Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 23-06: Male Erectile Dysfunction & Sexual Dysfunction + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Erectile dysfunction can have organic and psychogenic etiologies and the two frequently overlap Organic erectile dysfunction may be an early sign of cardiovascular disease and requires evaluation Peyronie disease is a common benign fibrotic disorder of the penis that causes pain, penile deformity, and sexual dysfunction +++ General Considerations ++ Consistent inability to maintain an erect penis with sufficient rigidity to allow sexual intercourse Erectile dysfunction occurs from arterial, venous, neurogenic, or psychogenic causes Most common cause of erectile dysfunction is a decrease in arterial flow resulting from progressive vascular disease Loss of orgasm: if libido and erections are intact, usually of psychological origin Premature ejaculation Anxiety related Due to a new partner Unreasonable expectations about performance Emotional disorders Priapism is the occurrence of penile erection unrelated to sexual stimulation, generally lasting longer than 4 hours Causes ischemic injury of the corpora cavernosa and erectile dysfunction (low flow or "ischemic" priapism); ischemic priapism requires immediate intervention to avoid irreversible penile damage Can be due to unregulated high blood flow May be caused by red blood cell dyscrasias, drug use, and any of the treatments for erectile dysfunction Loss of seminal emission may result from androgen deficiency by decreasing prostate and seminal vesicle secretions as well as sympathetic denervation as a result of spinal cord injury, diabetes mellitus, or pelvic or retroperitoneal surgery Retrograde ejaculation may occur as a result of mechanical disruption of the bladder neck due to congenital abnormalities, transurethral prostate surgery, pelvic radiation, treatment with alpha-blockers, or sympathetic denervation +++ Demographics ++ More than half of men aged 40–70 years have erectile dysfunction Incidence increases with age Most have an organic rather than psychogenic cause Peyronie disease primarily affects men aged 45–60 years, with average age at onset of 53 years Almost all patients with Peyronie disease are Caucasians (especially in those of northern European or Scandinavian heritage) It is much less common to rare in men of African heritage (unless diabetic), and rare to unknown in men of Asian heritage + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ History: erectile dysfunction should be distinguished from problems with penile deformity, libido, orgasm, and ejaculation Histories of prostate cancer treatment or Peyronie disease should be elicited Degree of the dysfunction—chronic, occasional, or situational Timing of dysfunction Determine whether the patient ever has any normal erections, such as in early morning or during sleep Inquire about dyslipidemia, hypertension, neurologic disease, diabetes mellitus, chronic kidney disease, endocrine disorders, depression, and cardiac or peripheral vascular disease Trauma to the pelvis, pelvic or prostate irradiation, or peripheral vascular surgery Use of drugs, alcohol, tobacco, and recreational drugs Physical examination of genitalia, testicles, and prostate Secondary sexual characteristics Motor and sensory examination Evaluate for penile scarring, plaque formation of Peyronie disease + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Urinalysis Fasting lipid profile Serum glucose Testosterone Measurement of free testosterone and luteinizing hormone indicated when testosterone or prolactin are abnormal +++ Imaging Studies ++ Diagnostic tests such as duplex Doppler ultrasound, penile cavernosography and pudendal arteriography can separate arterial from venous erectile dysfunction and help predict which patients may benefit from vascular surgery +++ Diagnostic Procedures ++ Direct injection of vasoactive substances into the penis (eg, prostaglandin E1 or papaverine) May be given diagnostically to reveal penile curvature of Peyronie disease When given therapeutically, prostaglandin E1 may be compounded with papaverine and/or phentolamine in order to increase effectiveness, but patients should be cautioned about the increased risk of priapism + Treatment Download Section PDF Listen +++ +++ Medications ++ In men with hypogonadism who have undergone complete endocrinologic evaluation, restoration of normal testosterone levels may improve sexual quality of life Injection of prostaglandin E1 (alprostadil) (2.5 mcg to 10 mcg/dose initially, increasing gradually by 5–10 mcg daily until