Presentation of an erectile dysfunction case
A 58-year-old man complained of loss of libido and erectile dysfunction. Pubertal development had been normal, as had sexual function until about two years ago. Since then, he had noted a gradual decline in his ability to achieve and maintain an erection. The patient was otherwise in good health and taking no medications.
On review of systems, the patient noted a history of frontal, throbbing headaches that he attributed to job-related stress. During the past six months, he had also noted some trouble with his vision. On additional questioning, he said that he did not need to shave as frequently as in the past, was experiencing fatigue and occasional hot flashes, had dry skin, had gained 10 lb during the past year, and was constipated. In addition to stress at work, he expressed concern about his relationship with his girlfriend.
This patient’s erectile dysfunction appears to be largely hormonal in origin. The causes of erectile dysfunction fall into five categories: vascular, neurogenic, hormonal, iatrogenic (i.e., caused by medication), and psychogenic. Typically, more than one cause is involved, and regardless of the precipitating factor, by the time the patient presents to a physician, there is also a psychogenic component.
A directed history is critical for distinguishing the different categories of erectile dysfunction. Historically, men with erectile dysfunction have not talked to their physicians about it, and physicians have not felt comfortable asking about it. While that reticence may be diminishing–in part owing to awareness of new treatment options–patients still rarely volunteer sufficient information.
The first step in the history is to determine the scope of the problem. Similar research is needed when male enhancement or penis enhancement is sought. Erectile dysfunction is defined as the consistent inability to attain and maintain penile erection sufficient to permit satisfactory sexual intercourse. That definition comprises a spectrum of possibilities: Does the patient have no erections at all? No morning erections? Does he have erections, but only partial ones? Although the degree of dysfunction does not correlate with the underlying cause, establishing a baseline of function is valuable for gauging the effect of therapy. Onset of the dysfunction does have diagnostic significance, however: gradual onset suggests a physiologic cause; psychogenic impotence typically–although not invariably–has an acute onset.
To narrow the differential diagnosis, physicians must be specific in their questioning, not only about erectile dysfunction but about other signs and symptoms. In this case, the patient had experienced both loss of libido and erectile dysfunction. Loss of the two functions can occur separately in men, although libido and sexual function usually are not separated in women. The mechanisms that control libido are not clearly understood, but it is known that decreased libido tends to be associated with hormonal deficits. One exception is psych-iatric medications; they can decrease libido without affecting erectile function.
This patient’s normal puberty suggests that maturation of the hypothalamic-pituitary-gonadal axis was normal. However, shaving less frequently and occasional hot flashes strongly suggest decreased androgen production. Just as women have hot flashes when their estrogen levels fall during menopause, men whose androgen levels are falling to prepubertal levels also experience hot flashes.
The history of headaches and the recent onset of visual problems are important clues–clues that too often are ignored in such cases. They suggest a space-occupying lesion of the hypothalamus or pituitary. Fatigue, weight gain, constipation, and dry skin are all nonspecific symptoms, but when added to the rest of the clinical picture, they suggest another pituitary deficiency: hypothyroidism caused by abnormal thyroid-stimulating hormone (TSH) secretion. Because thyroid dysfunction can cause erectile dysfunction, thyroid testing is indicated whenever there is a possibility of hypothyroidism, especially in an older patient. Although thyroid abnormalities are less common in men than in women, about 3% to 4% of men over age 60 have autoimmune thyroid disease.
Although it is unlikely, psychological stress cannot yet be ruled out as a cause of erectile dysfunction is this patient. He is under stress at work, is having problems with his relationship, and is undoubtedly suffering performance anxiety because of his erectile dysfunction.
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Case 1 Treatment
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The patient was treated with cortisol and thyroid hormone, after which transsphenoidal pituitary surgery was performed and the tumor resected. Histopathologic analysis confirmed that the tumor was a glycoprotein-secreting adenoma.
Several weeks after surgery, the patient reported that his libido and erections had returned. Six weeks postoperatively, hormonal therapy was withdrawn. Subsequent testing confirmed that pituitary function was normal.
figure 3This patient had a glycoprotein-secreting pituitary tumor, also known as a nonfunctioning pituitary tumor. The tumor usually occurs in older men who present with erectile dysfunction and headaches.
Once considered uncommon, glycoprotein-secreting pituitary tumors are now recognized as the second most common pituitary tumor. Prolactinomas are the most common, accounting for about 40% of cases. Growth hormone-secreting tumors, which cause acromegaly, account for about 10% of cases; ACTH-secreting tumors, which cause Cushing’s syndrome, cause 10% or fewer of pituitary tumors.
Pituitary tumors occur in about one in 10,000 persons. Until recently, many physicians did not look for these tumors, which escaped notice until they grew very large. Now that evaluation for hypogonadism in men with erectile dysfunction is being done more frequently, the tumors are being detected at an earlier stage.
The urologic literature used to recommend against performing a hormonal evaluation in men with erectile dysfunction, because a hormonal cause was found in less than 10% of cases. However, that figure reflected the experience in urologic practices, which assess large numbers of younger men with stress-induced erectile dysfunction. In a retrospective study of 100 men with erectile dysfunction seen at my endocrine impotence clinic, which serves an older group of patients with multiple systemic diseases, 48% of cases had a hormonal component. It was not necessarily the only cause–they also may have had vascular or neurogenic problems–but it was important enough not to miss, because treatment will not succeed if only part of the problem is addressed. Evaluation for hormonal deficiency is also important because there are many other risks associated with longstanding hypogonadism, such as osteoporosis and premature exacerbation of cardiovascular disease (probably due to estrogen deficiency, which occurs with loss of androgens).
It was previously thought that if a patient had a defect in pituitary hormone production before surgery, it meant that the pituitary had been irrevocably damaged, and that the patient would require life-long replacement therapy after the surgery. We now know that when the operation is performed by a skilled neurosurgeon who is able to remove the tumor while preserving the pituitary, normal pituitary function can return. About six weeks after surgery, hormone replacement therapy is stopped and patients are retested. If the surgery was successful, the prognosis is very good. Periodic follow-up with MRI scans is indicated to detect recurrences, but they are rare.
Should hypogonadotropic hypogonadism persist after tumor removal, the patient will need androgen replacement for androgenization or, to restore fertility, treatment with either human chorionic gonadotropin or pulsatile gonadotropin- releasing hormone (GnRH). At present, I use testosterone patches for androgen replacement. The patches are more expensive than intramuscular testosterone injections but allow closer mimicking of the normal diurnal variation in testosterone levels. The results are noticeable within a week of starting treatment of male stamina enhancement.
