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Expanding Treatment Options for Erectile Dysfunction

  • Authors: Hartmut Porst, MD
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Target Audience and Goal Statement

This activity is intended for urologists, primary-care physicians, and internists.

The central goals of this educational activity are to enhance recognition of, and care for, erectile dysfunction (ED) by exploring the epidemiology of this underrecognized condition, discussing interview and other diagnostic techniques, and considering the evidence supporting distinct treatment approaches.

Upon completion of this self-study activity, participants will be able to:

  1. Appreciate the true dimensions of ED and the needs of many patients and their partners more accurately.
  2. Enumerate risk factors for the condition.
  3. Discuss current first-line diagnostic assessments for ED, including a focused physical examination and three types of history: medical, sexual, and psychosocial.
  4. Delineate the biochemical cascade underlying physiologic erection.
  5. Discuss the effects of first-, second-, and third-line treatment modalities on ED.


  • Hartmut Porst, MD

    Professor of Urology, Medical University of Bonn, Germany.


    Disclosure: Hartmut Porst, MD, has disclosed that he serves as an advisor or consultant for Bayer, Pfizer, and Merck Germany. He serves an investigator for Lilly ICOS LLC, Takeda, Abbott, and Merck Germany. In this activity, Dr. Porst discusses the investigational product Tadalafil to treat erectile dysfunction.

Accreditation Statements

    For Physicians

  • Medical Education Collaborative, a nonprofit education organization, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

    Medical Education Collaborative designates this educational activity for a maximum of 1.5 hours in Category 1 credit towards the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.

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Expanding Treatment Options for Erectile Dysfunction

Authors: Hartmut Porst, MDFaculty and Disclosures



Defined as the inability to achieve and maintain a penile erection adequate for satisfactory sexual intercourse,[1] erectile dysfunction (ED) is a prevalent male health problem of global dimensions. Approximately 150 million men worldwide have some degree of ED, and this value is projected to more than double by the year 2025.[2] According to epidemiologic studies focusing on the United States, the prevalence of ED is approximately 30 million cases,[1] which is projected to increase by nearly 10 million by 2025.[2] With advancing age, beginning in the 40-year-old male, hormonal changes occur and increase in the next decades of life in a considerable number of patients. These hormonal changes are primarily a decline in the production of certain hormones, including growth hormone and insulin-like growth factor 1 (so-called somatopause), dehydroepiandrosterone (DHEA; adrenopause), and, of particular interest, testosterone (adrenopause orpartial androgen decline in the aging man). These hormonal changes are quite often associated with sexual dysfunctions, such as libido, erectile, and sometimes ejaculatory disorders (particularly with loss of ejaculate volume and orgasmic intensity), as well as loss of muscle mass and strength and increase in body fat (Figure 1).

  • As with other chronic disorders with which ED is comorbid (eg, hypertension, ischemic heart disease, hyperlipemia, arteriosclerosis, and diabetes), the incidence of ED increases sharply with age.[3] Erectile dysfunction appears to be a common cross-cultural denominator, affecting 19% to 64% of men aged 40 to 80 years, both in developing and industrialized countries (Figure 2). For example, a thorough survey conducted in the Boston area revealed that 52% of all men aged 40 to 70 years reported some degree of ED, with 9.6% suffering from complete ED, 25.2% moderate ED, and 17.2% mild ED.[3] In some countries, epidemiologic data may underestimate the true dimensions of the problem, because some men experience embarrassment or perceive a stigma in relation to self-reported ED.

  • Figure 1. Hormonal Changes in the Aging Male

    Figure 1.

    Hormonal Changes in the Aging Male

    (Enlarge Slide)
  • Despite its commonplace occurrence, ED is a notoriously underreported, underrecognized, and undertreated chronic illness. Considering the sales rates for sildenafil, the current market leader for this indication with more than a 90% market share, and comparing these rates both with the high prevalence rates of ED and reports in the literature, 70% to 90% of all ED goes undiagnosed.[4] In a recent Australian study[5] involving 62 general medical practices, approximately 34% of men reported ED, including nearly 12% with a complete inability to achieve erection, yet less than 12% of men with ED had been treated. Further, evidence suggests that treatment is generally suboptimal, on the one hand owing to inadequate education and training of many nonspecialists in managing this condition[6] and on the other hand owing to the conflicts between the time needed for diagnosing and treating this disease and the worldwide restricted budgets provided byhealthcare providers.The notion that ED is an inevitable consequence of aging that must be tolerated has been soundly rebuked by recent studies. Life expectancy in males has increased from approximately 47 years in 1900 to 74 years in 1997, with an increase of 10 years in the period between 1947 and 1997. A man reaching the age of 65 years in 1997 could expect to live approximately 16 more years,[7,8] and the quality of these years can be severely compromised by ED, among other bodily functions that decline considerably with age. Not only do many men with ED endure diminished self-image and self-esteem, anxiety and fears of rejection, and even depression, but elderly men are also acutely aware and appreciative of the social support associated with intimate relationships, and withdrawal from them can adversely impact their overall health status.[1]In a European study,[9] nearly 90% of male respondents aged 50 to 59 years were sexually active; thisproportion was 84% in men aged 60 to 69 years and 71% in those aged 70 to 80 years. Of men aged 60 to 69 years, 41% were unhappy with their sex lives, as compared with 44% of those 10 years older.[9] Similar findings were reported in a recent Japanese study of more than 9000 Japanese men, aged 30 years to older than 80 years, who were asked about their actual sexual activities.[10] In this survey, 80% to 88% of men in the 60- to 69-year age group, 55% to 70% in the 70- to 79-year group, and 44% of the 80-year or older age group reported regular sexual activities, although this did not imply that they could have successful sexual intercourse.

    A broad and expanding panoply of options is available for the management of ED, including oral phosphodiesterase type 5 (PDE5) inhibitors, dopamine agonists, and alpha-receptor blocking agents; intracavernosal (IC) and transurethral vasoactive agents, such as prostaglandin E1 (PGE1; alprostadil or papaverine and phentolamine for IC injection); vacuum erection devices (VEDs); and penile prostheses. Other surgical procedures, such as penile revascularization or penile vein ligation procedures, have lost considerable importance and are reserved for special indications that account for no more than 2% to 3% of all ED patients (Figure 3).

  • Figure 2. Worldwide Prevalence of ED

    Figure 2.

    Worldwide Prevalence of ED

    (Enlarge Slide)
  • On the other hand, there is a high rate of voluntary discontinuation of therapy associated with most treatment modalities.[1] Suboptimal treatment continuation rates may be attributed partly to inadequate education and knowledge both of the physicians dealing with this condition and the patients seeking relief from this disease, as well as inadequate conditions at home and unrealistic expectations of patients by their physicians. A supportive, nonjudgmental physician-patient alliance, coupled with a multidisciplinary approach targeted toward both organic and psychogenic components of care, is instrumental in optimizing the effectiveness of care. Irrespective of its underlying etiology, virtually all cases of ED show involvement of psychogenic factors; therefore, counseling of the patient and/or his partner is desirable even in apparently organic cases of ED.[15]

  • Figure 3. Therapeutic Approaches to ED

    Figure 3.

    Therapeutic Approaches to ED

    (Enlarge Slide)