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Do not prescribe testosterone to men with erectile dysfunction who have normal testosterone levels.

Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm .

The prevalence of erectile dysfunction increases with age.

The prevalence of erectile dysfunction increases with age.

Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References.

The five-question International Index of Erectile Function (IIEF-5) allows rapid clinical assessment of ED and can measure the effectiveness of ED treatments (see https://www.aafp.org/afp/2010/0201/p305.html#afp20100201p305-t3).

Other diagnostic options include a single-question self-assessment (Table 1) 4 and the Brief Male Sexual Function Inventory.5.

Single-Question Assessment of Erectile Dysfunction.

Impotence means not being able to get and keep an erection that is rigid enough for satisfactory sexual activity. Not impotent: always able to get and keep an erection good enough for sexual intercourse.

Minimally impotent: usually able to get and keep an order viagra online without prescription erection good enough for sexual intercourse.

Moderately impotent: sometimes able to get and keep an erection good enough for sexual intercourse.

Completely impotent: never able to get and keep an erection good enough for sexual intercourse.

Single-Question Assessment of Erectile Dysfunction.

Impotence means not being able to get and keep an erection that is rigid enough for satisfactory sexual discount sale viagra activity.

Not impotent: always able to get and keep an erection good enough for sexual intercourse.

Minimally impotent: usually able to get and keep an erection good enough for sexual intercourse.

Moderately impotent: sometimes able to get and keep an erection good enough for sexual intercourse. Completely impotent: never able to get and keep an erection good enough for sexual intercourse.

Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References. ED has vascular, neurologic, psychological, and hormonal causes. Conditions commonly associated with ED include diabetes mellitus, viagra 100mg buy online hypertension, hyperlipidemia, obesity, testosterone deficiency, and prostate cancer treatment (Table 2) .6 – 8 Performance anxiety and relationship issues are common psychological causes.

Erectile Dysfunction: Related Conditions and Approaches to Evaluation.

Endocrine disorders (e.g., hypogonadism, hyperprolactinemia, thyroid disorders) History and physical examination; if an endocrine disorder is suspected, consider laboratory testing.

Blood pressure; fasting glucose, high-density lipoprotein, and triglyceride levels; waist circumference. Neurologic conditions (e.g., multiple sclerosis, Parkinson disease, spinal cord injury, stroke) History and physical examination.

Prostate cancer treatment (e.g., surgery, radiation, hormone therapy) Psychological conditions (e.g., anxiety, depression, guilt, history of sexual abuse, marital or relationship problems, stress) History and physical examination; if venous leakage is suspected, consider urology consultation for venous flow testing. Erectile Dysfunction: Related Conditions and Approaches to Evaluation. Endocrine disorders (e.g., hypogonadism, hyperprolactinemia, thyroid disorders) History and physical examination; if an endocrine disorder is suspected, consider laboratory testing. Blood pressure; fasting glucose, high-density lipoprotein, and triglyceride levels; waist circumference. Neurologic conditions (e.g., multiple sclerosis, Parkinson disease, spinal cord injury, stroke) History and physical examination. Prostate cancer treatment (e.g., surgery, radiation, hormone therapy) Psychological conditions (e.g., anxiety, depression, guilt, history of sexual abuse, marital or relationship problems, stress) History and physical examination; if venous leakage is suspected, consider urology consultation for venous flow testing.

Many medications cause or exacerbate ED (Table 3) .9 – 12 Antidepressants are a common cause, especially the selective serotonin reuptake inhibitors citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft), and the serotonin-norepinephrine reuptake inhibitor venlafaxine.

Bupropion (Wellbutrin), mirtazapine (Remeron), and fluvoxamine are less likely to cause ED.11 Tobacco, alcohol, and illicit drugs can cause ED.13 , 14 Marijuana use may cause ED, although further study is needed.15. Medications and Substances That May Cause or Contribute to Erectile Dysfunction. Alcohol, nicotine, and illicit drugs (e.g., amphetamines, barbiturates, cocaine, marijuana, opiates) Analgesics (e.g., opiates) Anticonvulsants (e.g., phenobarbital, phenytoin [Dilantin]) Antidepressants (e.g., lithium, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants) Antihistamines (e.g., dimenhydrinate, diphenhydramine [Benadryl], hydroxyzine, meclizine [Antivert], promethazine) Antihypertensives (e.g., alpha blockers, beta blockers, calcium channel blockers, clonidine, methyldopa, reserpine) Antiparkinson agents (e.g., bromocriptine [Parlodel], levodopa, trihexyphenidyl) Antipsychotics (e.g., chlorpromazine, haloperidol, pimozide [Orap], thioridazine, thiothixene) Cardiovascular agents (e.g., digoxin, disopyramide [Norpace], gemfibrozil [Lopid]) Cytotoxic agents (e.g., methotrexate) Diuretics (e.g., spironolactone, thiazides) Hormones and hormone-active agents (e.g., 5-alpha-reductase inhibitors, androgen receptor blockers, androgen synthesis inhibitors, corticosteroids, estrogens, gonadotropin-releasing hormone analogs, progesterones) Immunomodulators (e.g., interferon alfa) Tranquilizers (e.g., benzodiazepines) Information from references 9 through 12 .

