madman
Super Moderator
Abstract
Purpose of Review
The goal of this paper is to provide a summary of the recent research, evaluation, work-up, and treatment recommendations regarding erectile dysfunction in adolescents and young adults to better equip pediatric urologists to manage patients with this condition.
Recent Findings
The latest research regarding erectile dysfunction in this population includes organic and psychogenic etiologies, correlations between the COVID-19 pandemic, and online pornography consumption.
Summary
In our large pediatric urology practice, we found an 31x increase of adolescent males presenting with erectile dysfunction since 2014. The majority of cases are attributed to a psychogenic etiology such as anxiety or depression. It is likely that with stress from anxiety and depression, cortisol levels rise, increasing vascular resistance and leading erectile dysfunction in this population. Most patients want to be reassured of normal testosterone levels, offered cognitive behavioral therapy, and be rehabilitated with tadalafil starting at 5 mg p.o. daily until tapered.
Introduction
Within the last few years, there has been a marked increase in adolescent males presenting to pediatric urologists with complaints of erectile dysfunction (ED). Unfortunately, there is very little published data on young adults and no data on adolescents regarding the pathophysiology, contributing causes, evaluation, and treatment of ED. It has been well established that the prevalence of ED is positively correlated with age. It affects about 20% of men over the age of 40, with a prevalence that is 4 times higher for men in their70 s compared to their 20 s [1]. ED is also more prevalent among men with comorbid conditions such cardiovascular disease, hypertension, diabetes mellitus, or neuropsychiatric conditions [2]. Unfortunately, much is unknown about ED in adolescents and young adults. Interestingly, the risk factors and medical conditions known to cause ED in the adult population are typically absent in the adolescent population. Therefore, we cannot apply the guidelines provided for typical evaluation and treatment of ED to the younger populations, since the guidelines are tailored to an older population.
The significant increase of younger populations presenting with ED demonstrates the complexities of the condition and highlights the need for further research regarding the potential etiologies, pathophysiology, work-up, and treatment of ED in this population. A proper evaluation and treatment tailored to this younger population is crucial given its profound effects on confidence, self-esteem, and mental health [3]. In this review,we will summarize the recent literature involving adolescent and young adults with ED and provide pediatric urologists with background and guidance for the treatment of these patients.
*Incidence Rates
*Pathophysiology of Erectile Dysfunction
Normal physiology: The formation of an erection includes a complex interplay of neuropsychiatric and vascular systems. External stimulus activates neurons in the hypothalamus which travel down the parasympathetic system to the sacral plexus, signaling the cavernous nerve terminals to release nitric oxide and initiate the erectile process. Nitric oxide permits the relaxation of the intracavernosal smooth muscles, allowing blood flow into the corpora cavernosa causing compression of the emissary veins and reduced venous outflow, permitting a rigid erection [8].
Pathophysiology of ED: The American Urological Association (AUA) defnes ED as the consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual satisfaction, including satisfactory sexual performance [9]. Psychogenic ED is the inability to achieve or maintain an erection secondary to psychogenic factors.Vascular ED is the inability to form an erection secondary to vascular dysfunction, such as impaired arterial inflow,venous leak, or structural abnormalities. Neurogenic ED is a classification of disorders impairing erections by neurologic impairment, such as stroke, spinal injury, or multiple sclerosis. The neurogenic origin compromises about 15% of types of ED [10]. Peripheral neurogenic ED can be secondary to the disruption of the signals to the brain or the eferentnerves facilitating the erection, while a central neurogenic ED can occur from lack of excitation or increased inhibition[10]. Excluding neuropsychiatric factors, there are several organic etiologies that may explain ED in younger populations which disrupt central or peripheral nerve signals such as spinal injuries, multiple sclerosis, medication side effects, Charcot-Marie-tooth, epilepsy, familial amyloid polyneuropathies, and diabetes mellitus [10].
*Psychogenic vs Organic Nature of Erectile Dysfunction in Young Populations
*The Association Between Anxiety and Depression in Adolescents and Young Adults with Erectile Dysfunction
*Online Forum, Reddit, to Explore Erectile Dysfunction in Young Adults
*Online Pornography
*Effects of the COVID‑19 Pandemic on Erectile Dysfunction
*ED as an Early Marker for Undiagnosed Prediabetes/Type II Diabetes and Cardiovascular Disease in Young Adult Men
*ED Drug Misuse Among Young Adults
*Work‑up and Evaluation for EDin Adolescents and Young Adults
*Proposed Treatment for Adolescent and Young Adult ED
Conclusions
ED in adolescent and young adult populations is a complex problem that can be multifactorial. There is no literature regarding the evaluation and treatment of ED in this specific age group, which makes management of this condition challenging for providers. It is essential to recognize the rising incidence of ED in this understudied population and understand the distress and impacts on psychological well-being this condition has on our patients. Potential etiologies of ED in this population include increased rates of depression and anxiety related to social media, the COVID-19 pandemic, and unrealistic expectations regarding sexual encounters with the increased consumption of online pornography. In addition to ruling out anatomic or hormonal abnormalities, reassuring patients that this is a common condition in adolescents and that their anatomy and testosterone levels are normal is helpful. In addition to reassurance and recommendations for behavioral therapy, we have found that offering a daily dose of tadalafil helps to build confidence and eventually rehabilitate erections. If the dose of 5 mg is not therapeutic, the dose can be increased to 10 mg or even up to 20 mg. If there is still no benefit, then these patients should be referred to a urologic sexual health specialist.
