Management of Erectile Dysfunction with Decreased Libido and Normal Testosterone Following Laminectomy
This patient requires immediate initiation of PDE5 inhibitor therapy (sildenafil, tadalafil, or vardenafil) as first-line treatment, with concurrent evaluation for neurogenic causes related to the laminectomy and screening for cardiovascular risk factors and depression. 1, 2
Critical Initial Assessment
Distinguish erectile dysfunction from premature ejaculation, as the absence of morning erections and inability to maintain erections during intercourse with preserved sensation and bulbocavernosus reflex suggests organic ED rather than PE. 1, 2 The combination of ED with decreased libido despite normal testosterone points toward either neurogenic etiology from the laminectomy or underlying depression. 2, 3
Key Diagnostic Elements to Document
The laminectomy history is crucial - spinal surgery can cause autonomic nerve damage leading to ED, particularly if the surgery involved lower lumbar or sacral levels. 1 The preserved bulbocavernosus reflex suggests intact sacral reflex arc, but autonomic pathways controlling erection may still be compromised. 4
Loss of morning erections indicates organic rather than psychogenic ED - psychogenic ED typically preserves nocturnal and morning erections. 2, 4 This finding combined with surgical history strongly suggests neurogenic or vascular etiology. 5
Screen for depression and relationship stressors, as decreased libido with normal testosterone frequently indicates mood disorder rather than hormonal deficiency. 2, 3 Depression commonly coexists with ED and requires concurrent treatment. 2
Assess cardiovascular risk factors - ED serves as a marker for underlying cardiovascular disease even without cardiac symptoms. 2, 6 Evaluate for hypertension, diabetes, dyslipidemia, smoking, and obesity. 6, 7
First-Line Treatment Algorithm
Initiate PDE5 inhibitor therapy immediately - these medications are effective in 60-65% of men with ED, including those with neurogenic causes such as post-surgical ED. 1, 6, 7 PDE5 inhibitors work for both organic and psychogenic ED and should be started regardless of suspected etiology. 2
PDE5 Inhibitor Dosing Strategy
Start conservatively and titrate to maximum dose - begin with standard starting doses and increase to maximum tolerated dose if initial response is inadequate. 1
Require at least 5-8 separate attempts at maximum dose before declaring treatment failure - many patients respond only after multiple attempts and dose optimization. 1
For post-surgical neurogenic ED, consider daily low-dose tadalafil rather than on-demand dosing, as daily therapy may provide better outcomes in nerve-damaged patients. 1, 8
Absolute Contraindications to Screen For
Never prescribe PDE5 inhibitors to patients taking nitrates in any form (sublingual, oral, transdermal, or recreational "poppers") due to risk of severe, potentially fatal hypotension. 6, 8 Screen for unstable angina, recent MI/stroke within 2 weeks, uncontrolled hypertension, severe heart failure, or high-risk arrhythmias. 1, 6
Management of Decreased Libido
Address depression first if present - the combination of ED with decreased libido and normal testosterone makes depression highly likely. 2, 3 However, recognize that many antidepressants worsen sexual function, so selective agents (bupropion, mirtazapine) may be preferred. 1, 2
Consider off-label bupropion or buspirone for hypoactive sexual desire disorder even without overt depression, as these agents may improve libido. 1
Testosterone therapy is NOT indicated with documented normal testosterone levels, even with decreased libido. 1, 2 The American College of Physicians recommends against testosterone treatment in men with normal levels. 1
Concurrent Interventions
Lifestyle Modifications
Implement cardiovascular risk reduction - smoking cessation, weight loss if BMI >30 kg/m², increased physical activity, reduced alcohol consumption, and optimization of blood pressure, lipids, and glycemic control. 2, 6
Psychosexual Therapy
Refer for sexual counseling or couples therapy to address the psychosocial impact of ED and decreased libido, particularly given the one-year duration. 1 Psychosocial interventions including cognitive behavioral therapy complement medical treatment effectively. 1
Second-Line Options if PDE5 Inhibitors Fail
If two different PDE5 inhibitors at maximum dose fail after adequate trials (5-8 attempts each), refer to urology for second-line therapies. 1, 2
Second-line options include:
- Intracavernosal vasoactive drug injection therapy (alprostadil) - highly effective with 70-80% success rates but requires patient training. 1
- Intraurethral alprostadil suppositories - less invasive than injections but lower efficacy. 1
- Vacuum erection devices - 90% initial efficacy, particularly useful in older patients with infrequent intercourse. 1
Third-Line Treatment
Penile prosthesis implantation is reserved for patients who fail medical therapies and is associated with high satisfaction rates (>90%) but is irreversible. 1, 2
Critical Pitfalls to Avoid
Do not delay cardiovascular risk assessment - men with organic ED should be considered at increased cardiovascular disease risk until proven otherwise, even without cardiac symptoms. 2, 6 ED may be an early precursor to cardiovascular events. 6
Do not assume the laminectomy is the sole cause - while neurogenic ED from surgery is likely, concurrent vascular or psychogenic factors frequently coexist and require evaluation. 4, 5
Do not treat ED alone when depression is suspected - addressing the underlying psychiatric condition is essential, as untreated depression will limit ED treatment success. 2
Do not prescribe testosterone with normal levels - this provides no benefit for ED or libido and carries potential cardiovascular and prostate risks. 1, 2