Medications and Substances That May Cause or Contribute to Erectile Dysfunction.

Alcohol, nicotine, and illicit drugs (e.g., amphetamines, barbiturates, cocaine, marijuana, opiates) Analgesics (e.g., opiates) Anticonvulsants (e.g., phenobarbital, phenytoin [Dilantin]) Antidepressants (e.g., lithium, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants) Antihistamines (e.g., dimenhydrinate, diphenhydramine [Benadryl], hydroxyzine, meclizine [Antivert], promethazine) Antihypertensives (e.g., alpha blockers, beta blockers, calcium channel blockers, clonidine, methyldopa, reserpine) Antiparkinson agents (e.g., bromocriptine [Parlodel], levodopa, trihexyphenidyl) Antipsychotics (e.g., chlorpromazine, haloperidol, pimozide [Orap], thioridazine, thiothixene) Cardiovascular agents (e.g., digoxin, order viagra online without prescription disopyramide [Norpace], gemfibrozil [Lopid]) Cytotoxic agents (e.g., methotrexate) Diuretics (e.g., spironolactone, thiazides) Hormones and hormone-active agents (e.g., 5-alpha-reductase inhibitors, androgen receptor blockers, androgen synthesis inhibitors, corticosteroids, estrogens, gonadotropin-releasing hormone analogs, progesterones) Immunomodulators (e.g., interferon alfa) Tranquilizers (e.g., benzodiazepines) Information from references 9 through 12 .

ED has been linked to each component of the metabolic syndrome (eTable A) , including increased fasting serum glucose levels, diabetes, hypertension, and abdominal obesity, as well as to an increased risk of cardiovascular disease (CVD).16 – 22. ? 100 mg per dL (5.6 mmol per L) High-density lipoprotein level† *— Criteria listed are the harmonized criteria proposed by the joint statement from the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity.

At least three criteria must be present to diagnose metabolic syndrome .

†— Patients currently receiving drugs to manage lipid disorders or high blood pressure are considered positive for these criteria .

‡— Thresholds according to International Diabetes Federation recommendations . §— Thresholds for white patients differ significantly according to the recommending organization. Thresholds listed are from the International Diabetes Federation. However, the American Heart Association and National Heart, Lung, and Blood Institute set thresholds of 40 inches (102 cm) for U.S.

women, noting that there is increased risk at the lower International Diabetes Federation values . Metabolic syndrome: insulin resistance and prediabetes . ? 100 mg per dL (5.6 mmol per L) High-density lipoprotein level† *— Criteria listed are the harmonized criteria proposed by the joint statement from the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity.

At least three criteria must be present to diagnose metabolic syndrome . †— Patients currently receiving drugs to manage lipid disorders or order viagra online without prescription high blood pressure are considered positive for these criteria . ‡— Thresholds according to International Diabetes Federation recommendations . §— Thresholds for white patients differ significantly according to the recommending organization. Thresholds listed are from the International Diabetes Federation. However, the American Heart Association and National Heart, Lung, and Blood Institute set thresholds of 40 inches (102 cm) for U.S. women, noting that there is increased risk at the lower International Diabetes Federation values . Metabolic syndrome: insulin resistance and prediabetes .

Low serum testosterone levels are one factor that may explain the relationship between metabolic syndrome and ED.23 The adipose tissue enzyme aromatase prevalent in obese men converts testosterone into estradiol, a significant cause of hypogonadism.24 – 26 Adipocytes also generate inflammatory cytokines associated with impaired endothelial function, cardiovascular events, and ED.27 – 29.

Patients with diabetes are three times more likely to develop ED, and a longer duration of diabetes is strongly associated with ED.18 , 30 , 31 Metabolic syndrome is associated with a 2.6-fold increase in the incidence of ED, and the fasting blood glucose level is the component associated with the highest risk of ED.32 , 33 The probability of having undiagnosed diabetes is one in 50 among men 40 to 59 years of age who do not have ED, but increases to one in 10 for those with ED.34.

ED and CVD share similar risk factors, including older age, hypertension, dyslipidemia, smoking, obesity, and diabetes. ED is associated with an increased risk of CVD, coronary artery disease (CAD), stroke, and all-cause mortality, and it is probably an independent risk factor for CVD.35. ED typically occurs two to five years before CAD, providing a potential window during which men diagnosed with ED can make lifestyle changes to prevent CAD.36 Men with ED are at higher risk of angina, myocardial infarction, stroke, transient ischemic attack, congestive heart failure, and cardiac arrhythmias compared with men who do not have ED.37 Men with ED have a 75% increased risk of developing peripheral vascular disease.38. ED has a positive predictive value for the development of CVD that is equal to or greater than that for smoking, hyperlipidemia, or a family history of myocardial infarction.37 , 39 ED can accurately predict silent CAD.40 – 45 ED in men 40 to 49 years of age is more predictive of CAD than in older men.36 In one study, the incidence of CAD in men younger than 40 years who had ED was seven times that in the control population.46 ED is a useful marker for assessing cardiovascular risk, particularly in younger men and minorities, for whom global risk assessment calculators may underestimate actual risk.47 , 48. Management of cardiovascular risk factors is recommended in men who have ED but no known CVD.49 , 50 Because diagnosing ED can help identify men at higher risk of CVD, use of the IIEF-5 is also recommended during CVD risk assessment. Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References. Medical and surgical history, sexual history, use of medications and other substances, and an assessment of psychological and relationship health are key components of the patient history.

