History

Fact Explanation
Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual intercourse[1],[11] Erectile dysfunction can occur due to neurological, vascular, endocrine and psychological causes. It is a common sexual dysfunction among males.[3],[10],[12]
Erectile dysfunction is common with aging, but psychologically induced causes are common among young males. [10] In elderly males erectile dysfunction is commonly due to diabetes mellitus[2], atherosclerosis , pelvic autonomic neuropathy, rectal surgery or pelvic rediotherapy, hyperprolactinaemia or due to side effects of medication such as: antihypertensives, beta blockers, diuretics, cimetidine, tricyclic antidepressants, antipsychotics [4] or monoamine oxidase inhibitors. [1],[6],[10],[12]
Sudden onset symptoms Sudden onset erectile dysfunction is more likely to be due to a psychological causes, where as pathological causes give a gradual deterioration. [5]
If erectile dysfunction is due to psychogenic cause symptoms are not persistent, they are usually situational [1] These symptoms may occur due to performance anxiety, depression, past history of sexual abuse,cultural taboos or personality problems.[7],[12] Nocturnal and early morning erections are preserved and the person is able to achieve an erection during masturbation. [1]
Substance use [8] Alcohol, tobacco and other psychoactive substances may decrease sexual performance. [8] smoking doubles the risk for erectile dysfunction and also causes peripheral vascular disease[9]
Relationship problems Conflicts within the relationship, infidelity, issues about sexual orientation, poor communication, insecurity, lack of privacy, fear of pregnancy, worries about subfertility can contribute to erectile dysfunction. [5],[12]
Depression Depression may be a causative factor and a complication.This acts as a vicious cycle. [1]
References
  1. PHILIP COWEN. PAUL HARRISON. TOM BURNS. Shorter Oxford Textbook of Psychiatry.6th ed. Oxford University: Oxford University Press. Aug 9, 2012.
  2. CORONA G, MANNUCCI E, MANSANI R, PETRONE L, BARTOLINI M, GIOMMI R, FORTI G, MAGGI M. Organic, relational and psychological factors in erectile dysfunction in men with diabetes mellitus. Eur Urol [online] 2004 Aug, 46(2):222-8 [viewed 28 May 2014] Available from: doi:10.1016/j.eururo.2004.03.010
  3. GALLé G, TRUMMER H. The etiology of erectile dysfunction and mechanisms by which drugs improve erection. Drugs Today (Barc) [online] 2003 Mar, 39(3):193-202 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12730703
  4. CUTLER A.J.. Sexual dysfunction and antipsychotic treatment. Psychoneuroendocrinology [online] 2003 January, 28:69-82 [viewed 31 May 2014] Available from: doi:10.1016/S0306-4530(02)00113-0
  5. FABBRI A, AVERSA A, ISIDORI A. Erectile dysfunction: an overview. Hum Reprod Update [online] 1997 Sep-Oct, 3(5):455-66 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9528911
  6. BRAUN M, WASSMER G, KLOTZ T, REIFENRATH B, MATHERS M, ENGELMANN U. Epidemiology of erectile dysfunction: results of the ‘Cologne Male Survey’. Int J Impot Res [online] December, 12(6):305-311 [viewed 28 May 2014] Available from: doi:10.1038/sj.ijir.3900622
  7. LAUMANN EDWARD O., PAIK ANTHONY, ROSEN RAYMOND C.. Sexual Dysfunction in the United States. JAMA [online] 1999 February [viewed 31 May 2014] Available from: doi:10.1001/jama.281.6.537
  8. SANTTILA P, SANDNABBA NK, JERN P, VARJONEN M, WITTING K, VON DER PAHLEN B. Recreational use of erectile dysfunction medication may decrease confidence in ability to gain and hold erections in young males. Int J Impot Res [online] 2007 Nov-Dec, 19(6):591-6 [viewed 31 May 2014] Available from: doi:10.1038/sj.ijir.3901584
  9. FELDMAN HENRY A., JOHANNES CATHERINE B., DERBY CAROL A., KLEINMAN KEN P., MOHR BETH A., ARAUJO ANDRE B., MCKINLAY JOHN B.. Erectile Dysfunction and Coronary Risk Factors: Prospective Results from the Massachusetts Male Aging Study. Preventive Medicine [online] 2000 April, 30(4):328-338 [viewed 03 June 2014] Available from: doi:10.1006/pmed.2000.0643
  10. HELLSTROM WJ, GITTELMAN M, KARLIN G, SEGERSON T, THIBONNIER M, TAYLOR T, et al. Vardenafil for Treatment of Men With Erectile Dysfunction: Efficacy and Safety in a Randomized, Double‐Blind, Placebo‐Controlled Trial. Journal of andrology. 2002;23(6):763-71.
  11. Impotence. NIH Consens Statement [Online] 1992 Dec 7-9 [viewed on 8 June 2014];10(4):1-31. Available from: http://consensus.nih.gov/1992/1992impotence091html.htm
  12. EID JF, NEHRA A, ANDERSSON KE, HEATON J, LEWIS RW, MORALES A, MORELAND RB, MULCAHY JJ, PORST H, PRYOR JL, SHARLIP ID, WAGNER G, WYLLIE M. First international conference on the management of erectile dysfunction. Overview consensus statement. Int J Impot Res [online] 2000 Oct:S2-5 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11035379

