Editing Pathophysiology of Erectile Dysfunction (section)

==== Drug-induced ====

* See Tables 26-11 and 26-12
* Self-reported and questionnaire data concerning ED as a medication side effect should be interpreted with caution

===== Antihypertensive Agents =====
* '''Almost all antihypertensive drugs have ED listed as a potential side effect''', though recent well-designed controlled clinical trials have clarified their association with ED
* '''<span style="color:#ff0000">Associated with ED (3)</span>'''
*# '''<span style="color:#ff0000">α2-agonists (e.g. clonidine)</span>'''
*# '''<span style="color:#ff0000">Methyldopa (centrally acting antihypertensive agent)</span>'''
*#'''<span style="color:#ff0000">Diuretics</span>'''
*#* '''<span style="color:#ff0000">Spironolactone</span>''' is a nonselective mineralocorticoid receptor antagonist with moderate affinity for progesterone and androgen receptors. The latter property increases the likelihood of endocrine side effects, including loss of libido, gynecomastia, and impotence
*#*'''<span style="color:#ff0000">Thiazides (e.g. hydrochlorothiazide)'''
* '''<span style="color:#ff0000">Variably associated with ED</span>'''
** '''<span style="color:#ff0000">β-blockers</span>'''
*** '''<span style="color:#ff0000">Non-selective β antagonists (e.g. propranolol, labetalol) are associated with ED</span>'''
*** '''<span style="color:#ff0000">β1-selective antagonists (e.g. acebutolol, atenolol, bisoprolol, metoprolol, esmolol) are not associated with ED</span>'''
*'''<span style="color:#ff0000">Not associated with ED</span>'''
*# '''<span style="color:#ff0000">ACE-inhibitors</span>'''
*# '''<span style="color:#ff0000">ARBs</span>'''
*# '''<span style="color:#ff0000">α1-blockers</span>'''
*#* May cause retrograde ejaculation
*# '''<span style="color:#ff0000">Calcium channel blockers</span>'''
** '''ARBs and α-blockers may exert a positive effect of erectile function[https://onlinelibrary.wiley.com/doi/full/10.1111/j.1524-6175.2005.05285.x?sid=nlm%3Apubmed#t1 §]'''

===== Psychotropics (antipsychotics, antidepressants, anxiolytics) =====
* '''Commonly produce sexual symptoms'''
* '''SSRIs'''
** '''Up to 50% of patients experience increased sexual dysfunction''', mainly anorgasmia.
*** Adverse effects can be modified by co-treatment with other drugs such as a PDE5 inhibitor or mianserin (atypical antidepressant).
** '''Differ in their ability to cause ED'''
*** '''Paroxetine associated with higher rates of ED compared to citalopram'''
* '''GABAergic drugs - inhibit erection'''
* '''Tricyclics - orgasmic dysfunction and inhibit ejaculation'''
* '''Monoamine oxidase inhibitors - orgasmic dysfunction'''
* '''Benzodiazepines - higher rate of sexual dysfunction'''
*'''<span style="color:#ff0000">Bupropion</span>'''
** '''A norepinephrine-dopamine reuptake inhibitor'''
** '''<span style="color:#ff0000">An alternative antidepressant that is not associated with ED</span>'''
*** Addition of bupropion or a PDE5 inhibitor to an antidepressant seems to be an effective method to correct antidepressant-associated ED

===== Antiandrogens =====
* Cause partial or near-complete blockade of androgen’s action by inhibiting production of or antagonizing the androgen receptor
* '''The effects of androgen deficiency on sexual activity are variable, ranging from complete loss to normal function'''
* '''LHRH antagonists or agonists''' 
**'''Use results in a profound loss of sexual desire, which is usually accompanied by ED'''
*'''5α-reductase inhibitors (finasteride and dutasteride)'''
**'''Antiandrogens with the least effect on circulating testosterone'''
*** '''In randomized placebo-controlled studies of patients given finasteride (5 mg daily) for prostatic symptoms, approximately 5% complained of decreased desire and ED compared with 1% in the placebo group;''' at the lower dose used to treat male-pattern alopecia (1 mg daily), no sexual dysfunction was seen.  However, persistent sexual dysfunction, characterized by low libido, ED, decreased arousal, and difficulty with orgasm, has been reported for months to years after discontinuation of finasteride for hair loss

===== Anticonvulsants =====
* Carbamazepine - orgasmic dysfunction
* Valproate - loss of sexual desire

===== Miscellaneous drugs =====
* Generally based on anecdotal case reports or post-marketing drug alerts rather than controlled trials.
* '''Digoxin'''
* Statins: underlying disease process appears to be the cause of ED in men treated rather than the drug itself
* Sexual dysfunction is a common event after the introduction of '''antiretroviral therapy'''. Because these patients may have diseases involving several organ systems and may be taking multiple drugs, the precise mechanism is difficult to determine.
* '''Alcohol''' in small amounts improves erection and sexual drive due to its vasodilatory effect and suppression of anxiety; however, large amounts can cause central sedation, decreased libido, and transient ED