QuestionSBA
QuestionChoice
The patient's insidious presentation and normal libido suggests an organic cause for his erectile dysfunction.
10015745
e
Cognitive behavioural therapy
QuestionChoice
The patient's insidious presentation and normal libido suggests an organic cause for his ED. Further, SSRIs may cause/exacerbate erectile dysfunction.
10015744
d
Sertraline
QuestionChoice
The patient's insidious presentation and normal libido suggests an organic cause for his ED. As sildenafil is contraindicated due to his nitrate use (concurrent use of both of these may cause profound hypotension), this is the most appropriate management.
10015741
a
Intracavernosal prostaglandins
QuestionChoice
The patient's insidious presentation and normal libido suggests an organic cause for his erectile dysfunction.
10015743
c
Psychosexual therapy
QuestionChoice
Concurrent use of nitrates (such as ISMN) and sildenafil can cause profound hypotension.
10015742
b
Sildenafil
QuestionComment
Got me w the ISMN
37457
User
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Epidermis Abdominal
QuestionComment
Great Question
51612
User
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Supraventricular Lion
QuestionComment
Rookie error 
62326
User
subscriber
Kinase Serotonin
Concept
Chapter
# Summary

Erectile dysfunction (ED) is a common condition that involves the inability to achieve or maintain an erection sufficient for satisfactory sexual performance. It can be a result of a variety of factors, such as vascular disease, autonomic neuropathy, medications, psychogenic factors, endocrine causes, pelvic surgery, and anatomical abnormalities. Key investigations include a detailed sexual and psychological history and blood tests to evaluate hormone levels and overall health. Management strategies include psychosexual therapy, oral phosphodiesterase inhibitors like Sildenafil, vacuum aids, intra-cavernosal injections, and the use of prostheses. Sildenafil has certain contraindications and requires caution in certain patient populations.

# Definition

Erectile dysfunction (ED) is defined as the consistent or recurrent inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance.

# Epidemiology

Erectile dysfunction is common, particularly among older men. It affects more than 50% of men aged over 60. However, ED is not considered a normal part of aging and can affect men at any age.

# Aetiology

Several factors can contribute to erectile dysfunction, including:

- Vascular disease: Atherosclerosis can lead to impaired blood flow to the penis, leading to ED.
- Autonomic neuropathy: This can cause penile denervation, most commonly seen in conditions like diabetes or with excessive alcohol intake.
- Medications: Certain drugs, such as antihypertensive agents, can cause ED.
- Psychogenic: Anxiety, depression, and other psychological factors can contribute to ED.
- Endocrine causes: Conditions like prolactinoma and hypogonadism can cause hormonal imbalances leading to ED.
- Pelvic surgery: Procedures involving the bladder, prostate, or other pelvic structures can damage nerves and blood vessels, leading to ED.
- Anatomical abnormalities: Conditions like Peyronie's disease, characterized by fibrous scar tissue inside the penis, can cause ED.

# Signs and Symptoms

The primary symptom of erectile dysfunction is the inability to achieve or maintain an erection sufficient for sexual intercourse. This can also lead to:

- Reduced sexual desire
- Difficulty in ejaculation
- Anxiety or depression related to sexual performance
- Signs which suggest an organic cause is more likely - lack tumescence, slow-onset, normal libido.
- Signs which suggest a psychogenic cause - if situational, high levels of stress, still having early morning erections. 

# Differential Diagnosis

Conditions with similar symptoms include:

- Premature ejaculation: Characterized by uncontrolled ejaculation either before or shortly after sexual penetration.
- Hypogonadism: Characterized by low testosterone levels, resulting in low sex drive, fatigue, and mood changes.
- Peyronie's disease: Presents with a significant bend in the penis during erection, which can interfere with sexual function.

# Investigations

Evaluating erectile dysfunction includes:

- A detailed sexual and psychological history to identify potential contributing factors.
	- Generally, if there is acute onset, the cause is most likely psychogenic and if the onset is more gradual there is more likely to be an organic cause (e.g. atherosclerosis).
- Blood tests: Full blood count, urea and electrolytes, thyroid function tests, lipid profile, testosterone, and prolactin to evaluate overall health and hormonal status.
	- ED can sometimes be the first presentation of sequalae of cardiovascular disease and so presentation should prompt investigation of cardiovascular health.

# Management

Management strategies for erectile dysfunction include:

- Psychosexual therapy to address any underlying psychological factors.
- Oral phosphodiesterase inhibitors, such as Sildenafil, to enhance the effect of nitric oxide, increasing blood flow to the penis.
	- Side effects - headache, flushing, hypotension, blue tinge to vision (memory aid: little blue pill). 
- Vacuum erection devices to draw blood into the penis by applying negative pressure.
- Intra-cavernosal injections to directly increase blood flow.
- Penile prostheses for cases resistant to other treatments.

# Contraindications and cautions of Sildenafil

Sildenafil, while an effective treatment for ED, has specific contraindications and requires caution in certain patients:

- Contraindicated in: 
	- Individuals taking nitrates
	- Hypertension/hypotension
	- Arrhythmias
	- Unstable angina
	- Stroke
	- Recent myocardial infarction.
- Caution in:
	- Patients with angina
	- Peptic ulcer
	- Liver or kidney impairment
	- Peyronie's disease
	- Those on complex antihypertensive regimes

	
# NICE Guidelines

[NICE Clinical Knowledge Summary (CKS): Erectile dysfunction](https://cks.nice.org.uk/topics/erectile-dysfunction/)

# References

[BMJ Best Practice: Erectile Dysfunction](https://bestpractice.bmj.com/topics/en-gb/213)

[British National Formulary (BNF): Sildenafil](https://bnf.nice.org.uk/drug/sildenafil.html)

1013
1071
Erectile Dysfunction
Topic
22
Urology
15692
Organic causes of erectile dysfunction in men with normal libido may require treatment with intracavernosal prostaglandins if they have contraindications to phosphodiesterase inhibitors.
Presentation
240
Erectile dysfunction
UkmlaTopic
22
Renal and urology
A 45-year-old man visits his GP complaining of erectile dysfunction. He describes a gradual onset of symptoms, and is frustrated that while he has normal libido, he cannot maintain an erection. He has diabetes and a history of angina, for which he takes metformin and isosorbide mononitrate.

What is the most appropriate management for his symptoms?
a