Sexual Health as the Portal to Men's Health

Educational Objectives

The goal of this program is to improve management of sexual dysfunction in men. After hearing and assimilating this program, the clinician will be better able to:

1. Identify causes of sexual dysfunction.
2. Recommend lifestyle modifications and medications to improve sexual function.
3. Incorporate findings of erectile dysfunction into risk stratification for cardiovascular disease.

Summary

Male sexual health: encompasses, eg, low libido, male hypogonadism, erectile dysfunction (ED), ejaculatory dysfunction

Premature ejaculation (PE): the definition of PE has evolved; men with PE may ejaculate before or shortly after vaginal penetration; a sense of ejaculatory control is lacking and men may experience distress stemming from the condition; the most common sexual disorder in men 18 to 50 yr of age; treatment — drugs are available that dampen the hyperexcitability response, eg, selective serotonin reuptake inhibitors (SSRIs), topical creams; the start-stop technique involves starting sexual activity followed by squeezing the glans to stop ejaculation; agents may be used to dampen the nerve response (eg, injection of onabotulinumtoxinA [Botox]), or the dorsal penile nerve may be transected; SSRIs, creams, and the start-stop technique are effective; physicians also may consider off-label use of, eg, tamsulosin (Flomax) which may delay ejaculation; a dose of 0.4 mg 1 to 2 hr before sexual activity is recommended

Delayed ejaculation: studies by Morgentaler et al (2017) and Althof et al (2016) suggest that DE has a strong psychological component; may also be caused by use of tamsulosin or finasteride, or result from spinal cord injury or diabetes; DE is not thought to be associated with low serum testosterone levels; treatment — often difficult to treat; dopaminergic drugs may be given, but significant side effects warrant judicious use

Erectile dysfunction (ED): Feldman et al (1994) — data from the Massachusetts Male Aging Study showed a clear association between ED and cardiovascular (CV) medical diseases; ED was directly correlated with heart disease, hypertension, diabetes, associated medications, and indices of anger and depression; ED was inversely correlated with serum dehydroepiandrosterone (DHEA), high density lipoprotein (HDL) cholesterol, and an index of dominant personality; cigarette smoking was associated with a greater probability of complete impotence in men with heart disease and hypertension

Sildenafil: introduced in 1998 (Revatio, Viagra); Goldstein et al (1998) found that oral sildenafil is effective and well tolerated; men using sildenafil developed CV issues upon re-engaging in sexual activity, which requires CV reserve of 3 to 5 metabolic equivalents; Arora et al (1999) studied the case of a 70-yr-old man with acute myocardial infarction after self-administration of sildenafil and nitrates; providers were concerned by the use of sildenafil by men with cardiac disease or taking nitrates; the patient in the study had a history of hypertension, high cholesterol, and atypical chest pain

Sildenafil and cardiovascular disease (CVD): a consensus panel of cardiologists (Cheitlin et al, 1999) developed guidance for physicians and patients related to concerns about CVD; recommendations — sildenafil should not be used with nitrates because of the large drop in blood pressure that results; providers should exercise caution prescribing sildenafil to patients with ischemia, heart disease (eg, congestive heart failure), patients on complicated, multidrug antihypertensive programs, or taking drugs that may prolong the half-life of sildenafil; DeBusk et al (2000) — used a multispecialty approach to develop a system to classify patients into high, low, and intermediate categories of cardiac risk with use of sildenafil; Rosen et al (2005) — epidemiologic studies in several countries demonstrated that modifiable lifestyle (eg, physical activity) or risk factors (eg, sedentary lifestyle, smoking, high cholesterol, diabetes, and hypertension), are directly related to ED; levels of physical activity predict ED prevalence and incidence; lifestyle changes were demonstrated to be effective in partially modifying ED

ED and vascular disease: ED is a warning sign of silent vascular disease; a man with ED and no cardiac symptoms may be considered a cardiac patient until proven otherwise; Kostis et al (2005) — concluded that men with ED and other CV risk factors should receive counseling for lifestyle modifications; patients at low risk for CVD (eg, regularly exercising, hypertension is controlled, not experiencing shortness of breath or chest pain) may take sildenafil unless opposed by their cardiologist or primary care physician (PCP); providers are recommended to be cautious when prescribing sildenafil to patients with angina or taking multidrug antihypertensive regimens; physicians may refuse sildenafil for patients at high-risk as stated above; ED is a common age-related disorder and is associated with vasculopathy (eg, peripheral arterial disease); PCPs should ask about ED because of its association with CVD; CV risk factors should be identified during evaluation of ED; Inman et al (2009) — clinical data suggests that ED is a potential marker of CVD; epidemiologic evidence indicates that ED in men 40 to 60 yr of age is a silent marker for future cardiac disease and cardiac events; ED in men >60 yr of age does not have the same prognostic significance

Screening: men with CVD risk factors should be screened for ED; men with ED should undergo a thorough medical assessment, including serum testosterone, lipid profile, fasting glucose, blood pressure, and weight; initiating treatment may increase metabolic reserves and improve sexual function; however, reversal of ED through treatment of hypertension, abnormal cholesterol levels, and angina, and smoking cessation, may take several years; Nehra et al (2012) — considered the evaluation and management of CV risk in men with ED and no known CVD; previous recommendations for evaluation of CV risk associated with sexual activity in men with known CVD were re-evaluated and modified

