erectile%20dysfunction
ERECTILE DYSFUNCTION

Erectile dysfunction is the inability to attain and maintain an erection enough to have satisfactory sexual performance for ≥3 months.

It is when the patient complains of partial erection that could not attain vaginal penetration.

Complete loss of penile rigidity is uncommon.

Initial penile erections can penetrate but early detumescence occurs without ejaculation.

Diagnosis

  • Thorough sexual, medical & psychosocial history
    • Erectile dysfunction may be the first presentation of an underlying serious medical condition (eg hypertension, diabetes mellitus)

History

Sexual History

  • Patient consistently or recurrently is unable to maintain/attain an erection that is adequate for sexual satisfaction
  • May use validated psychometric questionnaires, eg International Index for Erectile Function (IIEF)

Physical Examination

  • Physical exam: Abdomen, penis, testicles, secondary sexual characteristics & lower extremity pulse, digital rectal examination (DRE)
    • A digital rectal examination is not mandatory in erectile dysfunction but should be done in the presence of a genitourinary or protracted secondary ejaculatory symptoms

Laboratory Tests

  • Fasting blood glucose or HbA1c, lipid profile, testosterone assay to evaluate hypothalamic-pituitary-gonadal axis, urinary microscopy, etc as necessary
  •  Prostate-specific antigen (PSA) is measured before initiating & at regular intervals during testosterone therapy

Assessment

Treatment of erectile dysfunction in patients w/ cardiovascular disease is associated w/ a small increase in the risk of myocardial infarction (MI) related to sexual activity independent of the method of treatment

Cardiovascular risk level:

  • High-risk - Should not receive therapy for sexual dysfunction until cardiac condition becomes stable
    • Unstable/refractory angina
    • Uncontrolled hypertension
    • Systolic blood pressure (SBP) >180 mmHg
    • Left ventricular dysfunction (LVD) or congestive heart failure (CHF) (NYHA class IV)
    • Recent myocardial infarction or cardiovascular accident (CVA) within the past 2 weeks
    • High-risk arrhythmias
    • Hypertrophic obstructive & other cardiomyopathies
    • Moderate-severe valvular disease
  • Intermediate-risk - Should be referred for further evaluation of cardiac status before receiving treatment
    • Recent myocardial infarction or cerebrovascular accident (ie within the last 2-6 weeks)
    • Left ventricular dysfunction or congestive heart failure (NYHA class III)
    • Asymptomatic but ≥3 risk factors for coronary artery disease (CAD) (excluding gender)
    • Moderate, stable angina
    • Murmur of unknown cause
    • Recurrent transient ischemic attacks (TIA)
    • Heart transplant
  • Low-risk - All 1st-line therapies may be considered
    • Asymptomatic coronary artery disease
    • Less than 3 risk factors for coronary artery disease (excluding gender)
    • Controlled hypertension
    • Mild, stable angina that has been evaluated &/or being treated
    • Post-successful coronary revascularization
    • Uncomplicated previous myocardial infarction
    • Mild valvular heart disease
    • Left ventricular dysfunction or congestive heart failure (NYHA class I or II)
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