Erectile dysfunction (ED) is defined as consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual satisfaction.1 Although simple in construction, this definition encompasses a number of important considerations when addressing the issue of ED; specifically, a man with ED may be able to achieve an erection but unable to sustain it during or after penetration. Similarly, the inclusion of a consideration for overall satisfaction (applied primarily to the man himself but theoretically applicable to the sexual partner’s satisfaction) indicates how satisfaction, bother, and interpersonal dimensions are critical determinants of clinically relevant ED.
ED has been a concern of men throughout recorded history; it is highly likely that ED affected men before recorded history and was a concern then as well. Although ED is a widely acknowledged condition, it is just one of several sexual dysfunctions that may affect men of all ages.1 Conditions such as decreased libido, premature ejaculation (PE), delayed ejaculation, and Peyronie disease may sometimes be confused (or comorbid) with ED.
In this chapter we will briefly address our approach to management of the man presenting with difficulty attaining or maintaining penile erection. Optimal management of ED requires an understanding of the physiological basis of penile erection and how vascular, neuronal, hormonal, iatrogenic, and psychosocial factors may disturb this process. The reader is referred to Chapter 2 for more information on these critical details. Key points are summarized in Table 12-1.
TABLE 12-1Key Points in Erectile Dysfunction Management ||Download (.pdf) TABLE 12-1 Key Points in Erectile Dysfunction Management
Erectile dysfunction (ED) is a distressing medical condition that has both organic and psychological components in virtually all cases.
ED is a predictor of all-cause mortality, largely related to comorbid cardiovascular disease; ED may be an early warning sign of incipient vascular issues.
Behavioral change (e.g., increased physical activity, weight loss) has been shown in small studies to improve erectile function in men with ED.
Mental health assessment and close involvement of the sexual partner(s) are associated with improved outcomes in ED management.
Current guidelines do not mandate a stepwise approach to ED management, but most men will be best served by management with simple interventions as initial management followed by escalation of therapy as indicated/tolerated.
Oral phosphodiesterase type 5 inhibitors, vacuum tumescence devices, vasodilators applied to the penis by intracavernous injection or intraurethral suppository, and surgical placement of penile prosthetics are the current standards of care in ED management.
Diagnostic Evaluation of the Man with ED
Discussing Sex with Patients
The fundamental underpinning of medical evaluation for any concern is the targeted history and physical examination. Issues of sexual dysfunction broadly (and ED specifically) are no exception. Due to the very sensitive and potentially embarrassing nature of this topic, many patients are hesitant ...