Listen as our expert guest Dr. Ashley Winter @AshleyGWinter (Northwest Kaiser Permanente, Portland, OR) helps us explore the spectrum of erectile dysfunction management for the internist and primary care clinician. This episode will empower you to provide evidence based, patient-centered care to erectile dysfunction while maintaining an astute and holistic diagnostic approach. We also explore treatment and patient counseling techniques.
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Dr Winter’s diagnostic framework for erectile dysfunction can be split into: 1) physical, 2) psychogenic, or 3) combination of both. An illness script for the physical etiologies would be a patient with medical comorbidities or a history of pelvic surgery or pudendal injury. An illness script for the psychogenic etiologies may be a patient who can maintain an erection during masturbation (“unpartnered sexual activity”) but cannot maintain one during intercourse with a partner, or who has other signs of performance anxiety.
Questions can help elucidate physical versus psychogenic causes of erectile dysfunction. Overcome stigma and inquire about what the patient experiences during partnered and unpartnered sexual activity, as well as the presence of morning erections (Montorsi 2005). Obtain a history of medical conditions (including cardiovascular disease or diabetes), surgeries, or injuries. Ask what the patient observes during erection (ex. Do they have Peyronie’s disease (Gaffney 2020) which leads to abnormal curvature during erection).
Ask about medication use. Spironolactone is a frequent culprit for erectile dysfunction, as it has anti-androgen properties (Giagulli 2013, Alberti 2013). Finasteride is a 5-alpha-reductase inhibitor and can contribute to ED (Liu 2016). Over-the-counter or prescription nasal decongestants (McVary 2007) can cause erectile dysfunction, so ask about use!
Pearl for the internist: The degree of erectile dysfunction strongly correlates with the severity of cardiovascular disease, and erectile dysfunction may be considered a sentinel marker for occult vascular disease.
2018 American Urological Association (AUA) Erectile Dysfunction Guidelines: “Symptoms of ED may precede a cardiovascular event by up to five years. Further, when ED is present in younger men, it predicts a marked increase (up to 50 fold) in the risk of future risk cardiac events, suggesting that young men with ED in particular may benefit from CVD risk factor screening and interventions. (Hodges 2007, Montorsi 2003, Inman 2009)
History should also explore information about the patient’s partner with whom they are trying to achieve penetration. For example, is anal penetrative intercourse difficult (anal sphincter pressure is higher than vaginal pressure), or is the partner a post-menopausal woman with impaired vaginal lubrication?
Also, ask about patient levels of concern. For example, a patient may not be bothered by an inability to achieve penetrative intercourse, but instead be raising the issue to ask whether it is an indicator of their overall health.
Start with the basic vitals including blood pressure. Genitourinary exam should include an external exam and inspection of the testicles (atrophic or other signs of hypogonadism? varicocele?)(McVary 2007). Examination of the penis should include a visual and tactile skin exam (Peyronie’s plaques? Scar tissue?) and assessment of penile stretch/flaccid length. Dr. Winter’s expert opinion: perform a prostate exam for older patients presenting with erectile dysfunction.
Young, healthy patients who meet an illness script for psychogenic causes (ex. Stress, performance anxiety, able to achieve erection with masturbation) likely do not need labs in Dr. Winter’s expert opinion. Middle-aged or older patients with absent/reduced morning erections or reduced erection with masturbation should have a morning testosterone (before 10am) checked (McVary 2007). The 2018 American Urological Association (AUA) Erectile Dysfunction Guidelines recommend checking FSH and LH if the testosterone level is low. Obtain A1C (Brown 2007) and lipids as part of diabetes and cardiovascular disease screening. Dr. Winter checks a PSA for patients with a prostate between 55-70 years old (in part to have that value available before counseling if treatment is needed for hypogonadism).
Dr. Winter: “Just ask. I will get the comment all the time after appointments, ‘I was scared to see a female urologist…and you just made this so normal. You just asked me these questions the way someone would ask me about my knee pain.”
Clinic intake questionnaires can be a first step to gleaning sexual discomfort concerns of symptoms from patients before they enter the exam room. Gender-inclusive language (ex. Name the body part = “penis”) can also be utilized.
Dr. Winter recommends uses open ended questions and being upfront and matter-of-fact to help patients themselves overcome their potential discomfort bringing up sexual function concerns. YOU can be the person who normalizes conversations about sex, helping a patient to overcome stigma, taboo, cultural forces, and ageism. You can talk to a patient about a condition that you don’t have: “You don’t need a penis to talk to someone about their penis.”
