Erectile Dysfunction

Aka: Erectile Dysfunction, Impotence

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II. Definitions

  1. Erectile Dysfunction
    1. Inability to achieve or maintain Erection
    2. Erection not satisfactory for sexual intercourse

III. Epidemiology

  1. Incidence in United States
    1. Ages 20 to 39 years: 7.5%
    2. Ages 40 to 49 years: 11%
    3. Ages 50 to 59 years: 18%
    4. Ages 60 to 69 years: 38%
    5. Age over 70 years: 57%
  2. Prevalence in United States: 10-20 Million

IV. Pathophysiology

  1. See Penile Anatomy and Erection physiology
  2. Organic disease responsible for 80% of cases
  3. Arterial or venous disease accounts for 70% of cases

V. Causes

  1. See Erectile Dysfunction Causes

VI. History

  1. Assess Severity of symptoms
    1. See International Index of Erectile Function Questionnaire (IIEF-5)
  2. Characteristics of Erectile Dysfunction
    1. Frequency and duration of Impotence
    2. Partial or complete lack of rigidity (and absent of morning Erection)
      1. Vascular causes (e.g. Peripheral Vascular Disease)
      2. Medication causes of Erectile Dysfunction
      3. Pelvic surgery
    3. Libido difficulties
      1. Hypogonadism
      2. Hpothyroidism
      3. Maor depression
    4. No orgasm (anorgasmia) or decreased quality of orgasm
      1. Alcohol Abuse
      2. Thyroid disease
      3. Medication causes of Erectile Dysfunction
      4. Major Depression
      5. Pelvic surgery or irradiation
    5. Decreased ejaculate volume
      1. Normal aging
      2. Chronic Prostatitis
      3. Ejaculatory duct obstruction
      4. Retrograde ejaculation
    6. Painful sexual intercourse
      1. Sexual abuse
      2. Genital Piercings
      3. Sexually Transmitted Disease (e.g. Herpes Simplex Virus Infection)
  3. Symptoms suggestive of Psychogenic Impotence
    1. Depressions Screening in all cases (e.g. PHQ-9)
    2. Sudden onset of Impotence
    3. Impotence in age under 40 years
    4. Strained relationship with sexual partner
    5. Morning or nocturnal Erections still present
    6. Erections achieved with masturbation or oral sex
  4. Review potential Impotence Causes
  5. Consider comorbid conditions
    1. Coronary Artery Disease is common in Impotence
      1. Solomon (2003) Am J Cardiol 91:230-1 [PubMed]

VII. Exam

  1. Blood Pressure
    1. Cardiovascular disease
    2. Peripheral Vascular Disease
  2. Heart Rate
    1. Generalized Anxiety Disorder
    2. Hyperthyroidism
    3. Stimulant Disease
    4. Cardiovascular Disease
  3. Body Mass Index (BMI)
    1. Diabetes Mellitus or Metabolic Syndrome
    2. Cushing Syndrome
  4. Auscultate Great Vessels for Arterial Bruits
    1. Peripheral Vascular Disease
  5. Penile curvature
    1. Peyronie Disease
    2. Ruptured corpora cavernosum
    3. Venous leakage
  6. Endocrine exam
    1. Thyroid Exam
    2. Hypogonadism Signs
      1. Testicular atrophy
      2. Gynecomastia
  7. Neurologic function (Rectal Tone, Bulbocavernosus Reflex, perineal Sensation)
    1. Lumbar central spinal stenosis
    2. Pelvic surgery
    3. Pelvic Trauma
  8. Prostate enlargement
    1. Benign Prostatic Hyperplasia

VIII. Evaluation: Scales

  1. Depression Screening (e.g. PHQ-9)
  2. International Index of Erectile Function Questionnaire (IIEF-5)

IX. Labs: Initial

  1. Fasting Serum Glucose (or Hemoglobin A1C)
  2. Fasting Lipid profile
  3. Morning Total Testosterone Level
    1. Indications: Hyogonadism signs (controversial)
      1. Small Testes
      2. Lack of male secondary sex characteristics
      3. Very low libido
      4. Inadequate PDE-5 Inhibitor (e.g. Viagra) response
      5. Indicated in most cases (especially men over age 50 years, and in signs of Hypogonadism)
    2. Interpretation
      1. Total Testosterone <300 ng/ml suggests Hypogonadism
      2. Confirm abnormal Serum Testosterone with repeat test in 2-3 months
        1. Consider free Testosterone Level if repeatedly normal, however levels are not standardized
      3. Consider Testosterone Supplementation for persistently low Testosterone
  4. Thyroid Stimulating Hormone (TSH)
    1. Especially indicated in all older men

X. Labs: Endocrine as indicated

  1. Follicle Stimulating Hormone (FSH)
  2. Luteinizing Hormone (LH) Indications
    1. Hypogonadism evaluation for low Testosterone
  3. Prolactin Level Indications
    1. Suspected Prolactinoma
    2. Serum Free Testosterone decreased
    3. Libido decreased significantly

XI. Labs: Other tests if indicated

  1. Serum Chemistry Panel (Chem7)
  2. Urinalysis
  3. Complete Blood Count
  4. Prostate Specific Antigen (PSA)

XII. Evaluation: Assessment of nighttime Erection

  1. Indication: Psychogenic cause suspected
  2. Rarely performed now
  3. Techniques
    1. Snap-gauge cuff
    2. Rigiscan (Nocturnal penile tumescence monitoring)

XIII. Evaluation: Advanced Testing by Urology

  1. Biothesiometry
  2. Penile-brachial index
  3. Duplex Ultrasound (Color flow doppler)
  4. Cavernosometry or Cavernosography
  5. Arteriography
  6. Psychological Testing

XIV. Management

  1. See Erectile Dysfunction Management

XV. Precautions: Cardiovascular Risk

  1. Erectile Dysfunction is a Cardiovascular Risk
    1. Mortality Hazard Ratio: 2.04
    2. Cardiovascular event Hazard Ratio: 1.62
    3. More severe Erectile Dysfunction is associated with higher Cardiovascular Risk
    4. Bohm (2010) Circulation 121:1375-1376 [PubMed]
  2. Erectile Dysfunction may be comorbid with cardiovascular disease
  3. Consider Cardiovascular Risk management

XVI. References

  1. Beaudreau (August, 2000) Federal Practitioner, p. 11-8
  2. Ferris (1997) Fam Pract Recert 19(1):47-58
  3. Napolatono (1998) Fam Pract Recert 20(11): 34-58
  4. Dewire (1996) Am Fam Physician 53(6): 2101-6 [PubMed]
  5. Greiner (1996) Am Fam Physician 54(5): 1675-82 [PubMed]
  6. Guay (1995) Postgrad Med 97(4): 127-43 [PubMed]
  7. Jordan (1999) Postgrad Med 105(2): 131-47 [PubMed]
  8. Viera (1999) Am Fam Physician 60(4): 1159-66 [PubMed]
  9. Heidelbaugh (2010) Am Fam Physician 81(3): 305-12 [PubMed]
  10. McVary (2007) N Engl J Med 357(24): 2472-81 [PubMed]
  11. Rew (2016) Am Fam Physician 94(10): 820-7 [PubMed]

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