Essential parts of the physical examination include measurement of blood pressure, body mass index, and waist circumference to assess abdominal obesity; a genital examination; and an assessment of male secondary sex characteristics. Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References. The A1C or fasting glucose level can be used to assess for diabetes. A thyroid-stimulating hormone order viagra online without prescription level is recommended for men with signs or symptoms of hypothyroidism. Routine measurement of testosterone levels is controversial.

As part of the Choosing Wisely campaign, the American Urological Association recommends that physicians not prescribe testosterone to men with ED who have normal testosterone levels.

A diagnosis of hypogonadism must be based on more than just an abnormal laboratory test result.51 Measurement of morning total testosterone may be considered for men with small testes, lack of male secondary sex characteristics, significantly low libido, or a history of inadequate response to phosphodiesterase-5 (PDE-5) inhibitors; if the initial result is abnormal, the test should be repeated in a few months. Free testosterone levels vary widely across laboratories and are not uniformly recommended for screening. However, when hypogonadism is clinically suspected but the morning total testosterone level is repeatedly normal, bioavailable testosterone or free testosterone may account for the effects of sex hormone–binding globulin levels on testosterone activity.

Levels of follicle-stimulating hormone, luteinizing hormone, sex hormone–binding globulin, estradiol, and prolactin can help differentiate between primary and secondary causes of testicular hypogonadism.52.

Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References.

An algorithm for the diagnosis and management of ED is shown in Figure 2 .6 – 17 , 33 , 49 – 68. Algorithm for the diagnosis and management of erectile dysfunction.

Information from references 6 through 17 , 33, and 49 through 68 . Algorithm for the diagnosis and management of erectile dysfunction. Information from references 6 through 17 , 33, and 49 through 68 . Lifestyle modifications can improve IIEF-5 scores in men with ED.53 Regular exercise, weight loss in obese or overweight men, and improved control of diabetes, hypertension, and hyperlipidemia are recommended.

Weight loss can modestly improve low testosterone levels, although the extent of the benefit on ED is unclear.54 Statin use seems to improve ED, as measured by IIEF-5 scores.55 Tobacco cessation is highly recommended.

Compared with men who have never smoked, the risk of ED is increased by 51% in current smokers and 20% for ex-smokers.14. Oral PDE-5 inhibitors are first-line order viagra online without prescription treatments for ED.57 Sexual stimulation is needed to produce an erection; the PDE-5 inhibitor helps to maintain the erection by enhancing the vasodilatory effects of endogenous nitric oxide.

Four PDE-5 inhibitors with similar effectiveness and safety profiles are currently approved by the U.S.

Food and Drug Administration (FDA) for treatment of ED: avanafil (Stendra), sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra).

Table 4 summarizes these medications.56 – 58 All are effective within about one hour of dosing and are typically used on an as-needed basis.

The effects may be delayed or decreased if the patient has recently eaten a fatty meal, particularly for sildenafil and vardenafil.69 PDE-5 inhibitors are ineffective in some men, particularly those with severe ED. Headache, flushing, and dyspepsia are common adverse effects.58 PDE-5 inhibitors are contraindicated in men using nitroglycerin or other nitrates because of the risk of catastrophic low blood pressure.

Tadalafil has a longer half-life, which gives men the option of taking it up to 12 hours before sex or as a lower-dose, once-daily medication; however, adverse effects also last longer. Vardenafil is available as a 10-mg oral disintegrating tablet. Sildenafil is the only PDE-5 inhibitor that is available generically; generic

formulations

PDE-5 Inhibitors for Treatment of Erectile Dysfunction. NA ($280 for 30 tablets) 10 or 20 mg once daily as needed. note : Contraindications include concomitant use of nitrates, stroke or myocardial infarction in the past six to eight weeks, significantly low blood pressure, uncontrolled high blood pressure, unstable angina, severe cardiac failure, severe liver impairment, and end-stage kidney disease requiring dialysis. Lower doses should be used in patients with chronic kidney disease or moderate liver impairment .

NA = not available or not applicable; PDE-5 = phosphodiesterase-5 . *— Other PDE-5 inhibitors not currently approved by the U.S.

Food and Drug Administration include lodenafil, mirodenafil, and udenafil . †— Estimated retail cost based on information from http://www.goodrx.com (accessed July 27, 2016). Generic price listed first; brand price in parentheses . PDE-5 Inhibitors for Treatment of Erectile Dysfunction. NA ($280 for 30 tablets) 10 or 20 mg once daily as needed.