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Erectile Dysfunction




Upon completion of the chapter, the reader will be able to:

  1. Explain the pathophysiology of erectile dysfunction (ED).

  2. Recognize risk factors and medications associated with the development of ED.

  3. Identify the goals of therapy when treating ED.

  4. Describe current nonpharmacologic and pharmacologic options for treating ED, and determine an appropriate first- and second-line therapy for a specific patient.

  5. Identify patients with significant cardiovascular risk and recommend an appropriate treatment approach for their ED.

  6. Compare and contrast the benefits and risks for the current phosphodiesterase (PDE) inhibitors.

  7. Assess reasons for PDE failure and determine an optimal approach to improve treatment efficacy.


Erectile dysfunction (ED) is defined as the persistent inability to achieve or maintain an erection sufficient for sexual intercourse. ED is the most prominent sexual problem in men, and it can lead to lower quality of life and self-esteem.1 Patients may also develop libido or ejaculatory disorders, but these are not considered ED.


ED increases with age. Few men report erection problems before age 50, but ED increases to 20% to 40% in men aged 60 to 69 years and 50% to 100% in men older than 70 years.2 The increase in incidence could be due to physiologic changes that occur with aging, the onset of chronic disease states associated with ED, increased medication use, lifestyle factors, or a combination of the above.


The penis consists of three components, two dorsolateral corpora cavernosa and a ventral corpus spongiosum that surrounds the penile urethra and distally forms the glans penis.

Sympathetic and parasympathetic nerves innervate the penis. In the flaccid state, arterial and corporal smooth muscles are tonically contracted, and a balance exists between blood flow into and out of the corpora. With sexual stimulation, nerve impulses from the brain travel down the spinal cord triggering a reduction in sympathetic tone and an increase in parasympathetic activity. This leads to an increased production of nitric oxide (NO). NO enhances the activity of guanylate cyclase, which results in increased production of cyclic guanosine monophosphate (cGMP). Vasoactive peptide and prostaglandins E1 and E2 stimulate increased production of cyclic adenosine monophosphate (cAMP). Both cAMP and cGMP reduce calcium concentrations within smooth muscle cells of the penile arteries and the sinusoidal spaces, leading to smooth muscle relaxation and increased blood flow. As the spaces become engorged, intracavernosal pressure increases, subtunical venules are compressed by the tunica albuginea, and the penis becomes rigid and elongated (Figure 51–1).

FIGURE 51–1.

Mechanism of erection and sites of action of various treatment modalities for erectile dysfunction (ED). Penile erection is achieved through relaxation of smooth muscle cells ...

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