© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
Lifestyle and medication changes
Making healthy lifestyle changes may reduce the
symptoms of EDand improve general physical health.
102
Patients need tounderstand thatwhat is bad for the heart
is bad for the penis. Elimination of smoking tobacco
is helpful in reducing incident ED.
102
Dietary issues
including reduced cholesterol and trans-fats, eliminating
hyperglycemiawhen present, anddecreasing salt intake
when salt-sensitive hypertension is noted, all help to
diminish vascular insufficiency progression. Exercise
will increase cardiac output and improve peripheral
circulation.
102
A recent study of obese men with ED
without diabetes, hypertension, or dyslipidemia, found
that reducing caloric intake and increasing physical
activitywas associatedwith improved sexual function in
about one third of obese men.
51
These positive changes
were associated with significant improvements in
erectile function, whichwere highly correlatedwith both
amount of weight loss and increased activity levels.
51
Exercise training improves endothelial function in the
coronary
103
and peripheral circulation.
104
Endurance
programs clearly have a positive effect on vasculature
probably by moving endothelial function related to an
increase in NO production and decreased oxidative
stress, which leads to an increase in NO availability.
105
These recommendations will help men be healthier
and, hopefully, happier, although their effect on erectile
functioning may not be instantly apparent.
Changing medication regimens to remove ED
causative agents can be tried when clinically possible.
Examples of this might be discontinuing a thiazide
diuretic and substituting an alpha-adrenergic blocker
(although it may lead to ejaculatory dysfunction), or
weaning the patient from digoxin or a beta-blocker
if the medication is not necessary. Treatment of
antidepressant-induced sexual dysfunction can
sometimes be managed by reducing drug dosages,
altering timing of drug dosages, taking drug holidays,
adding an adjunctive drug, and switching to an
alternative antidepressant.
106
These substitutions and
eliminations may meet with some success, but need to
be individualized depending on clinical circumstances.
Direct pharmacologic and surgical treatment
Specific treatment regimens for ED include oral
medications, transurethral suppositories, intracavemosal
injection, vacuum devices, and surgery. First-line
therapies include oral medications and vacuum
constrictiondevices. The FDAapproved oral treatments
include 1) sildenafil (Viagra), tadalafil (Cialis), vardenafil
(Levitra) and avanafil (Stendra - not available in
Canada).
107
PCPs are writing about 80%-85% of all the
prescriptions for PDE5 inhibitors in the United States.
108
Other pharmacologic treatments being used
primarily by the urologist and much less often
by PCPs include intraurethral or intracavernosal
injections of vasodilating medications, apomorphine,
a dopamine agonist that causes central initiation of
an erection through specific action in the brain, is
available in Europe but not in the United States or
Canada. Vacuum devices are a reasonable choice for
many men who are in a stable relationship and their
partners are willing to accept the inconvenience and
loss of spontaneity.
109
Testosterone augmentation, available as patches,
gels, underarm solution, buccal patch (not in Canada),
injection, or insertion of subcutaneous pellets
(not in Canada) is best reserved for patients with
documented hypogonadism based on the morning
serum testosterone level. Generally, testosterone
augmentation is associatedwith enhanced libido. This
may improve erectile status by restoring interest and
perhaps through other neurohormonal mechanisms,
but relying solely on testosterone to restore erectile
function in the dysfunctional male is inappropriate.
Testosterone treatment for testosterone deficiency
requires thorough evaluation and monitoring for
changes in both Hct and PSA.
The most common surgical treatment for ED is
penile implant surgery that is primarily performed by
urologists. This is a successful therapy in the properly
identified patient and should be reserved for those
patients who have considered or at least tried several
other treatments. The surgery should be considered
irreversible since the normal function of the corpora
cavemosa is obliterated with this procedure. There
are two types of implants – the inflatable and non-
inflatable or semi-rigid. These implants are essentially
mechanical devices and as such can suffer from
mechanical failures, that requires another surgical
procedure to fix the “failure.”
Some clinicians have advised that ED can be
managed naturally, although no controlled trials exist.
A dietary program rich in whole foods including
vegetables, fruits, whole grains, and legumes has been
suggested with key nutrients including zinc, essential
fatty acids, vitamin A, vitamin B-6, L-arginine, and
vitamin E being recommended. Herbal supplements
such as ginseng, gota kola, and saw palmetto have
also been discussed. Spices reported to increase
sexual desire include nutmeg, saffron, parsley, vanilla,
avocado, carrot oil, and celery.
Optimizing oral treatment with PDE5 inhibitors
Phosphodiesterase type 5 inhibitors (PDEi) have been
available for the treatment of ED since 1998. The
33
Erectile dysfunction in primary care: a focus on cardiometabolic risk evaluation and stratification for future
cardiovascular events
