Erectile dysfunction

From greek.doctor

Erectile dysfunction (ED) is the persistent inability to achieve and/or maintain a sufficient erection. It usually causes significant psychosexual morbidity, decreased self-esteem, anxiety, and depression, which might worsen the ED, causing an evil cycle.

Epidemiology

  • Affects 50% of men aged 40 – 70
  • Prevalence increases with age

Physiological erection

  • Flaccid penis
    • Sympathetic nervous system predominates
    • Cavernous smooth muscle is contracted
    • Artery is vasoconstricted
  • Erect penis
    • Parasympathetic nervous system predominates
    • Cavernous smooth muscle relaxes
    • Artery is vasodilated

Diagnosis and evaluation

  • Diagnosis is clinical
  • Anamnesis
    • International Index of Erectile Function (IIEF)
  • Physical examination
    • Hypogonadism
    • Neurological disease
    • Vascular disease
  • Labs
    • Testosterone
    • CVD risk factors
  • Nocturnal penile tumescence
    • Erections physiologically occur during the night
    • This test monitors the penis for erections during the night
      • If erections -> most likely psychogenic ED
      • If no erections -> most likely organic ED

Organic erectile dysfunction

  • Due to vasculogenic, neurologic, hormonal, or cavernosal abnormalities
  • Often co-exists with cardiovascular disease
    • ED can be an early manifestation of CVD
  • Etiology
    • Hypertension
    • Diabetes
    • Cardiovascular disease
    • Smoking
    • Alcohol
    • Neurologic disease
    • SSRIs
    • Radical prostatectomy
    • Pelvic injury

Psychogenic erectile dysfunction

  • Due to central inhibition of the erectile mechanism
  • Etiology
    • Depression
    • Anxiety
    • Relationship issues
    • Stress

Mixed type erectile dysfunction

  • Features of both organic and psychogenic ED

Treatment

  • Psychotherapy
  • First line
    • PDE5 inhibitors
      • Sildenafil
      • Vardenafil
      • Tadalafil
      • Contraindicated in patients who take nitrates or other NO-donor drugs
    • Vacuum tumescence device
      • Vacuum tube creates negative pressure around the penis
  • Second line therapy
    • Intracavernous injection
    • Intraurethral insertion of pellet
    • Alprostadil
  • Third line
    • Penile prosthesis implantation