Review Article Erectile dysfunction J. CHANDRA SINGH, ANTONY DEVASIA, LIONEL GNANARAJ, K. NINAN CHACKO )*564)+6 With phosphodiesterase inhibitors, a safe and effective oral therapy has emerged for erectile dysfunction. Increasing aware- ness, particularly through the media, is inducing more men to seek help for this condition. Erectile dysfunction is defined as the persistent inability to achieve or maintain an erection adequate for satisfactory sexual activity. The prevalence increases with age. Basic and clinical research is identifying the neurovascular and humoral control of the mechanisms. The initial evaluation should differentiate erectile dysfunction from premature ejaculation and loss of libido. Myocardial insufficiency, hypogonadism and peripheral neuropathy should be looked for. Initial laboratory investigations should be re- stricted to identifying previously undetected medical illness that may directly contribute to erectile dysfunction. Discussing the available options with the couple is an impor- tant aspect. If erectile dysfunction is secondary to other treatable disorders these should be treated simultaneously. When other diseases that require intervention are ruled out and if there are no contraindications, therapy may be initiated with a phospho- diesterase inhibitor. In selected cases, psychosexual therapy may be beneficial. If phosphodiesterase inhibitors are contraindi- cated, vacuum constriction devices may be tried. Further options include intracavernosal injection, intraurethral instillation, penile revascularization and prosthesis. The availability of effective and well-tolerated oral medica- tions has dramatically changed the clinical approach to erectile dysfunction. Pharmacotherapy is the preferred cost-effective first-line therapy in the vast majority of patients. A stepped-care approach is followed in the primary care and family practice settings. Appropriate urological, endocrine and psychiatric referrals, and shared decision-making with the couple will enable effective treatment of men with erectile dysfunction. Natl Med J India 2005;18:13943 INTRODUCTION The current media interest in and availability of an effective and safe oral therapy for erectile dysfunction (ED) has resulted in more men seeking help. As a consequence, physicians without clinical experience in the evaluation and treatment of ED get involved in its management. The primary care physician and those who care for patients at risk for ED such as cardiologists, psychiatrists, endocrinologists and neurologists are likely to face more queries about the treatment of ED. ED is defined as the persistent inability to achieve or maintain an erection adequate for satisfactory sexual activity. 1 After prema- ture ejaculation, it is the most common disorder of sexual function in men. 2 In an analysis of 1000 consecutive patients with sexual disorders attending a psychosexual clinic, ED was the presenting complaint of 23.6%. 3 According to the Massachusetts Male Ag- ing Study, the overall probability of complete impotence tripled from 5% in men 40 years of age to 15% in those 70 years of age. 2 Despite this startling prevalence of ED and the adverse impact it has on a man’s self-esteem and quality of life, ED largely remained an ignored disorder until the recent availability of effective oral therapy. Erection is a neurovascular phenomenon under hormonal con- trol, which includes arterial dilatation, trabecular smooth muscle relaxation and activation of the corporal veno-occlusive mecha- nism. 4,5 Recent advances in basic and clinical research have led to the development of several treatment options for ED, including new drugs for intracavernosal, intraurethral and oral use. The advent of medical therapy with results superior to that of recon- structive vascular surgery has had a major impact on the manage- ment of this disorder. There has been a change in the approach to the management of ED (Table I). 6 EVALUATION OF A PATIENT Medical and psychosexual history The initial evaluation should differentiate ED from premature ejaculation and loss of libido. It should attempt to identify the aetiological factors (Table II). The presence and extent of myocar- dial insufficiency and medications for this condition will influence the treatment options that can be offered to the patient. The cardiovascular risk of treating ED in a patient with heart disease derives from the physical overload resulting from sexual activity. It is thus important to determine in each patient whether coital activity represents low, moderate or severe cardiovascular risk © The National Medical Journal of India 2005 Christian Medical College and Hospital, Vellore 632004, Tamil Nadu, India J. CHANDRA SINGH, ANTONY DEVASIA, LIONEL GNANARAJ, K. NINAN CHACKO Department of Urology Correspondence to J. CHANDRA SINGH; chandrasingh@cmcvellore.ac.in TABLE I. Changing approach and attitude to the treatment of erectile dysfunction 6 Time frame Treatment Aim Pre-1960 Early surgery, natural Any improvement remedies, psychotherapy 1960 Pumps Any improvement 1970 Penile implants Successful erection 1980 Injections Successful erection 1998 Oral agents Successful erection At present Future treatment Normal sexual life THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 18, NO. 3, 2005 139