Urology Book

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Erectile DysfunctionAka: Impotence

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  1. Definition
    1. Inability to achieve or maintain Erection
    2. Erection not satisfactory for sexual intercourse
  2. Epidemiology
    1. Incidence in United States
      1. Ages 20 to 39 years: 7.5%
      2. Ages 40 to 49 years: 11%
      3. Ages 50 to 59 years: 18%
      4. Ages 60 to 69 years: 38%
      5. Age over 70 years: 57%
    2. Prevalance in United States: 10-20 Million
  3. Pathophysiology
    1. See Penile Anatomy and Erection physiology
    2. Organic disease responsible for 80% of cases
    3. Arterial or venous disease accounts for 70% of cases
  4. Causes
    1. See Impotence Causes
  5. History
    1. Characteristics of Erectile Dysfunction
      1. Frequency and duration of Impotence
      2. Partial or complete lack of rigidity
      3. Libido difficulties
    2. Symptoms suggestive of Psychogenic Impotence
      1. Sudden onset of Impotence
      2. Impotence in age under 40 years
      3. Strained relationship with sexual partner
      4. Morning or nocturnal Erections still present
      5. Erections achieved with masturbation or oral sex
    3. Review potential Impotence Causes
    4. Consider comorbid conditions
      1. Coronary Artery Disease is common in Impotence
        1. Solomon (2003) Am J Cardiol 91:230
  6. Exam
    1. Blood Pressure
    2. Auscultate great vessels for Arterial Bruits
    3. Signs of Hypogonadism (e.g. Testicular atrophy)
    4. Penile Plaque (i.e. Peyronie's Disease)
    5. Breast Exam
      1. Gynecomastia
      2. Nipple tenderness
    6. Rectal tone
    7. Bulbocavernosus reflex
    8. Prostate enlargement
  7. Initial Evaluation
    1. Evaluate night time Erection (Assess psychogenic cause)
      1. Rarely performed now
      2. Techniques
        1. Snap-gauge cuff
        2. Rigiscan (Nocturnal penile tumescence monitoring)
    2. Baseline lab testing
      1. Fasting Serum Glucose
      2. Testosterone Level Indications
        1. Men over age 50 years
        2. Men under age 50 with signs of Hypogonadism
    3. Other baseline lab tests to consider
      1. Serum Chemistry Panel (Chem7)
      2. Urinalysis
      3. Complete Blood Count
      4. Prostate Specific Antigen (PSA)
      5. Thyroid Stimulating Hormone (TSH)
        1. Indicated in all older men
    4. Endocrine labs when indicated
      1. Follicle Stimulating Hormone (FSH)
      2. Luteinizing hormone (LH) Indications
        1. Hypogonadism evaluation for low testosterone
      3. Prolactin Level Indications
        1. Suspected Prolactinoma
        2. Serum Free Testosterone decreased
        3. Libido decreased significantly
  8. Advanced Evaluation Testing by Urology
    1. Biothesiometry
    2. Penile-brachial index
    3. Duplex Ultrasound (Color flow doppler)
    4. Cavernosometry or Cavernosography
    5. Arteriography
    6. Psychological Testing
  9. Resources
    1. Impotence Information Center Hotline
      1. Phone: (800) 843-4315
    2. Recovery of Male Potency
      1. Phone: (800) 835-7667
  10. Management
    1. See Impotence Management
  11. References
    1. Beaudreau (August, 2000) Federal Practitioner, p. 11-8
    2. Dewire (1996) Am Fam Physician 53(6):2101
    3. Ferris (1997) Fam Pract Recert 19(1):47-58
    4. Greiner (1996) Am Fam Physician 54(5):1675
    5. Guay (1995) Postgrad Med 97(4):127
    6. Jordan (1999) Postgrad Med 105(2):131
    7. Napolatono (1998) Fam Pract Recert 20(11): 34-58
    8. Viera (1999) Am Fam Physician 60(4):1159

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