Although many prescription medications have been implicated in disorders of sexual desire, arousal, and orgasm, medications to treat hypertension and psychiatric disorders are most frequently cited as contributing to these dysfunctions.
Antihypertensive Medications.
The majority of antihypertensive medications have been implicated in sexual disorders. However, some substances are more likely than others to cause ED. For example, diuretics (e.g., chlorthalidone, hydrochlorothiazide, and spironolactone), central antiadrenergic agents (e.g., clonidine, methyldopa, reserpine), and guanethidine are commonly cited as causes of ED. However, β-blockers, with the exception of propranolol, are less likely to cause ED, but can cause desire disorders. Angiotensinconverting enzyme inhibitors may be least likely to cause ED. In addition, minoxidil, hydralazine, prazosin, and furosemide rarely cause sexual side effects, although hydralazine and prazosin have been associated with priapism in case reports.
Psychiatric Medications.
Psychiatric medications also commonly affect sexual function. Antidepressants (e.g., amitriptyline, amoxapine, clomipramine, desipramine, nortriptyline, protriptyline) have frequently been associated with ED and can cause a delayed or absent orgasmic response. Similar side effects have been reported with selective serotonin reuptake inhibitors, such as fluoxetine and sertraline. Antipsychotic medications (e.g., thioridazine, chlorpromazine), without exception, have the potential for disrupting sexual response. Lithium and monoaminooxidase inhibitors may impair sexual desire and erectile function. Many other prescription medications in diverse therapeutic classes are frequently cited as causing sexual dysfunctions. These include carbamazepine, digoxin, disulfiram, and ketoconazole. In addition, antihyperlipidemic agents like clofibrate and gemfibrozil have been associated with ED. The statins appear to have a lower risk. Hormonal agents, including antiandrogens, LH-RH analogs, and estrogens, also increase the risk of ED. Other drugs associated with ED include protease inhibitors, cytotoxic agents, and H2-receptor antagonists.
Psychogenic Causes of ED
Psychogenic ED frequently coexists with other sexual dysfunctions, notably hypoactive sexual desire, and with major psychiatric disorders, particularly depression and anxiety disorders. In the latter cases, a primary diagnosis may be difficult to establish, and concomitant treatment of the patient’s psychiatric disorder may be indicated as the initial step in management.
Many men with ED also have comorbid depression, and the relation between them appears to be bidirectional; the occurrence of either disorder may cause, result from, or exacerbate the other. There are five models, not mutually exclusive, that describe a possible relation between ED and depression.
- First, ED may lead to “secondary” depression in vulnerable individuals. Studies have shown that men with ED are more likely to report depressive symptoms than are men without ED.
- Second, ED can be symptomatic of a “primary” depressive episode. That is, men who are depressed frequently manifest symptoms of ED. Furthermore, some men with major depressive disorder develop a reversible loss of nocturnal penile tumescence, suggesting that depression can influence erectile neurophysiology .
- Third, a common factor may be related to the development of both conditions. ED and depression frequently co-occur with other conditions, including diabetes, hypertension, cardiovascular disease, neurologic disorders (e.g., parkinsonism, multiple sclerosis), and endocrine disorders (e.g., adrenal, thyroid, gonadal). Numerous epidemiologic studies have indicated that the concurrence of depressive symptoms, particularly major depressive disorder, increased the risk of ischemic heart disease and mortality. Other data showed that depression was a significant, independent risk factor for the development of symptomatic ischemic heart disease in otherwise healthy individuals. Conversely, medical illness can precipitate depression in a predisposed individual. Significantly, ED, depression, and vascular disease share a number of risk factors, including smoking, obesity, dyslipidemia, and a sedentary lifestyle.
- Fourth, ED can be an adverse effect of medication treatments for these conditions, including antidepressants, antihypertensives, cardiac drugs, and numerous other agents. Between 5 and 80% of patients taking antidepressants experience side effects related to sexual function. Similarly, between 10 and 50% of men taking antihypertensives experience ED while on therapy.
- Finally, as relatively prevalent conditions, ED and depression can be coincidentally comorbid and, thus, etiologically unrelated.
The significance of psychosocial factors in the etiology of ED has been highlighted in epidemiological studies. In the MMAS, ED was significantly associated with depressive symptoms, pessimistic attitudes, or a negative outlook on life. Similarly, in the National Health and Social Life Survey, ED was significantly associated with emotional stress and a history of social coercion. These studies underline the significant effects of psychosocial factors in the etiology of ED. Female viagra pills
Generally, psychosocial determinants of ED are divided into immediate and remote causes. Immediate causes include performance anxiety (or fear of failure), lack of adequate stimulation, and relationship conflicts. Among the remote or early developmental causes, various researchers have emphasized the role of sexual trauma in childhood, sexual identity or orientation issues, unresolved partner or parental attachments, and religious or cultural taboos.
Frequently, interpersonal and relationship factors have been associated with ED. Communication difficulties, lack of intimacy or trust, and power conflicts have been emphasized as frequent concomitants of arousal difficulties in both sexes. Loss of sexual attraction has also been implicated.
An expanded classification system for psychogenic ED has been proposed by the nomenclature committee of the International Society of Impotence Research. This new classification is intended to broaden the previously limited focus of psychogenic ED and incorporates clinical features (general vs situational ED) and hypothesized etiologic mechanisms (central excitation vs inhibition) of psychogenic ED. Recent studies have strongly implicated the role of central excitatory and inhibitory mechanisms in the control of male sexual arousal. These concepts are incorporated into the proposed classification system.
In addition to the clinical subtypes of generalized vs situational, psychogenic ED can be characterized as lifelong (primary) or acquired (secondary).
Primary psychogenic ED refers to the lifelong inability to achieve successful sexual performance, whereas secondary psychogenic ED occurs after a period of satisfactory sexual performance. Primary psychogenic ED is relatively rare and usually associated with a chronic pattern of sexual or interpersonal inhibition. Psychogenic ED may also be classified as secondary to substance abuse or a major psychiatric disorder.
