Updated: 12/18/2021

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
  • 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
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