Erectile dysfunction (ED) is an extremely common condition that can have far-reaching consequences on the self-esteem and relationships of those involved. Some estimates count men with complete ED as high as 10-20 million in the U.S. alone; these figures increase to more than 30 million men if moderate to complete erectile dysfunction is included. The worldwide incidence of ED is projected to rise higher than 322 million by 2025. Despite these statistics, the overall incidence of erectile dysfunction is both under-recognized and under-reported.
Erectile Dysfunction Categories and Underlying Causes
There are several underlying causes that contribute to ED: arteriogenic, venogenic, endocrinologic, neurologic, psychological, and medicinal. Vascular disease, such as hypertension, is one of the most common causes of organic ED and as the severity of hypertension increases, so do reports of ED severity from patients. The incidence of ED in diabetic men rises with age and degree of glycemic control (men with better control have less severe erectile dysfunction).
- Arteriogenic (insufficient arterial blood supply) – Possible causes include atherosclerosis, HTN, hyperlipidemia, smoking, pelvic trauma and diabetes mellitus.
- Cavernosal (abnormal arterial inflow) - Possible causes include vascular disease, diabetes mellitus, Peyronie’s disease and age.
- Endocrinologic (decline in serum testosterone levels) - Possible causes include hypogonadism, hyperthyroidism, hypothyroidism and obesity.
- Medications – Possible medications that can contribute to ED include antihypertensives, antidepressants, antipsychotics, alcohol abuse, smoking, antiandrogens, alpha adrenergic blockers, beta blockers, thiazide diuretics, cimetidine and marijuana use.
- Neurologic (neurologic impairment or dysfunction) - Possible causes include retroperitoneal or pelvic surgery, spinal cord injury, neurologic disease (such as spina bifida, Parkinson's disease, Alzheimer's disease), diabetes mellitus, pelvic trauma, ETOH abuse, stroke and pelvic irradiation.
- Psychological (mental and emotional issues) - Possible causes include anxiety, depression, stress and relationship issues among others.
- Systemic disease-induced (state of the entire system) - Possible causes include chronic renal failure, coronary heart disease, congestive heart failure, recent heart attack CHF and liver failure.
Many men will complain of erectile problems and will self-refer for evaluation of erectile issues in the absence of any disease. In these cases ED may provide a clue to the subtle onset of numerous systemic diseases. ED can be successfully treated even without the knowledge of the precise nature of its cause.
Erectile Dysfunction Evaluation and Diagnostic Testing
The evaluations for erectile dysfunction include those specific to sexual function: the precise nature of the dysfunction (i.e., whether the problem is attaining or sustaining an erection, insufficient rigidity, penetration, or ejaculation); whether ED occurs with all sexual partners or only specific partners; psychosocial factors; the presence or absence of nocturnal and morning erections; and any treatments (pharmacologic and non-pharmacologic) that the patient has tried. The Sexual Health Inventory for Men (SHIM) assesses the degree to which ED impacts the quality of the patient’s life.
If there are no other known medical conditions, a full physical examination is necessary. In patients with recognized chronic conditions, the focus will be on a genital exam, and will include cardiovascular examination for cardiovascular risk assessment.
The results of patient’s history and physical examination will determine which laboratory evaluations are completed. Laboratory evaluations will assess total and bioavailable testosterone, luteinizing hormone (LH) and follicle stimulating hormone (FSH). Prolactin levels and estradiol may also be included if the patient has a high body mass index (BMI). Additional laboratory evaluation commonly includes a urinalysis, PSA, thyroid studies, fasting lipid profile, liver function studies, screening for diabetes and a complete blood count (CBC).
Available diagnostic testing modalities include:
- Nocturnal penile tumescence (NPT) monitoring - erections during sleep are monitored using a machine that measures the number, strength, and duration of erections occurring during sleep.
- Duplex ultrasonography - evaluation of the penile vessels with pharmacological erection; examination of the changes in flow velocities of the cavernosal arteries after injection of a vasoactive agent (PGE1 or papaverine/phentolamine).
- Cavernosometry/cavernosography - invasive testing to determine the capacity of penile tissue to trap blood, by measuring its ability to trap infused saline under pharmacological stimulation.
- Phalloarteriography - arteriogram of the penile vessels to determine candidates for penile revascularization.
Erectile Dysfunction Treatment Options
Medical management of erectile dysfunction can be very successful, and patients may typically progress from less invasive to more invasive options.
A vacuum erection device can create an erection that is satisfactory for sexual activity without any pharmacologic intervention. Several oral medications are available for treatment of erectile dysfunction. An intra-urethral agent and several versions of medication that is injected directly into the penis are also available.
Each option for treatment of erectile dysfunction has individualized education points that are addressed in the clinic, in order to assure that each patient understands the correct method of administration and has appropriate expectations for outcomes.
The medical treatment option that is appropriate for an individual will be determined by physical examination, laboratory evaluation, medical history and patient preference. Patients will have a follow-up appointment with their provider 3 to 6 months after trying one of these options.
Specialized sexual therapy is also an option at any time during the treatment for erectile dysfunction.
While it may seem that revascularization of the penis would be a reasonable treatment, this is an option in a very small subset of men with erectile dysfunction, who meet very precise criteria.
Surgery is not routinely indicated for the first-line treatment of erectile dysfunction. However, it is an option for the patient who cannot tolerate oral or injectable or intra-urethral treatments for erectile dysfunction. A penile prosthesis may be an appropriate option, and requires surgery under general anesthetic for implantation.
For additional information see www.urologyhealth.org.
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