Erectile Dysfunction Clinical Presentation

  • Author: Edward David Kim, MD, FACS; Chief Editor: Edward David Kim, MD, FACS   more...
 
Updated: May 1, 2012
 

History

The first step in the management of erectile dysfunction (ED) is taking a thorough sexual, medical, and psychosocial history. Taking the patient's history is both informative to the physician and an opportunity to educate the patient. Adequate time must be set aside for a full interview and to conduct a physical examination. Formal questionnaires may be valuable. See History Taking in the Erectile Dysfunction Patient for more information on this topic.

Even clinicians who are not comfortable dealing with ED should inquire into this important aspect of the patient's health. A simple way to do this is simply to ask, "How's your sex life? Everything working all right?" This type of inquiry should elicit a clear, quick, direct "Everything's fine" from the patient. Any other response or even just a delay in answering should suggest potential ED in that patient.

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Physical Examination

A physical examination is necessary for every patient, with particular emphasis on the genitourinary, vascular, and neurologic systems. A focused physical examination entails an evaluation of the patient's blood pressure, peripheral pulses, sensation, status of the genitalia and prostate, size and texture of the testes, the presence of the epididymis and vas deferens, and abnormalities of the penis such as hypospadias and Peyronie plaques.

The physical examination may corroborate history findings or may reveal unsuspected physical findings, such as penile plaques, small testes, evidence of possible prostate cancer, prostate infections, or hypertension.

Several studies have demonstrated a strong correlation between hypertension and ED. This is not surprising, since both are manifestations of a vascular disorder. In a large hypertension clinic, men who also demonstrated ED had a much higher prevalence of complications related to high blood pressure. Another investigator has suggested that hypertensive patients with ED and poor cavernosal artery blood flow as measured during duplex ultrasonography studies should proceed to a full cardiac evaluation because of the high prevalence of associated problems.

A number of recent studies have shown a correlation between benign prostatic hyperplasia and ED. The causality for this relationship is not yet clear.

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Contributor Information and Disclosures
Author

Edward David Kim, MD, FACS  Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

Coauthor(s)

Stanley A Brosman, MD  Clinical Professor, Department of Urology, University of California, Los Angeles, David Geffen School of Medicine

Stanley A Brosman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for Cancer Research, American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Clinical Oncology, American Urological Association, Association of Clinical Research Professionals, International Society of Urological Pathology, Société Internationale d'Urologie (International Society of Urology), Society for Basic Urologic Research, Society of Surgical Oncology, Society of Urologic Oncology, and Western Section American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Martha K Terris, MD, FACS  Professor, Department of Surgery, Section of Urology, Director, Urology Residency Training Program, Medical College of Georgia; Professor, Department of Physician Assistants, Medical College of Georgia School of Allied Health; Chief, Section of Urology, Augusta Veterans Affairs Medical Center

Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Society of Clinical Oncology, American Urological Association, Association of Women Surgeons, New York Academy of Sciences, Society of Government Service Urologists, Society of University Urologists, Society of Urology Chairpersons and Program Directors, and Society of Women in Urology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Jeffrey Noble, MD  Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS  Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

