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Key Features

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


  • 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

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


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