Erectile dysfunction

Question 1

Definition

Answer 1

Impotence is the inability to achieve or maintain an erection of sufficient quality for satisfactory intercourse.

It does not refer to ejaculation, fertility or libido.

Question 2

Probability diagnosis

Answer 2

Ageing

Drugs esp. excess alcohol

Diabetes (autonomic dysfunction)

Stress/anxiety/depression

Look for other causes e.g.

• psychogenic
• hormonal—uncommon
• vascular disease

Question 3

Serious disorders not to be missed

Answer 3

Vascular:

• Generalised arteriopathy esp. lower limbs

Infection:

• Generalised: viral, bacterial

Tumours:

• Pituitary fossa

Other:

• Systemic illness
• Chronic kidney disease

Question 4

Pitfalls (often missed)

Answer 4

Pelvic trauma

Excessive cigarette smoking

Iatrogenic e.g. prostate surgery, drugs

Thrombosis corpus callosum

Rarities:

• Neurological e.g. MS
• Hypogonadism e.g. Klinefelter’s
• Anatomical e.g. tight frenulum, Peyroine’s disease

Question 5

Masquerades checklist

Answer 5

Depression including drugs

Diabetes

Drugs: various

Thyroid/other endocrine: several (see history)

Spinal dysfunction e.g. spinal cord pathology, cauda equina lesion

Question 6

Is the patient trying to tell me something?

Answer 6

Consider psychosexual dysfunction incl;

• marital disharmony
• performance anxiety

Question 7

Key history

Answer 7

Nature of onset including nature of sexual relationship

Ask about nocturnal and early morning erections

Drug history incl

• alcohol, nicotine (4 times risk)
• street drugs (cocaine, cannabis)

Pharmaceutical agents esp:

• antihypertensives (beta blockers, diuretics)
• hypolipidaemic agents
• antiandrogens (prostate cancer treatment)
• antidepressants, antipsychotics
• H2-receptor antagonists

Question 8

Key examination

Answer 8

1. Genitourinary, include a rectal examination;
2. cardiovascular lower limbs
3. neurogenic examinations / lower limbs
4. genitalia esp.

• testicles and penis.
• cremasteric and bulbocavernosus reflexes.

Question 9

Key investigations

Answer 9

First line:

• fasting blood glucose
• FBE
• free testosterone (androgen deficiency)
• thyroxine (hypothyroidism)
• prolactin (hyperprolactinaemia)
• LH (pituitary function)
• FSH
• Urinalysis

Consider:

• LFTs esp. GGT (alcohol effect) and KFTs
• nocturnal penile tumescence
• Doppler flow studies

Question 10

Diagnostic tips

Answer 10

Endocrine causes to consider include;

• androgen/testosterone deficiency
• hyperprolactinaemia
• hypothyroidism.

Consider pituitary fossa tumour.

Question 11

Management

Answer 11

Treat cause. If psychogenic, refer for personal or sexual counselling.

If androgen deficiency step-wise trial:

1. oral: testosterone undecanoate (Andriol)
2. IM: testosterone enanthate (Primoteston Depot) or testosterone esters (Sustanon)
3. subcutaneous implantation: testosterone implants (last 5–6 mths)

If functional: oral mediation (PDE-5 inhibitors):

• sildenafil (Viagra) 50–100 mg (o) 1/2–1 h before sex
• tadalafil (Cialis) 10–20 mg (o) 1–2 h before sex
• vardenafil (Levitra) 10–20 mg (o) 1/2–1 h before sex
• If erection > 2 hrs take 2 x 60 mg pseudoephedrine tabs.
• Avoid in those on nitrates for angina.

Intrapenile injection prostaglandin E (alprostadil):

• intracavernosal injections
• self-administered after supervised teaching
• max. of 3/wk (use 2 pseudoephedrine tabs for prolonged erection >2 h)