What is Erectile Dysfunction (ED)?
 

Erectile Dysfunction (ED) is the inability to achieve or maintain an erection for staisfactory sexual performance. It may be situational or generalized. 
 

• Onset: Gradual onset (typically suggestive of organic or vascular etiology) versus sudden onset (often associated with psychogenic factors or acute psychological stressors).

• Nocturnal Tumescence: Presence or absence of morning or nighttime erections (preserved nocturnal erections strongly point toward a psychogenic cause, while absent nocturnal erections suggest an organic etiology).

• Scenario: Situational or Generalized

Primary Causes of ED
 

• Vascular Disorders: Atherosclerosis, hypertension, hyperlipidemia, peripheral vascular disease

• Neurological Disorders: Diabetic neuropathy, spinal cord injury, multiple sclerosis, stroke, pelvic trauma, or nerve damage from prostate or pelvic surgeries.

• Structural Conditions: Peyronie's disease, penile trauma, congenital penile anomalies, and severe phimosis.

• Endocrinological Disorders: Hypogonadism (primary or secondary testosterone deficiency) and hyperprolactinemia.

Secondary Causes of ED
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• Psychological Factors: Depression, anxiety, relationship factors, religious factors, and stress.

• Medical Illnesses: Chronic kidney disease, cirrhosis, COPD, and obstructive sleep apnea (OSA).

• Metabolic & Lifestyle Factors: Obesity, sedentary lifestyle, metabolic syndrome, smoking, chronic alcohol and drug use. 

• Medication-Induced ED: Antihypertensives (spirinolactone, hydrochlorothiazide, beta-blockers), many psychiatric medications, antiandrogens, 5-alpha-reductase inhibitors, and recreational drugs.

Diagnostics
 

• History & Physical Examination: Detailed sexual history (using validated tools like the IIEF), evaluation of cardiovascular and neurological status, genital examination (assessing for testicular size, penile plaques, and secondary sex characteristics)

• Laboratory Testing:

  • Early morning total serum testosterone and free testosterone (drawn between 8:00 AM and 11:00 AM).

  • Fasting blood glucose and hemoglobin A1c (screening for diabetes).

  • Lipid panel and comprehensive metabolic panel (renal and hepatic function).

  • Prolactin and thyroid-stimulating hormone (TSH) if suspected

• Specialized & Vascular Diagnostics:

  • Nocturnal penile tumescence (NPT) testing.

  • Intracavernosal vasoactive injection test (pharmacopenile duplex ultrasonography) to evaluate penile arterial inflow and veno-occlusive function.

Management 
 

Non-Pharmacological Management
 

• Lifestyle Modification & Risk Factor Control: Regular aerobic exercise, weight loss, smoking cessation, moderating alcohol intake, and optimizing glycemic control and blood pressure.

• Psychosocial & Sex Therapy

• Physical & Mechanical Devices

• Penile prosthesis implantation
   

Pharmacological Management
 

• Oral Phosphodiesterase Type 5 (PDE5) Inhibitors: First-line pharmacotherapy (e.g., sildenafil, tadalafil, vardenafil, avanafil) to enhance smooth muscle relaxation and increase blood flow during sexual stimulation.

• Eroxon - an over-the-counter gel that works quickly by causing a cooling sensation leading to nerve and blood flow stimulation.  

• Intracavernosal Injections & Intraurethral Therapy: Second-line therapies using vasoactive agents (e.g., alprostadil, papaverine, phentolamine) injected directly into the corpora cavernosa or administered as a urethral suppository (MUSE).

• Hormone Replacement Therapy (if low testosterone)

• Medication Reconciliation: Reviewing and modifying or substituting current prescription medications contributing to ED (e.g., switching from an SSRI or beta-blocker to a drug with a lower sexual side-effect profile, under medical supervision).