How can males improve libido and erectile function?

Improving Libido and Erectile Function in Males

Lifestyle modifications including regular exercise (160 minutes weekly), weight loss, smoking cessation, healthy diet, and moderate alcohol consumption are the foundation for improving libido and erectile function in men, with testosterone replacement therapy recommended for men with documented low testosterone levels below 300 ng/dL. 1

Assessment and Diagnosis

When evaluating males with decreased libido or erectile dysfunction (ED), consider:

• Testosterone level measurement (morning sample preferred)

  • Total testosterone <230 ng/dL: Testosterone replacement therapy (TRT) usually beneficial
  • Total testosterone >350 ng/dL: TRT usually not required
  • Total testosterone 230-350 ng/dL: Consider TRT if symptomatic 1

• Cardiovascular risk assessment

  • All men with ED should have cardiovascular risk evaluated 1
  • ED is often an early marker of endothelial dysfunction and cardiovascular disease

• Medical history focusing on:

  • Comorbidities (diabetes, hypertension, obesity, metabolic syndrome)
  • Medications that may affect sexual function
  • Psychological factors (stress, anxiety, depression)

Treatment Algorithm

First-Line: Lifestyle Modifications

1. Physical Activity:

   • 40 minutes of moderate to vigorous aerobic exercise 4 times weekly (160 minutes total) 2
   • Regular exercise improves erectile function by enhancing endothelial function and increasing nitric oxide availability 3

2. Dietary Changes:

   • Mediterranean diet (emphasizing fruits, vegetables, beans, legumes, whole grains, nuts, fish, poultry, lean red meat) 1
   • Reduces inflammation and improves vascular health 4

3. Weight Management:

   • Weight loss in overweight/obese men significantly improves erectile function 5
   • Studies show 56% of men following intensive lifestyle intervention regained normal erectile function after 2 years compared to 38% in control group 5

4. Smoking Cessation:

   • Smoking cessation reduces mortality by 36% and improves vascular health 1

5. Moderate Alcohol Consumption:

   • Limit to <21 units/week for men 1

Second-Line: Pharmacological Management

1. For Erectile Dysfunction:

   • PDE5 inhibitors (sildenafil, vardenafil, tadalafil) are first-line pharmacotherapy 1, 6
   • Tadalafil can be used daily (2.5-5mg) or on-demand (10-20mg) 6
   • Efficacy at 24 hours: 61% success with tadalafil 20mg vs 37% with placebo 6
   • Efficacy at 36 hours: 64% success with tadalafil 20mg vs 37% with placebo 6

2. For Low Testosterone:

   • TRT for men with total testosterone <300 ng/dL and symptoms 1
   • Contraindications: active prostate cancer, hematocrit >50%, severe untreated sleep apnea, desire for fertility 7
   • Monitor: hematocrit, PSA, and testosterone levels during treatment 7

Third-Line Options (for ED unresponsive to above treatments):

• Intraurethral alprostadil
• Intracavernous vasoactive drug injection
• Vacuum constriction devices
• Penile prosthesis implantation 1

Special Considerations

Hypogonadism and ED

• Low testosterone is present in approximately 36% of men seeking treatment for sexual dysfunction 1
• Hypogonadism is a potential cause of poor response to PDE5 inhibitors 1
• TRT improves response to PDE5 inhibitors in hypogonadal men 1

Cardiovascular Health and ED

• ED and cardiovascular disease share common pathophysiology (endothelial dysfunction) 8
• Physical activity reduces incident type 2 diabetes and coronary heart disease by 30-50% 1
• Men with ED should be considered at increased cardiovascular risk until proven otherwise 1

Common Pitfalls to Avoid

1. Ignoring testosterone levels: All men with ED should have testosterone measured 1

2. Focusing only on pharmacotherapy: Lifestyle modifications can be as effective as medications for many men 5

3. Overlooking cardiovascular risk: ED often precedes cardiovascular events by 3-5 years 1

4. Neglecting psychological factors: Sexual counseling may be beneficial alongside medical treatment 1

5. Using PDE5 inhibitors with nitrates: This combination is contraindicated due to risk of dangerous hypotension 6

By implementing these comprehensive strategies, most men can experience significant improvements in both libido and erectile function, with corresponding benefits to overall health and quality of life.