Hormonal Testing and Pharmacologic Treatment of Erectile Dysfunction

Who developed these guidelines?

The American College of Physicians (ACP) developed these recommendations. Members of the ACP are internists, specialists in the care of adults.

What is the problem and what is known about it so far?

Erectile dysfunction (impotence or ED) is an inability to get or keep an erection firm enough for sexual intercourse. Causes can be psychological or physical. Physical causes include advanced age, heavy drinking, chronic diseases (such as diabetes), hormonal abnormalities (such as low testosterone levels), and use of some drugs (such as some treatments for high blood pressure or depression). Because hormonal abnormalities can be a cause of ED, some doctors will routinely measure hormone levels in men with this condition. However, the value of this testing in men who have no other signs of hormone problems is unclear. Phosphodiesterase-5 (PDE-5) inhibitors are drugs available to treat ED. Commonly prescribed PDE-5 inhibitors include sildenafil (known by the brand name Viagra [manufactured by Pfizer, New York, New York]), vardenafil (known by the brand name Levitra [manufactured by GlaxoSmithKline, Brentford, United Kingdom]), and tadalafil (known by the brand name Cialis [manufactured by Lilly, Indianapolis, Indiana]).

How did the ACP develop these recommendations?

The authors reviewed published studies about the value of hormonal testing for men with ED and about the benefits and harms of the different PDE-5 inhibitor drugs. They also looked for studies that compared 1 PDE-5 inhibitor drug to another.

What did the authors find?

The authors found a lack of high-quality research to define the value of hormonal testing for men with ED. Studies show improvements in patients' ability to get and keep an erection with a PDE-5 inhibitor compared with no active treatment regardless of the cause of ED. Some evidence showed that higher doses of sildenafil and vardenafil showed better response than lower doses. This was not true for tadalafil. Also, higher doses increased the risk for adverse effects. Side effects were mainly mild or moderate (such as headache or nausea) in most people. However, people who took PDE-5 inhibitors and nitrate medications at the same time or had unstable heart disease had a risk for heart attack. There are several reports of blindness in patients taking a PDE-5 inhibitor, but these cases do not prove that the condition is related to the drug. There is not enough evidence to conclude that 1 PDE-5 inhibitor is better than another with respect to benefit or side effects.

What does the ACP suggest that patients and doctors do?

For men who seek treatment of ED, a PDE-5 inhibitor drug is appropriate unless the patient is taking a nitrate medication or has unstable heart disease.

Patients taking nitrate medications should not take a PDE-5 inhibitor.

The choice between PDE-5 inhibitors should be based on patient's preferences, including ease of use, cost, and adverse effects. There is no strong evidence that 1 PDE-5 inhibitor is clearly better than another.

Whether to measure hormone levels before treating ED is a decision that the doctor and patient must make knowing that no good studies are available to determine the benefits and harms of testing.

What are the cautions related to these recommendations?

These recommendations may change as new studies become available.