Diagnostic Considerations

In addition to the conditions listed in the differential diagnosis, the following conditions should be taken into consideration:

Cancer and cancer treatment
Epilepsy
Multiple sclerosis
Guillain-Barré syndrome
Alzheimer disease
Epispadias
Widower syndrome
Performance anxiety
Malnutrition
Leukemias
Medications (eg, antidepressants, antipsychotics, antihypertensives, antiulcer drugs, hyperlipidemia medications)

Excessive expectations on the part of men who actually have normal erectile function should also be considered in the differential diagnosis.

General models for diagnosis and management

The Process of Care Model for the Evaluation and Treatment of Erectile Dysfunction was developed to advance new guidelines for the diagnosis and management of ED in primary care and multidisciplinary settings.^[72]The key components of this model are the following:

A rational approach to diagnosis and treatment
Emphasis on clinical history taking and a focused examination
Specialized testing and referral in predefined situations
A stepwise management approach with ranking of treatment options
Incorporation of patient and partner needs and preferences in the decision-making process

An alternative model was developed that included algorithms and consensus guidelines.^[73]This approach is oriented toward patient goals and involves a minimum of testing. The patient and his partner express a preference for reasonable and appropriate treatment options and work with the physician to implement this plan.

Differential Diagnoses

Workup

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Lei Q, Wang D, Liu C, Ji Z, Yan S. Comparison of the efficacy and safety of low-intensity extracorporeal shock wave therapy versus on-demand sildenafil for erectile dysfunction. Transl Androl Urol. 2021 Feb. 10 (2):860-868. [QxMD MEDLINE Link]. [Full Text].
Porst H. Review of the Current Status of Low Intensity Extracorporeal Shockwave Therapy (Li-ESWT) in Erectile Dysfunction (ED), Peyronie's Disease (PD), and Sexual Rehabilitation After Radical Prostatectomy With Special Focus on Technical Aspects of the Different Marketed ESWT Devices Including Personal Experiences in 350 Patients. Sex Med Rev. 2020 Jun 1. 5 (2):255-66. [QxMD MEDLINE Link]. [Full Text].
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Media Gallery

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.

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Table 1. Diseases and Conditions Associated With Erectile Dysfunction

Vascular causes	Atherosclerosis Peripheral vascular disease Myocardial infarction Arterial hypertension Vascular injury from radiation therapy Vascular injury from prostate cancer treatment Blood vessel and nerve trauma (eg, from long-distance bicycle riding) Medications for treatment of vascular disease
Systemic diseases	Diabetes mellitus Scleroderma Renal failure Liver cirrhosis Idiopathic hemochromatosis Cancer and cancer treatment Dyslipidemia Hypertension
Neurologic causes	Epilepsy Stroke Multiple sclerosis Guillain-Barré syndrome Alzheimer disease Trauma
Respiratory disease	Chronic obstructive pulmonary disease Sleep apnea
Endocrine conditions	Hyperthyroidism Hypothyroidism Hypogonadism Diabetes
Penile conditions	Peyronie disease Epispadias Priapism
Psychiatric conditions	Depression Widower syndrome Performance anxiety Posttraumatic stress disorder
Nutritional states	Malnutrition Zinc deficiency
Hematologic diseases	Sickle cell anemia Leukemias
Surgical procedures	Brain 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
Medications	Antihypertensives Antidepressants Antipsychotics Antiulcer agents (eg, cimetidine) 5-Alpha reductase inhibitors (eg, finasteride and dutasteride) Cholesterol-lowering agents Methadone

Table 2. Advantages and Disadvantages of Different Types of Penile Implants for Erectile Dysfunction

Treatment	Advantages	Disadvantages
Semirigid or malleable rod implants	Simple 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 implants	Mimics 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 implants	Mimics natural process of rigidity-flaccidity Patient controls state of erection Natural appearance No concealment problems Simpler surgical procedure than that required for 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