Examination

Fact Explanation
Features suggestive of endocrine disorder such as gynecomastia, testicular atrophy In secondary causes of erectile disorder hormonal problems such as hypogonadism and low circulating testosterone gives rise to impotence and gynecomastia.[1],[6]
Peripheral Vascular Disease causing low volume peripheral pulses with bruits and peripheral gangrenous ulcers Arteriosclerosis is a known cause of erectile dysfunction, occurring due to reduced blood flow through the penile artery.
Features of hypercholesterolemia such as cornea larcus, xanthelasma, xanthomata Atherosclerosis and smoking is a risk factor for peripheral vascular disease, causing occlusion and reduced blood flow of the penile artery. [5]
Complications of Diabetes Mellitus such as foot ulcers, peripheral neuropathy (examine with monofilament) .Diabetes causes erectile dysfunction due to autonomic neuropathy. [1],[3],[5]
Examination of external genitalia Look for obvious abnormalities of the penis and examine testicular size and consistency. [6],[8]
Hypertension Increases the risk of atherosclerosis.
Central Nervous System examination: motor and sensory examination of lower limbs, anal sphincter tone, perianal sensation and bulbocavernosus reflex must be examined. Spinal cord injuries, stroke, rectal or pelvic surgeries can be associated with erectile dysfunction. [7]
Mental State Examination Look for depression or an overly anxious personality. [3,4]
References
  1. MORANO S. Pathophysiology of diabetic sexual dysfunction. J Endocrinol Invest [online] 2003, 26(3 Suppl):65-9 [viewed 31 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12834025
  2. SLAG MICHAEL F.. Impotence in Medical Clinic Outpatients. JAMA [online] 1983 April [viewed 31 May 2014] Available from: doi:10.1001/jama.1983.03330370046029
  3. LEVY J.. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. The British Journal of Diabetes & Vascular Disease [online] 2002 July, 2(4):278-280 [viewed 31 May 2014] Available from: doi:10.1177/14746514020020040801
  4. CUTLER A.J.. Sexual dysfunction and antipsychotic treatment. Psychoneuroendocrinology [online] 2003 January, 28:69-82 [viewed 31 May 2014] Available from: doi:10.1016/S0306-4530(02)00113-0
  5. SEFTEL ALLEN D., SUN PETER, SWINDLE RALPH. THE PREVALENCE OF HYPERTENSION, HYPERLIPIDEMIA, DIABETES MELLITUS AND DEPRESSION IN MEN WITH ERECTILE DYSFUNCTION. The Journal of Urology [online] 2004 June, 171(6):2341-2345 [viewed 02 June 2014] Available from: doi:10.1097/01.ju.0000125198.32936.38
  6. CORONA GIOVANNI, MAGGI MARIO. The role of testosterone in erectile dysfunction. Nat Rev Urol [online] December, 7(1):46-56 [viewed 02 June 2014] Available from: doi:10.1038/nrurol.2009.235
  7. STEERS W.D.. Neural pathways and central sites involved in penile erection: neuroanatomy and clinical implications. Neuroscience & Biobehavioral Reviews [online] 2000 July, 24(5):507-516 [viewed 03 June 2014] Available from: doi:10.1016/S0149-7634(00)00019-1
  8. EID JF, NEHRA A, ANDERSSON KE, HEATON J, LEWIS RW, MORALES A, MORELAND RB, MULCAHY JJ, PORST H, PRYOR JL, SHARLIP ID, WAGNER G, WYLLIE M. First international conference on the management of erectile dysfunction. Overview consensus statement. Int J Impot Res [online] 2000 Oct:S2-5 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11035379

