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Erectile dysfunction
OVERVIEW: Dissatisfaction with size, rigidity, or duration of erection. Male sexual dysfunction encompasses an even larger group of complaints and disorders of arousal, desire, orgasm, sensation, and relationship. Transient periods of impotence occur in about half of adult males and are not considered dysfunctional.
System(s) affected: Reproductive, Nervous, Cardiovascular, Renal/Urologic
Genetics: Rarely related to chromosomal disorders
Incidence/Prevalence in USA: Erectile failure involves about 10% of men, but is underreported by patients
Predominant age:
• Patients with psychologic, gender, and primary organic problems often present themselves for help between adolescence and the third decade
• Patients with relationship problems, but concerned mainly about physical problems, tend to seek care in the sixth decade
• Most patients with physical problems are in the seventh and eighth decade, but rarely seek help
Predominant sex: Male only
SIGNS AND SYMPTOMS: • Reduction of erectile size and rigidity
• Inability to maintain erection
• Inability to achieve erection
• Reduced body hair
• Thyromegaly
• Gynecomastia
• Testicular atrophy or absence
• Deformed penis
• Peripheral vascular disease
• Neuropathy
CAUSES: • Endocrine
• Neurologic
• Vascular
• Medication
• Psychological
• Structural
RISK FACTORS: • Prior pelvic surgery
• Medication use
• Risk factors for disorders listed in Causes
DIAGNOSIS DIFFERENTIAL DIAGNOSIS: • Endocrine
• Low or high thyroxine
• Low testosterone
• High prolactin
• Diabetes
• High estrogen effect
• Renal failure
• Zinc deficiency
• Neurological
• Central
• Spinal
• Peripheral
• Vascular
• Arterial insufficiency
• Cavernosal insufficiency
• Venous insufficiency
• Medication
• Many types, e.g., beta-blockers, thiazides
• Psychological
• Depression
• Schizophrenia
• Relationship disorders
• Personality disorders
• Anxiety
• Structural
• Microphallus
• Chordee and Peyronie's disease
• Cavernosal scarring
• Phimosis
• Hypospadias
• Postsurgical sequelae
LABORATORY: • CBC
• Glucose
• K+
• Na+
• Albumin
• BUN/creatinine
• TSH
• Prolactin
• Testosterone
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS: Most men over age 55 will have some test abnormality or risk factor, but it is not necessarily the cause of the patient's impotence
SPECIAL TESTS: • 24 hour urine zinc
• Dorsal nerve somatosensory evoked potentials
• Sacral evoked response
• Penile-brachial blood pressures
• Aortogram
• Selective pudendal angiogram
• Dynamic cavernosography
• Nocturnal penile tumescence (NPT) testing
• Penile blood pressure
IMAGING: Doppler, angiogram, cavernosogram
DIAGNOSTIC PROCEDURES: Response to papaverine or alprostadil injection
TREATMENT APPROPRIATE HEALTH CARE: Since erectile dysfunction is multifactorial, evaluation by a generalist in an outpatient setting
GENERAL MEASURES: • Early use of penile implants is now discouraged because of success with vacuum erectile devices, sensate focus therapy, injection therapy and oral therapy
• Improve partner communication
• Reduce performance pressure
• Use sensate focus therapy
• Try vacuum erectile device or oral therapy
• Use of psychiatrists, psychologists, sex therapists, vascular surgeons, urologists, endocrinologists, neurologists, plastic surgeons, etc., often necessary for refractory cases
SURGICAL MEASURES: N/A
ACTIVITY: No restrictions
DIET: Control diabetes if present
PATIENT EDUCATION: The New Male Sexuality by Bernie Zilbergeld, PhD., Bantam Books, 1992; and problem-specific handouts
MEDICATIONS DRUG(S) OF CHOICE: • If hypogonadism present, testosterone cypionate 200 mg IM every two weeks
• If hyperprolactinemia present, bromocriptine 2.5 mg bid up to 40 mg/day
• To induce erection
• Intracavernous injection of a solution containing phentolamine 0.5-1.0 mg and papaverine 30 mg per mL, starting with 0.1 mL
or
• Alprostadil (Caverject) 10-20 µg/mL; inject into the dorsolateral aspect of proximal third of the penis. Do not exceed 60 mg dose. Do not use more than 3 times a week or more than once in 24 hours. Patient to notify physician if erection lasts > 6 hours for immediate attention.
• Alprostadil (Muse) urethral suppository 125 mg, 250 mg, 500 mg, and 1000 mg pellets. Maximum of 2 uses in 24 hours.
• Sildenafil (Viagra) 25 mg, 50 mg, or 100 mg tablets. 50 mg 1 hr before desired erection. May be effective in 30 minutes and up to 4 hours after dosage. Older patients or those with renal or hepatic disease need half the dose of others to achieve similar blood levels. Side effects: headache, flushing, indigestion, visual changes.
Contraindications:
• Injections should be avoided in patients with bleeding disorders, patients with sickle cell disease or trait, and in patients with penile deformities.
• Avoid use in patients with known allergies to constituents
Precautions:
• With testosterone, watch for urinary retention, acne, sodium retention and gynecomastia
• With bromocriptine, watch for self-limited nausea, vomiting
• With injection therapy, watch for priapism, fibrosis, hypotension and nausea
• With urethral suppositories, watch for penile pain and irritation, as well as testicular pain. No reports yet of priapism.
• Lowered blood pressure is common with sildenafil; NTG should not be given in tandem with this drug.
Significant possible interactions: N/A
ALTERNATIVE DRUGS: Use vacuum erection device before injections
FOLLOW UP PATIENT MONITORING: Meet with patient and, if possible, his partner, as required by cause, therapy, and response
PREVENTION/AVOIDANCE: Since erectile dysfunction is multifactorial, referral to a sex therapist or couples therapist may help to speed recovery and prevent future problems
POSSIBLE COMPLICATIONS: Specific to therapy
EXPECTED COURSE AND PROGNOSIS: • Given that the majority of patients have unspecified causes of their erectile disorders, vacuum erection device, injection or suppository therapy with alprostadil, oral sildenafil and penile implant have improved the outlook greatly
• Expect 20% failure rate of vacuum erection device, high drop-out rate from injection therapy, and a 10-30% non-use rate for penile implants
• Spontaneous cure rate is about 15%
• Studies indicate a response rate of 40-60% for urethral alprostadil compared to 85-90% for the injection
• Sildenafil works in about 70% of persons at maximum dose
MISCELLANEOUS ASSOCIATED CONDITIONS: N/A
AGE-RELATED FACTORS:
Pediatric: N/A
Geriatric: Aging alone is not a cause of impotence
Others: N/A
PREGNANCY: N/A
SYNONYMS: Impotence
ICD-9-CM: 302 Sexual disorders
302.7 Psychosocial dysfunction
302.70 Psychosocial dysfunction nos
302.71 Inhibited sexual desire
302.72 Inhibited sex excitement
302.79 Psychosocial dysfunction nec
302.8 Psychosocial disease nec
302.89 Psychosexual disease nec
302.9 Psychosexual disease nos
V41.7 Sexual function problem
607.84 Impotence, organic origin
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