 Table 1 summaries the oral PDE5 drugs approved by the U.S.

Table 1: Phosphodiesterase-5 inhibitors for erectile dysfunction. These oral medications reversibly inhibit penile-specific PDE5 and enhance the nitric oxide–cGMP pathways of cavernous smooth muscle relaxation; that is, all prevent the breakdown of cGMP by PDE5.

It is important to emphasize to patients that these drugs augment the body’s natural erectile mechanisms, therefore the neural and psychoemotional stimuli typically needed for arousal still need to be activated for the drugs to be efficacious. According to a review of all randomized controlled trials evaluating sildenafil by the American Urological Association (AUA) Consensus Panel on Erectile Dysfunction, 36% to 76% of patients receiving the drug were "able to achieve intercourse" during treatment.

For tadalafil, four randomized controlled trials revealed that 11% to 47% of patients were "able to achieve intercourse." Similar efficacy has been observed with vardenafil, although studies are fewer.

19 A meta-analysis published in 2013 clearly demonstrated increased efficacy over placebo for all PDE5 inhibitors. 24 Head-to-head comparison suggested that tadalafil outperforms sildenafil on validated measures of erectile dysfunction, including the international index of erectile function and sexual encounter profile-2 and -3. Typical side effects include headache, flushing, dyspepsia, and nasal congestion. Visual abnormalities are encountered with sildenafil, but are unlikely with vardenafil and tadalafil.