What is the medical workup for a 35-year-old male with hypoactive sexual desire (Low Libido) and erectile dysfunction, reporting absent nocturnal penile tumescence, and a pertinent past medical history (PMH) of anxiety and depression?

From the Guidelines

For a 35-year-old male with low libido, erectile dysfunction (ED), absence of nocturnal/morning erections, and a history of anxiety and depression, a comprehensive medical workup is essential to identify underlying causes and guide treatment. This workup should start with a thorough medical, sexual, and psychosocial history, as well as a physical examination and selective laboratory testing, as recommended by the American Urological Association (AUA) guideline on erectile dysfunction 1.

Key Components of the Workup

• Laboratory tests should include morning serum total testosterone levels, as recommended by the AUA guideline 1, as well as other tests such as luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, thyroid function tests (TSH, free T4), comprehensive metabolic panel, lipid profile, and hemoglobin A1c.
• Physical examination should assess secondary sex characteristics, testicular size, and cardiovascular health.
• Given the patient's psychiatric history, a medication review is crucial, as many antidepressants (particularly SSRIs) can cause sexual dysfunction.

Treatment Considerations

• If testosterone is low, replacement therapy may be considered, typically 50-100mg testosterone cypionate weekly by injection, or topical formulations like AndroGel 1.62% 40.5mg daily.
• If depression medications are contributing, discussing alternatives with less sexual side effects like bupropion (Wellbutrin) 150-300mg daily may be beneficial.
• PDE5 inhibitors like sildenafil (Viagra) 50mg as needed or tadalafil (Cialis) 5-10mg daily may help with ED, as suggested by the NCCN guidelines for survivorship 1.
• Psychological counseling should also be considered, as anxiety and depression can both cause and result from sexual dysfunction, creating a challenging cycle to break, and referral to a mental health professional may be necessary to promote treatment adherence and reduce performance anxiety 1.

Importance of Comprehensive Approach

The absence of nocturnal erections suggests an organic rather than purely psychological cause, making this medical workup particularly important. A comprehensive approach addressing both physical and psychological aspects is crucial for effective management of low libido and erectile dysfunction in this patient.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Medical Workup for Male Low Libido and Erectile Dysfunction

The medical workup for a 35-year-old male with low libido and erectile dysfunction, including the absence of nocturnal morning erections, and a pertinent past medical history (PMH) of anxiety and depression, involves several key components:

• A full medical and personally and culturally sensitive sexual history 2
• A focused clinical examination 2
• Laboratory tests, including:
  • Fasting glucose levels 2
  • Fasting lipid profile 2
  • Total testosterone level, particularly if hypogonadism is suspected 2, 3, 4, 5, 6
  • Prostate-specific antigen test, in select cases 2

Role of Testosterone in Erectile Dysfunction

Testosterone plays a significant role in male sexual function, including erectile function 3, 5, 6. However, the relationship between low testosterone levels and erectile dysfunction is complex and influenced by various factors, including vascular damage, anxiety, and depression 3, 5, 6.

Treatment Options

Treatment options for erectile dysfunction include:

• Lifestyle modification 2, 5
• Reduction of comorbid vascular risk factors 2
• Pharmacotherapy, such as phosphodiesterase type 5 inhibitors (PDE5i) 2, 5, 6
• Testosterone replacement therapy (TRT), in cases of hypogonadism 3, 4, 5, 6
• Patient-administered intracorporal injection therapy using vasodilator drugs, such as alprostadil 2
• Surgical treatment, including multicomponent inflatable penile implants 2