What are the management options for loss of libido and erectile dysfunction?

Management of Loss of Libido and Erectile Dysfunction

Start with lifestyle modifications and cardiovascular risk assessment, measure morning testosterone levels, then initiate PDE5 inhibitors as first-line pharmacological therapy, reserving invasive options for refractory cases. 1, 2

Initial Assessment

Cardiovascular Risk Evaluation

• All men presenting with ED require cardiovascular risk assessment, as ED often precedes coronary artery disease symptoms by 2-5 years. 3, 4
• Screen for diabetes, hypertension, hyperlipidemia, and metabolic syndrome, as these conditions both cause ED and indicate increased cardiovascular mortality risk 3, 2
• ED severity correlates with cardiovascular disease extent—more severe ED indicates greater risk of major cardiovascular events 4

Laboratory Testing

• Measure morning total testosterone level in all men with ED and decreased libido, as hypogonadism (testosterone <300 ng/dL) commonly contributes to sexual dysfunction, especially in men over 65. 1, 2
• Obtain fasting glucose and lipid panel to identify metabolic risk factors 2, 5
• Consider thyroid-stimulating hormone testing if clinically indicated 6

Focused History and Examination

• Distinguish ED from other sexual dysfunctions including premature ejaculation and isolated libido loss 2, 7
• Assess for psychological factors: depression, anxiety, performance anxiety, and relationship issues 2, 5
• Review all medications, particularly antidepressants and antihypertensives, which commonly cause or worsen ED 5, 6
• Examine genitalia for anatomical abnormalities, secondary sexual characteristics, and lower extremity pulses 2

First-Line Management: Lifestyle Modifications

Implement these changes before or concurrent with pharmacotherapy, as they reduce cardiovascular risk by 30-50% and directly improve erectile function: 3

• Smoking cessation reduces total mortality by 36% in men with coronary disease and improves endothelial function 3
• Weight loss if overweight/obese, targeting BMI reduction through caloric restriction 1, 2
• Regular aerobic exercise (combined with PDE5 inhibitors is more effective than PDE5 inhibitors alone) 1
• Mediterranean diet emphasizing fruits, vegetables, whole grains, fish, and limiting red meat 3
• Moderate alcohol consumption: <14 units/week for women, <21 units/week for men 3, 1
• Optimize control of diabetes, hypertension, and hyperlipidemia 2, 6

Second-Line Management: Pharmacological Therapy

PDE5 Inhibitors (First-Line Pharmacotherapy)

PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) are the most effective oral treatment, with 60-65% of men successfully completing intercourse, including those with diabetes, hypertension, and spinal cord injury. 2, 8

• Start with conservative dosing and titrate for efficacy 1
• Consider daily low-dose therapy as alternative to on-demand dosing 1
• Contraindications: concurrent nitrate use (absolute), severe cardiovascular instability, recent stroke or myocardial infarction 9
• Common side effects: headache, flushing, nasal congestion, dyspepsia 9, 5
• Serious adverse events: sudden vision or hearing loss (NAION), priapism >4 hours requires immediate medical attention 9

Testosterone Replacement Therapy

For men with confirmed hypogonadism (testosterone <230 ng/dL) and symptoms of decreased libido or ED, testosterone replacement improves sexual function and may enhance PDE5 inhibitor response. 3, 1, 2

• Men with testosterone 230-350 ng/dL may benefit if symptomatic 3
• Testosterone >350 ng/dL does not usually require replacement 3
• Contraindications: men seeking fertility, prostate cancer 2
• Requires monitoring of hemoglobin, liver enzymes, and prostate-specific antigen due to prostate cancer risk 6
• Testosterone alone improves libido but requires minimal threshold levels for complete PDE5 inhibitor efficacy 3

Third-Line Management: Invasive Therapies

For PDE5 Inhibitor Failures

• Intracavernosal alprostadil injections are highly effective when oral medications fail 1, 2, 8
• Intraurethral alprostadil suppositories offer less invasive local therapy 2, 8
• Vacuum constriction devices provide non-invasive mechanical option, particularly useful with pharmacotherapy contraindications 1, 2

Surgical Options

• Penile prosthesis implantation for refractory ED achieves high patient satisfaction rates 1, 2, 8
• Consider only after exhausting non-surgical options 2

Adjunctive Treatments

Psychosexual Therapy

• Recommend psychosexual or couples counseling when psychological factors contribute, including performance anxiety, depression, or relationship issues 1, 2, 5
• Cognitive behavioral therapy improves outcomes in psychogenic ED 6
• Partner involvement in treatment decisions improves outcomes 2

Additional Interventions

• Pelvic floor muscle training may improve sexual function 1
• Consider multidisciplinary approach involving urology, endocrinology, and cardiology for complex cases with multiple comorbidities 1

Critical Caveats

• Ensure cardiac stability for sexual activity before prescribing ED treatments—sexual activity carries metabolic equivalent of 3-5 METs 1, 2
• PDE5 inhibitors require adequate testosterone levels for full efficacy; check testosterone in non-responders 3
• ED in younger men and minorities may indicate underestimated cardiovascular risk by traditional assessments 4
• Outcomes improve when treatment addresses both organic and psychological components simultaneously 2, 5