It is important to also be able to provide care to the patient who has a penis who does not identify as male. Use open-ended questions and be matter-of-fact with naming the body part or describing the activity (Rosendale 2018). Erectile dysfunction screening questionaires may have gendered language or assume heterosexual sexual partnerships, but ones like the Sexual Health Inventory for Men (SHIM) form can be used/modified to reference “partner” (ex. Referencing penetration in general versus vaginal penetration). Feminizing hormone treatment may lead to erectile dysfunction (McVary 2007). Dr. Winter also recommends asking if erectile rigidity is an important part of your patient’s sexual activity, understanding that sex will not include penetration for all patients with penises in your practice.
Dr. Winter: “The erection is a vascular event. An erection is a blood flow event. If you’re having issues with the blood flow in your penis, you may be having issues with the blood flow that gets to your heart or your brain and that’s why it’s important to see what’s going on”
Dr. Winter shares that she adds motivational interviewing and counseling for CV risk reduction or diabetes control into her treatment plan counseling for erectile dysfunction.
Dr. Winter: the PDE5i inhibitors “do NOT cause priapism!”
Several phosphodiesterase type 5 inhibitors (PDE5i) are on the market, including sildenafil, tadalafil, and vardenafil. They enhance one’s natural arousal, in that they will not cause an erection without a source of arousal. Efficacy is similar (Gong 2017) and choice may depend on duration of action, cost, availability of a generic option. Sildenafil has a duration of action of at least 4 hours (Eardley 2002) and potentially up to 8-12 hours (Gingell 2004) Tadalafil has a longer duration of action for “on demand” dosing of 20mg (48-72 hours = aka “the weekend pill”) (Coward 2008), and once daily dosing (5mg) will lead to steady-state concentrations which is clinically equivalent to “on demand” dosing which may augment patients’ sense of spontaneity. The 5mg daily tadalafil dose also has benefits for BPH symptoms, so Dr. Winter prefers this for dual therapy, especially as other BPH agents may impact affect sexual function. FDA prescribing information recommends lower doses for patients with renal or hepatic dysfunction.
The PDE5i’s are safe, and they are available over-the-counter in many countries. The effect on penile erection has a plateau effect, but the adverse effects (ex: headaches) do not—so going up on the dose doesn’t add benefit, may cause side effects, and uses up your money. Nitrate use is a contraindication to PDE5i due to vasodilatory effects that impact blood pressure (Schwartz 2010). Even if a patient has a PRN nitrate on their med list, ASK about how often they use it. Appropriate patient counseling about dosing of a nitrate relative to a PDE5i (and vice versa) can safely help patients with cardiovascular disease access these therapies.
Coverage and cost may be a limiting factor for patients, and insurance may meagerly cover, if at all. Dr. Winter prescribes tadalafil if the patient has BPH symptoms, too, as insurance covers it for BPH therapy. Counseling patients to ask pharmacies for the cash-pay price may also confirm that coverage is affordable for themselves.
Patients may disclose that they are using over-the-counter supplements (Balasubramanian 2019). Dr. Winter recommends avoiding most supplements, though she recommends L-arginine if a patient strongly prefers a nutraceutical as it is a nitric oxide donor and has vasodilatory effects (Leisegang 2021, Xu 2021).
Dr. Winter also recommends considering mirabegron, which may have pro-erection effects (Karakus 2021), if they have overactive bladder symptoms.
Suction devices can be tried, but they may be uncomfortable for patients. Other modalities include injections and surgery.
Different penile injections options, prescribed by urologists, include formulations of papaverine, papaverine + phentolamine, and papaverine + phentolamine + alprostadil (McVary 2007). Benefits include minimizing systemic symptoms compared to oral therapy and stronger erections. These agents DO cause priapism, and they do not depend on natural arousal being enhanced. Patients may have needle phobia, but very small gage needles are used. Counseling should include the patient and their partner.
Penile implants are FDA approved devices that permit rigid erections (McVary 2007). They are covered by Medicare but coverage is varied by state for Medicaid and varies for private insurances.
ED: erectile dysfunction
PDE5i: phosphodiesterase type 5 inhibitors
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Listeners will develop an understanding of the diagnosis and treatment of erectile dysfunction, especially in the primary care setting.
After listening to this episode listeners will…
Dr. Winter reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Abrams H, Winter A, Williams PN, Watto MF. “#317 Erectile Dysfunction”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. January 24, 2022.
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