Differential Diagnoses

Fact Explanation
Primary erectile dysfunction [1] A rare cause, usually has a physical cause such as neurological damage or leakage from the penile cavernous bodies. [1]
Secondary erectile dysfunction due to organic causes [2] These are commoner with aging. Etiologies are vascular, endocrine and diabetes mellitus. These should be thoroughly investigated. [1]
Erectile dysfunction due to substance abuse [3] Alcohol, recreational drugs and side effects of medication cause erectile dysfunction. [2],[3] A detailed history is mandatory.
References
  1. PHILIP COWEN. PAUL HARRISON. TOM BURNS. Shorter Oxford Textbook of Psychiatry.6th ed. Oxford: Oxford University Press. Aug 9, 2012
  2. American Psychiatric Association:Diagnostic And Statistical Manual of Mental Disorders,Fourth Edition.Washington, DC, American Psychiatric Association,1994.
  3. SANTTILA P, SANDNABBA NK, JERN P, VARJONEN M, WITTING K, VON DER PAHLEN B. Recreational use of erectile dysfunction medication may decrease confidence in ability to gain and hold erections in young males. Int J Impot Res [online] 2007 Nov-Dec, 19(6):591-6 [viewed 31 May 2014] Available from: doi:10.1038/sj.ijir.3901584

Investigations - Screening/Staging

Fact Explanation
Fasting venous plasma glucose Diabetes is a cause for erectile dysfunction. The patient may be having undiagnosed diabetes, in addition fasting plasma glucose in a diagnosed patient asses the level of control. ideal test to detect the level of control in diabetes is HbA1c level [1],[8],[9]
Lipid profile High levels of serum cholesterol with high LDL and VLDL and elevated total cholesterol/high-density lipoprotein ratio indicates atherosclerosis. [1],[7],[9]
Nerve Conduction Studies (NCS) Peripheral neuropathy and autonomic neuropathy can cause erectile dysfunction. [1]
Thyroid profile Screening for hypothyroidism.
Serum Prolactin For the detection of hyperprolactinaemia, erectile dysfunction associated with reduced sexual desire and sometimes with orgasmic or ejaculatory dysfunction is a common presenting symptom of hyperprolactinemia (HPRL). Can be a result of pituitary tumors, [3],[4],[9]
Morning testosterone levels Low testosterone levels in hypogonadism causes erectile dysfunction. [2],[4],[9]
Prostate Specific Antigen (PSA) levels (in males more than 40 years of age) [6] Ttestosterone therapy is an option in hypogonadism, however if considering testosterone therapy it is important to exclude the risk of prostate cancer. [5],[9]
References
  1. SEFTEL ALLEN D., SUN PETER, SWINDLE RALPH. THE PREVALENCE OF HYPERTENSION, HYPERLIPIDEMIA, DIABETES MELLITUS AND DEPRESSION IN MEN WITH ERECTILE DYSFUNCTION. The Journal of Urology [online] 2004 June, 171(6):2341-2345 [viewed 02 June 2014] Available from: doi:10.1097/01.ju.0000125198.32936.38
  2. CORONA GIOVANNI, MAGGI MARIO. The role of testosterone in erectile dysfunction. Nat Rev Urol [online] December, 7(1):46-56 [viewed 02 June 2014] Available from: doi:10.1038/nrurol.2009.235
  3. JOHNSON AR 3RD, JAROW JP. Is routine endocrine testing of impotent men necessary? J Urol [online] 1992 Jun, 147(6):1542-3; discussion 1543-4 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1593685
  4. BUVAT J. Hyperprolactinemia and sexual function in men: a short review. Int J Impot Res [online] 2003 Oct, 15(5):373-7 [viewed 02 June 2014] Available from: doi:10.1038/sj.ijir.3901043
  5. EID JF, NEHRA A, ANDERSSON KE, HEATON J, LEWIS RW, MORALES A, MORELAND RB, MULCAHY JJ, PORST H, PRYOR JL, SHARLIP ID, WAGNER G, WYLLIE M. First international conference on the management of erectile dysfunction. Overview consensus statement. Int J Impot Res [online] 2000 Oct:S2-5 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11035379
  6. Carroll, P., Albertsen, P.C., Greene, K., Babaian, R. J., Carter, H. B., Gann, P.H., Han, M., Kuban, D. A., Sartor, A. O., Stanford, J. L., Zietman, A.,: Prostate-Specific Antigen Best Practice Statement: 2009 Update. American Urological Association Education and Research, Inc., ©2009. http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf
  7. EATON C B, LIU Y L, MITTLEMAN M A, MINER M, GLASSER D B, RIMM E B. A retrospective study of the relationship between biomarkers of atherosclerosis and erectile dysfunction in 988 men. Int J Impot Res [online] December, 19(2):218-225 [viewed 08 June 2014] Available from: doi:10.1038/sj.ijir.3901519
  8. ISIDRO M. L.. Sexual dysfunction in men with type 2 diabetes. Postgraduate Medical Journal [online] December, 88(1037):152-159 [viewed 08 June 2014] Available from: doi:10.1136/postgradmedj-2011-130069
  9. BODIE JOSHUA, LEWIS JEAN, SCHOW DOUG, MONGA MANOJ. Laboratory Evaluations of Erectile Dysfunction: An Evidence Based Approach. The Journal of Urology [online] 2003 June, 169(6):2262-2264 [viewed 08 June 2014] Available from: doi:10.1097/01.ju.0000063940.19080.58
  10. BASKIN HJ. Endocrinologic evaluation of impotence. South Med J [online] 1989 Apr, 82(4):446-9 [viewed 08 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2495570

