Updated: 3/2/2020

Impotence / Erectile Dysfunction

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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
  • Epidemiology
    • incidence increases with age
    • demographics
      • > 40-year-old men
    • risk factors
      • hypertension
      • diabetes
      • chronic prostatitis
      • smoking
      • obesity
  • 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
  • Prognosis
    • natural history of disease
      • most can be managed but not cured
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

 

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