response, with maximum of 40–60 mcg/dose 3 times weekly) or papaverine (30–60 mg maximum 3 times weekly) intracavernously into the penis Performed using a tuberculin-type syringe or a metered-dose injection device Base or lateral aspect of the penis is used as injection site to avoid injury to superficial blood supply located dorsally Complications are rare and include priapism, penile pain, bruising, dizziness, fibrosis, and infection Alprostadil suppository pellets (125, 250, 500, and 1000 mcg) Sildenafil, vardenafil, tadalafil, and avanafil Inhibit phosphodiesterase type 5 (PDE-5), preventing the degradation of cGMP and increasing blood flow into the penis These medications have variable durations of onset, activity and side effects Each medication should be initiated at the lowest dose and titrated to achieve the desired effect There is no impact on libido and priapism is exceedingly rare These medications are contraindicated in patients taking nitroglycerin or nitrates since there may be exaggerated cardiac preload reduction causing hypotension and syncope All patients being evaluated for acute chest pain should be asked about the use of PDE-5 inhibitors before administering nitroglycerin, and close monitoring of blood pressure is warranted if there is concern regarding medication overlap The combination of PDE-5 inhibitors and alpha-receptor blockers (prescribed for lower urinary tract symptoms) may cause a larger reduction in systemic blood pressure than when PDE-5 inhibitors are used alone However, these two classes of medication may be safely used in combination if they are initiated and titrated in a stepwise fashion +++ Surgery ++ Penile prosthesis: rigid, malleable, hinged, or inflatable Surgery for disorders of the arterial system Vascular reconstruction Endarterectomy and balloon dilation for proximal arterial occlusion Arterial bypass procedures utilizing arterial (epigastric) or venous (deep dorsal vein) segments for distal occlusion Surgery for disorders of venous occlusion: ligation of the crura of the corpora cavernosa +++ Therapeutic Procedures ++ For erectile dysfunction Vacuum erection device: for patients with venous disorders of the penis and those who fail to achieve adequate erection with injection of vasoactive substances, use a vacuum device and rubber constriction band around penile base; serious complications are rare Behaviorally oriented sex therapy may be beneficial for men who have psychogenic erectile dysfunction For Peyronie disease Collagenase (derived from Clostridium histolyticum) injections Only FDA-approved medication for the treatment of Peyronie disease Collagenase is administered to the central portion of the penile plaque by needle injection Causes enzymatic digestion of the lesion with subsequent correction of penile curvature No oral therapies are FDA approved However, off-label trials of multiple vasodilatory, anti-inflammatory, and antioxidant drugs are common Surgery is an alternative for men with compromised sexual function due to severe curvature or lesions causing penile instability + Outcome Download Section PDF Listen +++ +++ Prognosis ++ The majority of men suffering from erectile dysfunction can be managed successfully +++ When to Refer ++ Patients with inadequate response to oral medications Patients with Peyronie disease or other penile deformity Patients who are dissatisfied with current treatment Patients with a history of pelvic or perineal trauma, surgery, or radiation Ischemic priapism is a medical emergency and requires immediate urology or emergency department referral + References Download Section PDF Listen +++ + +Chen L et al. Male sexual dysfunction: a review of literature on its pathological mechanisms, potential risk factors, and herbal drug intervention. Biomed Pharmacother. 2019 Apr;112:108585. [PubMed: 30798136] + +Dick B et al. An update on: long-term outcomes of penile prostheses for the treatment of erectile dysfunction. Expert Rev Med Devices. 2019 Apr;16(4):281–6. [PubMed: 30898042] + +Irwin GM. Erectile dysfunction. Prim Care. 2019 Jun;46(2):249–55. [PubMed: 31030826] + +Gabrielson AT et al. Collagenase Clostridium histolyticum in the treatment of urologic disease: current and future impact. Sex Med Rev. 2018 Jan;6(1):143–56. [PubMed: 28454897] + +Uddin SMI et al. Erectile dysfunction as an independent predictor of future cardiovascular events. Circulation. 2018 Jul 31;138(5):540–2. [PubMed: 29891569] + +Yafi FA et al. Update on the safety of phosphodiesterase type 5 inhibitors for the treatment of erectile dysfunction. Sex Med Rev. 2018 Apr;6(2):242–52. [PubMed: 28923561]