Management - General Measures

Fact Explanation
Patient education on the condition and improving communication with sexual partner Treatment of the erectile function depends on the etiology. [2] Education regarding the male and female reproductive system and normal sexual response. Patient co operation and basic knowledge of sexual anatomy is beneficial for management. In young males performance anxiety tends causes worry of duration of erections and lack of confidence leads to erectile dysfunction. [1] Poor relationship status leads to a vicious cycle. it is important to understand each others feelings,expectations and problems.[2]
Management of medical conditions Identification and management of aetiology and treatment for erectile dysfunction. Causes such as diabetes, hyperlipidaemia and depression can be treated. Medication causing erectile dysfunction should be discontinued with a replacement as necessary. [3]
Lifestyle modification Stop alcohol abuse, tobacco and other substance abuse, control diabetes mellitus and hyperlipidaemia, dietary modification,weight loss and adopting an active lifestyle. [3]
References
  1. ROSEN RAYMOND C., LEIBLUM SANDRA R.. Treatment of sexual disorders in the 1990s: An integrated approach.. Journal of Consulting and Clinical Psychology [online] 1995 December, 63(6):877-890 [viewed 02 June 2014] Available from: doi:10.1037/0022-006X.63.6.877
  2. PHILIP COWEN. PAUL HARRISON. TOM BURNS. Shorter Oxford Textbook of Psychiatry.6th ed. Oxford University: Oxford University Press. Aug 9, 2012.
  3. EID JF, NEHRA A, ANDERSSON KE, HEATON J, LEWIS RW, MORALES A, MORELAND RB, MULCAHY JJ, PORST H, PRYOR JL, SHARLIP ID, WAGNER G, WYLLIE M. First international conference on the management of erectile dysfunction. Overview consensus statement. Int J Impot Res [online] 2000 Oct:S2-5 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11035379

