History and exam
Key diagnostic factors
uncommon
abnormalities on exam of penis
May include plaques, deformities, and angulation. The testes are also examined for size and abnormalities.
abnormal androgenization
Abnormalities of hair pattern or gynecomastia may warrant testosterone evaluation.
Other diagnostic factors
common
premature ejaculation
abnormal prostate exam
Digital rectal examination is not required for evaluation of ED, but benign prostatic hyperplasia is a common comorbidity and should be considered and managed.[48]
uncommon
Peyronie disease
genital pain or numbness
Genital sensation such as pain or numbness may be present.
Risk factors
strong
coronary arterial disease
Atherosclerosis is a common pathway for several ED etiologies and is thought to act through impaired smooth muscle relaxation and venous occlusion as a result of diminished cavernosal artery flow and sequelae of diminished cavernous oxygen tension.[20]
peripheral arterial disease
Atherosclerosis is a common pathway for several ED etiologies and is thought to act through impaired smooth muscle relaxation and venous occlusion as a result of diminished cavernosal artery flow and sequelae of diminished cavernous oxygen tension.[20]
psychosexual/relationship problems
excess alcohol intake
Adverse effects can include ED.[22]
hypertension
Over 50 million Americans have hypertension and, among them, 35% have some element of ED.[23]
The incidence of ED among men with hypertension ages 34 to 75 years has been reported to be as high as 68% for any degree of disease, and 45% for severe ED.[24]
Arteriosclerosis as a complication of hypertension leads to vascular insufficiency in the penis, which impairs erectile function by diminishing cavernosal arterial flow, and disruption of endothelial function secondary to oxidative stress-related production of free radicals.[25]
hyperlipidemia
Dyslipidemias are associated with elevated risk for atherosclerotic disease and for diabetes. It is estimated that 50% of Americans have a form of dyslipidemia.[26]
Endothelial dysfunction is the underlying mechanism of ED, and oxidative stress is associated with elevated levels of low-density lipoprotein.[27]
diabetes mellitus
ED presents in >50% of diabetic men and occurs at an earlier age than in nondiabetic men.[28] It is linked to duration of the disease, age, and degree of glycemic control, measured by advanced glycated end products.[16] Autonomic neuropathy may also play a role, as do associated arteriosclerosis, hyperlipidemia, and hypertension.[29]
Poor glycemic control induces microangiopathy through oxidative stress impairing erectile/endothelial function.[30]
smoking
metabolic syndrome
Metabolic syndrome, consisting of glucose intolerance, hyperlipidemia, obesity, and hypertension, is mechanistically related to ED with impaired endothelial function possibly secondary to oxidative stress.[35]
Among men with metabolic syndrome, the prevalence of ED is as high as 74%, and the odds of developing ED over time are 2.9 times greater.[36]
neurologic disease
Neurogenic ED represents 10% to 19% of disease burden, but the presence of neurologic disease does not preclude other etiologies.[37]
radical pelvic surgery
Injury to the cavernous nerves during radical pelvic surgery is common: in radical prostatectomy, 43% to 100%;[38] in abdominal perineal resection, 15% to 100%.[39]
Nerve-sparing techniques have reduced this rate, but recovery of erectile function can take 6 to 24 months and can be improved with use of phosphodiesterase-5 inhibitors.[40]
spinal cord injury
Reflexogenic erections are preserved in 95% of upper cord lesions, but only 25% of complete lower cord lesions.[20]
Peyronie disease
May involve psychogenic component due to penile deformity.[42] Can result in vascular insufficiency secondary to plaque, venous leak, or both.
depression
hypogonadism
The influence of androgens on male sexual functioning is threefold: enhances sexual interest, increases frequency of sexual acts, and increases frequency of nocturnal erections.[20]
Deficiency in testosterone may lead to ED. Use of hormonal evaluation can be considered in men with lower serum testosterone and symptoms such as suppressed libido.[45]
antihypertensive use
Adverse effects can include ED.
antidepressant use
Treatment with selective serotonin reuptake inhibitors may inhibit erectogenic pathways by 5-HT2 and 5-HT3 receptor stimulation and may be associated with ED in 50% of patients.[43]
antiandrogenic agent use
May result in low testosterone-related ED.
desire/libido disorders
Recognized component of psychogenic/low testosterone-related ED.
benign prostatic hyperplasia
ED and lower urinary tract symptoms suggestive of benign prostatic hyperplasia commonly coexist in older men.[47]
weak
hyper/hypothyroidism
May lead to secondary alterations in circulating androgens that are proerectogenic.[17]
obesity
The prevalence of erectile dysfunction is significantly higher in men with obesity.[31] Factors include obesity-associated hypogonadism and an increased cardiovascular risk from metabolic syndrome.[12] However, one study showed that the association between erectile dysfunction and obesity to be independent from obesity-associated comorbidities and hypogonadism.[32]
pelvic fracture
Sexual dysfunction is identified in 21% of patients with pelvic fracture compared with 14% without pelvic fracture. The mechanism of this is thought to be multifactorial: cavernous nerve injury, vascular insufficiency, functional (i.e., immobility), or psychogenic.[41]
premature ejaculation
Persistent premature ejaculation may lead to performance-induced anxiety, leading to psychogenic ED.[44]
long-distance cycling
Associated with vasculogenic and neurogenic ED.[46]
corticosteroid use
Adverse effects can include ED.
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