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ED has vascular, neurologic, psychological, and hormonal causes. Conditions commonly associated with ED include diabetes mellitus, hypertension, hyperlipidemia, obesity, testosterone sildenafil teva 100mg price 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., sildenafil teva 100mg price 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, 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 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, sildenafil teva 100mg price but increases to one in 10 for those with ED.34.