Management - Specific Treatments

Fact Explanation
Behavioural sex therapy In young males erectile dysfunction is commonly due to psychogenic causes. These patients benefit from sex therapy. If he has a regular partner get her involved in treatment with the patient's consent. [6] Sex therapy as described by Masters and Johnson consists of four steps; 1. Non genital sensate focus: the couple is asked to engage in touching each others bodies, but must not touch the genital areas. They should not engage in sexual intercourse even if they are aroused. 2. Genital sensate focus: having negotiated the first stage successfully,the couple should then proceed to touch each others genital areas. Other instructions are same as 1st stage 3. Vaginal containment without movement: when the couple is aroused and relaxed, if the man has sufficient erection insert penis to female's vagina and hold it there without movement. 4. Vaginal containment with movement: finally the couple starts movement after containment.[7]
Pharmacological therapy: Phosphodiesterase (PDE5) inhibitors[13] It is the main pharmacological treatment. When sexual arousal sends signals through spinal cord and the peripheral nervous to the smooth muscle of the penis. This triggers the production of nitric oxide(NO) in the corpus cavernosum which includes the formation of cyclic GMP. Cyclic GMP relaxes smooth muscle in blood vessels supplying the corpus cavernosum,and the increased blood supply causes the erection. The levels of cyclic GMP can be increased by inhibiting the phosphodiesterase type5 that normally breaks it down in the penis. PDE5 inhibitors are effective treatment these mediators work only if there is sexual arousal. [10] In psychogenic causes these drugs can be used as short term therapy to build confidence, and in organic causes this is the treatment of choice. [1],[3],[5]
Intracavernous injections and intrathecal suppositories [13] eg; Alprostadil (PGE1), papaverine, and phentolamine Mechanism of action is by vasodilator properties. Can be used as monotherapy or combined therapy which can increase efficacy or reduce side effects. [13] Erection occurs 10-15 minutes later. This can be used in patients who are not benefited in PDE5 inhibitors or contraindicated painful erections, prolonged erections and haematoma at the site are problematic side effects. [2],[4],[8]
Vacuum constriction devices and implants [13] This is indicated if oral therapy fails. The penis is placed in a plastic tube, air is evacuated from the tube and blood is trapped in the penis with a constricting ring. [9],[13]
Penile implants Penile prostheses are implanted only if other treatment measures fail. these are of two types -inflatable -non inflatable (semi rigid). partner should be involved in the management. infection is the problematic complication of the surgery[13]
References
  1. GALLé G, TRUMMER H. The etiology of erectile dysfunction and mechanisms by which drugs improve erection. Drugs Today (Barc) [online] 2003 Mar, 39(3):193-202 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12730703
  2. LEUNGWATTANAKIJ S, FLYNN V JR, HELLSTROM WJ. Intracavernosal injection and intraurethral therapy for erectile dysfunction. Urol Clin North Am [online] 2001 May, 28(2):343-54 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11402586
  3. KALSI JS, CELLEK S, MUNEER A, KELL PD, RALPH DJ, MINHAS S. Current oral treatments for erectile dysfunction. Expert Opin Pharmacother [online] 2002 Nov, 3(11):1613-29 [viewed 28 May 2014] Available from: doi:10.1517/14656566.3.11.1613
  4. SHABSIGH R., KAUFMAN J.M., STEIDLE C., PADMA-NATHAN H.. RANDOMIZED STUDY OF TESTOSTERONE GEL AS ADJUNCTIVE THERAPY TO SILDENAFIL IN HYPOGONADAL MEN WITH ERECTILE DYSFUNCTION WHO DO NOT RESPOND TO SILDENAFIL ALONE. The Journal of Urology [online] 2004 August, 172(2):658-663 [viewed 02 June 2014] Available from: doi:10.1097/01.ju.0000132389.97804.d
  5. GOLDSTEIN IRWIN, LUE TOM F., PADMA-NATHAN HARIN, ROSEN RAYMOND C., STEERS WILLIAM D., WICKER PIERRE A.. Oral Sildenafil in the Treatment of Erectile Dysfunction. N Engl J Med [online] 1998 May, 338(20):1397-1404 [viewed 02 June 2014] Available from: doi:10.1056/NEJM199805143382001
  6. HAWTON K, CATALAN J, FAGG J. Sex therapy for erectile dysfunction: characteristics of couples, treatment outcome, and prognostic factors. Arch Sex Behav [online] 1992 Apr, 21(2):161-75 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1580787
  7. MASTERS, W.H.; JOHNSON, V.E.; KOLODONY, R.C. Masters and Johnson on Sex and Human Loving. Little, Brown and Company. 1988
  8. OTANI T. [Non-surgical treatment of impotence]. Hinyokika Kiyo [online] 1991 Nov, 37(11):1367-72 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1767761
  9. VRIJHOF H, DELAERE K. Vacuum constriction devices in erectile dysfunction: acceptance and effectiveness in patients with impotence of organic or mixed aetiology. British journal of urology. 1994;74(1):102-5.
  10. ANDERSSON KE. Mechanisms of penile erection and basis for pharmacological treatment of erectile dysfunction. Pharmacol Rev [online] 2011 Dec, 63(4):811-59 [viewed 28 May 2014] Available from: doi:10.1124/pr.111.004515
  11. HELLSTROM WJ, GITTELMAN M, KARLIN G, SEGERSON T, THIBONNIER M, TAYLOR T, et al. Vardenafil for Treatment of Men With Erectile Dysfunction: Efficacy and Safety in a Randomized, Double‐Blind, Placebo‐Controlled Trial. Journal of andrology. 2002;23(6):763-71.
  12. KIRBY M, CREANGA DL, STECHER VJ. Erectile function, erection hardness and tolerability in men treated with sildenafil 100 mg vs. 50 mg for erectile dysfunction. Int J Clin Pract [online] 2013 Oct, 67(10):1034-9 [viewed 04 June 2014] Available from: doi:10.1111/ijcp.12229
  13. EID JF, NEHRA A, ANDERSSON KE, HEATON J, LEWIS RW, MORALES A, MORELAND RB, MULCAHY JJ, PORST H, PRYOR JL, SHARLIP ID, WAGNER G, WYLLIE M. First international conference on the management of erectile dysfunction. Overview consensus statement. Int J Impot Res [online] 2000 Oct:S2-5 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11035379