Erectile dysfunction (ED), generally associated with reduced sexual desire and sometimes with orgasmic or ejaculatory dysfunction, is the major presenting symptom of hyperprolactinemia (HPRL) in men, a condition which should not be missed since many cases are due to pituitary tumors, likely to result in serious complications. It is generally believed that the mechanism of prolactin (PRL)-induced sexual dysfunction is a decrease in testosterone secretion. In fact, serum testosterone is normal in many hyperprolactinemic males and testosterone-independent mechanisms are also involved, probably mainly involving cerebral neurotransmitter systems. Systematic determinations of serum PRL have found very low prevalences of marked HPRL (> 35 ng/ml) in ED patients (0.76 in a compilation of more than 3,200 patients) and pituitary adenoma (0.4). In addition, the association of HPRL with ED may have been coincidental in some of these cases, since 10 of HPRLs diagnosed by the usual immunological assays are due to macroprolactins, which are biologically inactive or minimally active variants of PRL. Specific identification of PRL requires PRL chromatography which is only available in some specialized laboratories. No consensus has yet been reached concerning screening for HPRL in ED. Systematic determination of serum PRL may be justified, as HPRL is a serious but reversible disease, while there is presently no reliable clinical, psychometric or hormonal criteria (including serum testosterone level) allowing to restrict its determination to certain categories of ED patients without a risk of missing certain cases of HPRL. In the case of consistent HPRL, looking for hypothalamic or pituitary tumor is mandatory. Dopamine-agonist therapy is the first-line treatment for PRL-induced sexual dysfunction. Sexual counselling may be necessary for some patients.
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