Updated: 11/11/2018

Impotence / Erectile Dysfunction

Review Topic
  • A 35-year-old man with a past medical history of depression presents to his primary care physician for evaluation of difficulty maintaining an erection. He is married, has 3 children all under the age of 5, and was recently fired from a long-standing job. He reports feeling constantly fatigued and losing interest in activities he previously enjoyed, such as golfing. He reports never feeling like engaging in sexual intercourse, but feels pressure to do so from his wife. He reports having daily morning erections. His routine labs from 6 months ago at an annual visit reveal normal hemoglobin A1c and lipid levels.
  • 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
      • ↓ 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
      • endocrine
        • hypogonadism
        • hyperprolactinemia
  • Pathogenesis
    • normal physiology
      • nitric oxide is released, which 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
  • Symptoms
    • presence or absence of morning or nighttime erections
      • presence may suggest psychogenic etiology
    • difficulty with arousal
    • difficulty with orgasms
  • Physical exam
    • may have hypogonadism
  • Labs
    • fasting blood sugar
    • hemoglobin A1c
    • lipid profile
    • morning testosterone level
    • thyroid function tests
  • Nocturnal penile tumescence and rigidity test
    • help differentiate between primary and secondary etiology
  • Premature ejaculation
  • 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
  • Operative
    • implants or injection therapy
      • indications
        • if patients are contraindicated to PDE-5 inhibitors
  • Relationship problems


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