Male sexual dysfunction is a prevalent disorder and a common presenting clinical complaint. It is especially a challenge when simple "fixes" do not work.
The three major forms of male sexual dysfunction are erectile dysfunction (ED), ejaculatory dysfunction, and decreased libido. In my practice, ED is far and away the issue grappled with most, given the heavy representation of men over the age of 40 years with obesity, hypertension, and polypharmacy.
PDE5 inhibitors are an effective, first-line treatment for men presenting with ED. But discontinuation rates approach 50%, with most men citing lack of consistent efficacy as the cause for stopping. And with the amount of money that patients shell out for these drugs, we should not be surprised. Many of us may try other drugs in the same class, which is commonly an exercise in futility.
What else can we do?
Dr. Farid Dadkhah and colleagues published a randomized, controlled clinical trial evaluating the efficacy of atorvastatin among hyperlipidemic men who were "nonresponders" to sildenafil (Int. J. Impot. Res. 2010;22:51-60). In this study, 131 men were randomized to 40 mg of atorvastatin or matching placebo. Men were 18-70 years of age and had an inadequate response to sildenafil 100 mg, LDL cholesterol less than 160 mg/dL, and ED for more than 6 months. Potential subjects were excluded if they were currently using antilipidemics. Patients were asked to have sexual intercourse at least once per week, and they received medication for 12 weeks. Erectile function was assessed using the International Index of Erectile Function (IIEF-5).
The main outcome was improvement in the IIEF-5 total score. A global efficacy question (GEQ) was used that asked, "Did the treatment you were taking improve your erections?"
Atorvastatin was associated with a statistically significant improvement in the mean IIEF-5 score (P = .01) and GEQ (P = .001). Although 37% of subjects improved, none of the patients regained completely normal erectile function as defined by an IIEF-5 score greater than 21.
The study’s authors note that oxidized LDL inhibits vascular smooth-muscle relaxation. Statins decrease the action of oxidized LDL on endothelial cells, which increases the activity of nitric oxide,* the main vasodilator in penile erection. The investigators also remind us that PDE5 inhibitors are palliative, not curative.
But for our men with ED and dyslipidemia, adding atorvastatin to sildenafil can potentially provide both palliation and cure.
This column, "What Matters," regularly appears in Internal Medicine News, a publication of Frontline Medical Communications. Dr. Ebbert is professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He reports having no conflicts of interest. The opinions expressed are those of the author. Reply via e-mail at imnews@frontlinehealthcom.com.
* Corrected from earlier version of article.