Snapshot A 60-year-old man presents to his primary care physician for evaluation of erectile dysfunction. His wife died 5 years ago and he would like to start dating again. He denies having any life stressors. He reports having no morning or night-time erections. His past medical history includes hyperlipidemia managed with medication and pre-diabetes managed with an active lifestyle and diet. His physician sends him for further laboratory workup and counsels him on the use of sildenafil. Introduction Clinical definition impotence or erectile dysfunction is the inability to have or maintain an erection for intercourse Etiology Primary erectile dysfunction with normal functioning penis psychogenic fear of intimacy, depression, stress, anxiety, or guilt performance anxiety common post-myocardial infarction secondary to anxiety ↓ testosterone ↓ libido ↓ desire thyroid disease Cushing’s syndrome Secondary erectile dysfunction with an abnormally functioning penis vascular disease atherosclerosis causing ↓ blood flow to the organ diabetes drugs alcohol antidepressants neurologic stroke seizures multiple sclerosis endocrine hypogonadism hyperprolactinemia trauma Pathogenesis normal physiology nitric oxide is released and leads to formation of 3’,5’-cyclo-guanosine monophosphate (3,’5’-cGMP) 3’,5’-cGMP causes compression of veins which impedes venous return and causes an erection erectile dysfunction various etiologies likely interfere with the pathway, causing low concentrations of 3’,5’-cGMP Associated conditions depression benign prostatic hypertrophy Epidemiology Incidence increases with age Demographics > 40-year-old men Risk factors hypertension diabetes chronic prostatitis smoking obesity Presentation Symptoms presence or absence of morning or nighttime erections if present, this may suggest psychogenic etiology difficulty with arousal difficulty with orgasms Physical exam may have hypogonadism Studies Labs fasting blood sugar hemoglobin A1c lipid profile morning testosterone level if consistently low on 2 or more tests obtain luteinizing hormone (LH) follicle-stimulating hormone (FSH) thyroid function tests Nocturnal penile tumescence and rigidity test help differentiate between primary and secondary etiology Differential Premature ejaculation Treatment Conservative weight loss and diet modifications indications obesity and diabetes are risk factors for erectile dysfunction counseling indications for psychogenic erectile dysfunction Medical phosphodiesterase-5 (PDE-5) inhibitor drugs sildenafil vardenafil contraindications use with nitrates increased risk of syncope and hypotension Operative implants or injection therapy indications if patients are contraindicated to PDE-5 inhibitors Complications Relationship problems Prognosis Natural history of disease most can be managed but not cured