Erectile Dysfunction & Peyronie Disease

Key Features

Essentials of Diagnosis

• Erectile dysfunction is an exceedingly common disease that negatively impacts quality of life when left untreated

• Most erectile dysfunction is organic in nature, 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

• Loss of erections occurs from arterial, venous, neurogenic, or psychological causes

• Most common cause of erectile dysfunction is a decrease in arterial flow resulting from progressive vascular disease

• Many medications, especially antihypertensive and antidepressant agents, are associated with erectile dysfunction

• Loss of libido may indicate androgen deficiency

• 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 painful penile erection in the absence of sexual stimulation

  • Results in ischemic injury of the corpora cavernosa from venous congestion, blood coagulation within the cavernous sinuses, and complete cessation of arterial inflow (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 α-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 psychological cause

• Peyronie disease

  • Affects up to 10% of men and, similar to erectile dysfunction, is more common in men aged 45–60 years

  • Average age at onset is 53 years

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, ...