Phosphodiesterase 5 (PDE5) inhibitors: PDE5 inhibitors (eg, sildenafil, vardenafil [Levitra, Staxyn], tadalafil [Adcirca, Cialis], avanafil [Stendra]) are safe and effective in patients for whom they do not increase the risk for cardiac events; over-the-counter PDE5 inhibitors — may not contain PDE5 inhibitors; contamination is possible and quantities of medication are inconsistent; not regulated by the Food and Drug Amdministration (FDA); online pharmacies — may not perform sufficient screening of patients; PE and delayed ejaculation are likely not related to CVD, but ED is clearly associated with CVD

Testosterone and CVD: new formulations were introduced in 2000, eg, patch, topical gel (eg, Androgel, Axiron, Fortests), pellets; testosterone prescriptions doubled from 2010 to 2013; testosterone patches (Androderm) and gels (Androgel, Testim, Axiron) may be prescribed by primary care physicians without appropriate assessment of patients; baseline testosterone level, prostate specific antigen (PSA), and a complete blood count should be assessed; testosterone may affect hemoglobin and hematocrit and cause a small increase in PSA

FDA warning: Vigen et al (2013) and Finkle et al (2014) suggested that testosterone replacement therapy may be associated with cardiac disease or stroke; the FDA placed a black box warning, recommending caution about stroke, myocardial infarction, and deep vein thrombosis; various studies since have refuted linking TTh and an increased risk for cardiac events, but the FDA warning persists; Nguyen et al (2015) — FDA-issued position paper stating that prescription of testosterone may be inappropriate for patients with age-related hypogonadism or late-onset hypogonadism; Miner et al (2018) — a meta-analysis showed the existing evidence fails to support an increased CV risk with testosterone replacement therapy; evidence actually suggests real-world CV benefits; existing evidence shows benefits of testosterone therapy for older men without an etiology for testosterone deficiency; testosterone replacement may provide more energy and strength, leading to increased exercise and weight loss and a modest improvement in sexual function

Readings

Althof SE, McMahon CG. Contemporary management of disorders of male orgasm and ejaculation. Urology. 2016;93:9-21. doi: 10.1016/j.urology.2016.02.018. Epub 2016 Feb 24. PMID: 26921646; Finkle WD, Greenland S, Ridgeway GK, et al. Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men. PLoS ONE. 2014; 9: 76; Khera M. Testosterone Therapies. Urol Clin North Am. 2016 May;43(2):185-93. doi: 10.1016/j.ucl.2016.01.004. Epub 2016 Mar 18. PMID: 27132575; Miner M, Morgentaler A, Khera M, et al. The state of testosterone therapy since the FDA's 2015 labelling changes: Indications and cardiovascular risk. Clin Endocrinol (Oxf). 2018 Jul;89(1):3-10. doi: 10.1111/cen.13589. Epub 2018 Apr 14. PMID: 29486065; Miner M, Seftel AD, Nehra A, et al. Prognostic utility of erectile dysfunction for cardiovascular disease in younger men and those with diabetes. Am Heart J. 2012 Jul;164(1):21-8. doi: 10.1016/j.ahj.2012.04.006. Epub 2012 Jun 7. PMID: 22795278; Morgentaler A, Polzer P, Althof S, et al. Delayed Ejaculation and Associated Complaints: Relationship to Ejaculation Times and Serum Testosterone Levels. J Sex Med. 2017 Sep;14(9):1116-1124. doi: 10.1016/j.jsxm.2017.06.013. Epub 2017 Aug 12. PMID: 28807505; Nehra A, Jackson G, Miner M, et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc. 2012 Aug;87(8):766-78. doi: 10.1016/j.mayocp.2012.06.015. PMID: 22862865; PMCID: PMC3498391; Nguyen CP, Hirsch MS, Money D, et al. Testosterone and “Age-Related Hypogonadism”--FDA Concerns. The New England Journal of Medicine. 2015;373(8), 689–691. https://doi.org/10.1056/NEJMp1506632; Schneider D, Loeb CA, Brevik A, et al. Contemporary cost-analysis comparison of direct-to-consumer vs. traditional prescriptions of phosphodiesterase-5 inhibitors. Int J Impot Res. 2022 Apr 9:1–5. doi: 10.1038/s41443-022-00567-3. Epub ahead of print. PMID: 35397646; PMCID: PMC8994416; Shindel AW, Althof SE, Carrier S, et al. Disorders of ejaculation: an AUA/SMSNA guideline. J Urol. 2022 Mar;207(3):504-512. doi: 10.1097/JU.0000000000002392. Epub 2021 Dec 28. PMID: 34961344; Vigen R, O'Donnell CI, Baron AE, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels. JAMA. 2013; 310: 1829- 1836.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Seftel was recorded at the 4th Annual Meeting of the Androgen Society, held April 21-23, 2022, and presented by the Androgen Society in Orlando, FL. For more information on further CME activities from this presenter, please visit https://www.androgensociety.org. Audio Digest thanks the speakers for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

UR452002

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.