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These images depict penile anatomy. Note the sinusoidal makeup of the corpora and thick fascia (ie, Buck fascia) that covers the corpora cavernosa. The major blood vessels to the corpora cavernosa enter through tributaries from the main vessels running along the dorsum of the penis.
Vascular anatomy of the penis.
This penile tumescence monitor is placed at the base and near the corona of the penis. It is connected to a monitor that records a continuous graph depicting the force and duration of erections that occur during sleep. The monitor is strapped to the leg. The nocturnal penile tumescence test is conducted on several nights to obtain an accurate indication of erections that normally occur during the alpha phase of sleep.
The presence of normal skin sensation adequate to produce an erection is measured with this device.
A vasodilator such as prostaglandin E1 can be injected into one of the corpora cavernosa. If the blood vessels are capable of dilating, a strong erection should develop within 5 minutes.
Erectile dysfunction. This diagram depicts a cross-section of penile anatomy and is used to instruct patients in the technique of administering intracorporeal medications.
The Medicated Urethral System for Erections (MUSE) is a small suppository placed into the urethra with this device.
This image depicts a vacuum device used to produce an erection (also see next image). In this image, the elements are shown. They include the cylinder, a pump to create a vacuum, and a constriction ring to be placed at the base of the penis after an erection has been obtained in order to maintain the erection.
This image demonstrates the vacuum device in place (see previous image). Note the presence of the constricting ring at the base of the penis.
This is one of many types of constricting devices placed at the base of the penis to diminish venous outflow and improve the quality and duration of the erection. This is particularly useful in men who have a venous leak and are only able to obtain partial erections that they are unable to maintain. These constricting devices may be used in conjunction with oral agents, injection therapy, and vacuum devices.
Two rigid cylinders have been placed into the corpora cavernosa. This type of implant has no inflation mechanism but provides adequate rigidity to the penis to allow penetration.
This inflatable penile prosthesis has 3 major components. The 2 cylinders are placed within the corpora cavernosa, a reservoir is placed beneath the rectus muscle, and the pump is placed in the scrotum. When the pump is squeezed, fluid from the reservoir is transferred into the 2 cylinders, producing a firm erection. The deflation mechanism is also located on the pump and differs by manufacturer.
Table 1. Diseases and conditions associated with ED
Vascular causesAtherosclerosis



Peripheral vascular disease



Myocardial infarction



Arterial hypertension



Vascular injury from radiation therapy



Vascular injury from prostate cancer treatment



Blood vessel and nerve trauma (eg, due to long-distance bicycle riding)



Medications for treatment of vascular disease



Systemic diseasesDiabetes mellitus



Scleroderma



Renal failure



Liver cirrhosis



Idiopathic hemochromatosis



Cancer and cancer treatment



Dyslipidemia



Hypertension



Neurologic causesEpilepsy



Stroke



Multiple sclerosis



Guillain-Barré syndrome



Alzheimer disease



Trauma



Respiratory diseaseChronic obstructive pulmonary disease



Sleep apnea



Endocrine conditionsHyperthyroidism



Hypothyroidism



Hypogonadism



Diabetes



Penile conditionsPeyronie disease



Epispadias



Priapism



Psychiatric conditionsDepression



Widower syndrome



Performance anxiety



Posttraumatic stress disorder



Nutritional statesMalnutrition



Zinc deficiency



Hematologic diseasesSickle cell anemia



Leukemias



Surgical proceduresBrain and spinal cord procedures



Retroperitoneal or pelvic lymph node dissection



Aortoiliac or aortofemoral bypass



Abdominal perineal resection



Proctocolectomy



Transurethral resection of the prostate



Radical prostatectomy



Cryosurgery of the prostate



Cystectomy



MedicationsAntihypertensives



Antidepressants



Antipsychotics



Antiulcer agents (eg, cimetidine)



5-Alpha reductase inhibitors (eg, finasteride, dutasteride)



Cholesterol-lowering agents



Table 2. Penile Implants for Erectile Dysfunction
Treatment Advantages Disadvantages
Semirigid or malleable rod implantsSimple surgery



Relatively few complications



No moving parts



Least expensive implant



Success rate of 70-80%



Highly effective



Constant erection at all times



May be difficult to conceal



Does not increase width of penis



Risk of infection



Permanently alters or may injure erection bodies



Most likely implant to cause pain or erode through skin



If unsuccessful, interferes with other treatments



Fully inflatable implantsMimics natural process of rigidity-flaccidity



Patient controls state of erection



Natural appearance



No concealment problems



Increases width of penis when activated



Success rate of 70-80%



Highly effective



Relatively high rate of mechanical failure



Risk of infection



Most expensive implant



Permanently alters or may injure erection bodies



If unsuccessful, interferes with other treatments



Self-contained inflatable unitary implantsMimics natural process of rigidity-flaccidity



Patient controls state of erection



Natural appearance



No concealment problems



Simpler surgery than fully inflatable prosthesis



Success rate of 70-80%



Highly effective



Sometimes difficult to activate the inflatable device



Does not increase width of penis



Mechanical breakdowns possible



Long-term results not available



Risk of infection



Relatively expensive



Permanently alters or may injure erection bodies



If unsuccessful, interferes with other treatments



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