Purpose of Review
The goal of this paper is to provide a summary of the recent research, evaluation, work-up, and treatment recommendations regarding erectile dysfunction in adolescents and young adults to better equip pediatric urologists to manage patients with this condition.
Recent Findings
The latest research regarding erectile dysfunction in this population includes organic and psychogenic etiologies, correlations between the COVID-19 pandemic, and online pornography consumption.
Summary
In our large pediatric urology practice, we found an 31x increase of adolescent males presenting with erectile dysfunction since 2014. The majority of cases are attributed to a psychogenic etiology such as anxiety or depression. It is likely that with stress from anxiety and depression, cortisol levels rise, increasing vascular resistance and leading erectile dysfunction in this population. Most patients want to be reassured of normal testosterone levels, offered cognitive behavioral therapy, and be rehabilitated with tadalafil starting at 5 mg p.o. daily until tapered.
Introduction
Within the last few years, there has been a marked increase in adolescent males presenting to pediatric urologists with complaints of erectile dysfunction (ED). Unfortunately, there is very little published data on young adults and no data on adolescents regarding the pathophysiology, contributing causes, evaluation, and treatment of ED. It has been well established that the prevalence of ED is positively correlated with age. It affects about 20% of men over the age of 40, with a prevalence that is 4 times higher for men in their70 s compared to their 20 s [1]. ED is also more prevalent among men with comorbid conditions such cardiovascular disease, hypertension, diabetes mellitus, or neuropsychiatric conditions [2]. Unfortunately, much is unknown about ED in adolescents and young adults. Interestingly, the risk factors and medical conditions known to cause ED in the adult population are typically absent in the adolescent population. Therefore, we cannot apply the guidelines provided for typical evaluation and treatment of ED to the younger populations, since the guidelines are tailored to an older population.
The significant increase of younger populations presenting with ED demonstrates the complexities of the condition and highlights the need for further research regarding the potential etiologies, pathophysiology, work-up, and treatment of ED in this population. A proper evaluation and treatment tailored to this younger population is crucial given its profound effects on confidence, self-esteem, and mental health [3]. In this review,we will summarize the recent literature involving adolescent and young adults with ED and provide pediatric urologists with background and guidance for the treatment of these patients.
*Incidence Rates
*Pathophysiology of Erectile Dysfunction
Normal physiology: The formation of an erection includes a complex interplay of neuropsychiatric and vascular systems. External stimulus activates neurons in the hypothalamus which travel down the parasympathetic system to the sacral plexus, signaling the cavernous nerve terminals to release nitric oxide and initiate the erectile process. Nitric oxide permits the relaxation of the intracavernosal smooth muscles, allowing blood flow into the corpora cavernosa causing compression of the emissary veins and reduced venous outflow, permitting a rigid erection [8].
Pathophysiology of ED: The American Urological Association (AUA) defnes ED as the consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual satisfaction, including satisfactory sexual performance [9]. Psychogenic ED is the inability to achieve or maintain an erection secondary to psychogenic factors.Vascular ED is the inability to form an erection secondary to vascular dysfunction, such as impaired arterial inflow,venous leak, or structural abnormalities. Neurogenic ED is a classification of disorders impairing erections by neurologic impairment, such as stroke, spinal injury, or multiple sclerosis. The neurogenic origin compromises about 15% of types of ED [10]. Peripheral neurogenic ED can be secondary to the disruption of the signals to the brain or the eferentnerves facilitating the erection, while a central neurogenic ED can occur from lack of excitation or increased inhibition[10]. Excluding neuropsychiatric factors, there are several organic etiologies that may explain ED in younger populations which disrupt central or peripheral nerve signals such as spinal injuries, multiple sclerosis, medication side effects, Charcot-Marie-tooth, epilepsy, familial amyloid polyneuropathies, and diabetes mellitus [10].
*Psychogenic vs Organic Nature of Erectile Dysfunction in Young Populations
*The Association Between Anxiety and Depression in Adolescents and Young Adults with Erectile Dysfunction
*Online Forum, Reddit, to Explore Erectile Dysfunction in Young Adults
*Online Pornography
*Effects of the COVID‑19 Pandemic on Erectile Dysfunction
*ED as an Early Marker for Undiagnosed Prediabetes/Type II Diabetes and Cardiovascular Disease in Young Adult Men
*ED Drug Misuse Among Young Adults
*Work‑up and Evaluation for EDin Adolescents and Young Adults
*Proposed Treatment for Adolescent and Young Adult ED
Conclusions
ED in adolescent and young adult populations is a complex problem that can be multifactorial. There is no literature regarding the evaluation and treatment of ED in this specific age group, which makes management of this condition challenging for providers. It is essential to recognize the rising incidence of ED in this understudied population and understand the distress and impacts on psychological well-being this condition has on our patients. Potential etiologies of ED in this population include increased rates of depression and anxiety related to social media, the COVID-19 pandemic, and unrealistic expectations regarding sexual encounters with the increased consumption of online pornography. In addition to ruling out anatomic or hormonal abnormalities, reassuring patients that this is a common condition in adolescents and that their anatomy and testosterone levels are normal is helpful. In addition to reassurance and recommendations for behavioral therapy, we have found that offering a daily dose of tadalafil helps to build confidence and eventually rehabilitate erections. If the dose of 5 mg is not therapeutic, the dose can be increased to 10 mg or even up to 20 mg. If there is still no benefit, then these patients should be referred to a urologic sexual health specialist.
