Nonorganic ED Might be Managed with Pharmacotherapy

An Evaluation of a Clinical Care Pathway for the Management of Men With Nonorganic Erectile Dysfunction
Lawrence C. Jenkins MD, MBA; Matthew Hall MD; Serkan Deveci MD; Patricia Guhring RN; Marilyn Parker RN; Christian J. Nelson PhD; John P. Mulhall MD, MSc
FIRST PUBLISHED: August 20, 2019 – The Journal of Sexual Medicine
DOI: https://doi.org/10.1016/j.jsxm.2019.07.013

Introduction
A man with nonorganic erectile dysfunction (ED) [also called adrenaline-mediated ED] typically presents with ED despite normal hormone levels, normal vascular assessments, and no major risk factors for organic ED.

While some men with nonorganic ED do have psychiatric disorders, clinical experience demonstrates that most do not, and erection difficulties might be due to situational (performance) anxiety.
Many different psychological approaches for men with nonorganic ED have been studied, but there is little literature on the outcome of medical therapy on those men.
Phosphodiesterase type 5 inhibitors (PDE5i) are a “first-line” ED therapy, and men with nonorganic ED may benefit from their use with or without psychological interventions.
This study described a program in which men with nonorganic ED were treated with pharmacotherapy only.
Methods

The participants were 116 men with an average age of 38 years. Their androgen and vascular evaluations were normal. None of the men had a history of psychiatric disorders.
Vascular risk factors (diabetes, hypertension, dyslipidemia, coronary artery disease, obesity, and cigarette smoking) were assessed. Eighty-four percent of the men had no risk factors, 14% had one risk factor, and 2% had two risk factors.

Thirty-one percent of the men were partnered with an average relationship duration of 8 months.
Twenty-one percent had seen a psychologist; only three men had more than one visit.
All of the men underwent early morning tests for serum total testosterone and gonadotropins. Penile duplex Doppler ultrasound (DUS) was used for vascular assessments.

Clinical Care Pathway
At first, all patients were treated with a PDE5i at the maximum dose. “The patients were encouraged to try the first 2 attempts without a partner to minimize anxiety and to establish confidence in the medication.” They were also encouraged to titrate down the medication over time and to seek mental health support.
If PDE5i therapy responses were inconsistent or not successful, intracavernosal injection (ICI) therapy was suggested. After 3 to 6 months, patients using ICI therapy could be rechallenged with PDE5i therapy, gradually decreasing the PDE5i dose as appropriate.

Follow up appointments occurred 3 months after diagnosis, then every 6 months thereafter.
Erectile function was assessed with the International Index of Erectile Function at baseline and at each follow-up point.

Results
Eighty-one percent of the men responded to initial PDE5i treatment, but only 68% had consistently good results.
Thirty-two men proceeded to ICI therapy, and all of them were able to achieve functional erections.

At an average of 11 months after DUS, 83% of the men who consistently responded to the PDE5i had stopped using medication because they could achieve erections on their own.
Among those who used ICI therapy, 11% still used injections 6 months after starting. The rest were transitioned back to PDE5i therapy. Of those who transitioned, 66% had stopped taking the pill by their last follow up because it was no longer needed.

Discussion
Before making a diagnosis of nonorganic ED, clinicians should consider a man’s medical history, physical examination, lab test results, and psychological stressors. However, “for the practicing urologist, this is often difficult to determine in the limited office time available and the lack of mental health training during urology training.”
In this study, 19% of the men did not respond to the first round of PDE5i therapy and for about a third of the men who did respond, success was inconsistent. This result might be explained by an adrenaline discharge during sex that interferes with the effectiveness of oral agents.

Clinical Implications
Clinical implications of this study were described by the authors as follows:
(i) Not all men with nonorganic ED respond to PDE5i initially and many of those who respond, do so only intermittently;
(ii) Such patients are potentially curable and, using erectogenic pharmacotherapy for erectile confidence restoration, most men are capable of being weaned from drug therapy; and
(iii) Very few such men are comfortable utilizing mental health professional support despite our strong recommendation and the presence of such a person in our practice.
Limitations

It was acknowledged that the diagnosis of nonorganic ED in the study population was “presumptive” that follow-up could be considered short-term. In addition, the patients’ psychological status was unknown.

Conclusion
“The use of PDE5i and the temporary use of ICI in PDE5i failure patients can restore confidence such that a successful PDE5i rechallenge is likely and, furthermore, many men can wean completely from erectogenic pharmacotherapy.”



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