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Erectile dysfunction
Definition of erectile dysfunction ?
Consistent inability to achieve or sustain an erection of
sufficient rigidity for sexual intercourse to the point of
satisfaction of both partners

💡 The term erectile dysfunction is more preferred than the term

impotence because the latter is a comprehensive label for
disturbances which may occur in libido, erection, ejaculation, or
orgasm.

Aetiology of erectile dysfunction ?

Psychogenic causes:
Depression

Sexual ignorance

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 Phobias (Fear of pregnancy or venereal diseases, and fear of failure which
is called performance anxiety).

Fixation at an early stage of infantile sexuality e.g. oral erotic stage

Sense of guilt as from extramarital relations

Unattractive partner

Family troubles and poor communication between partners.

Honeymoon impotence

Widower impotence

Organic causes ( CEE MVIN )

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 Congenital penile deformities
Epispadias: urethral meatus opens proximally on the dorsum of the penis

Penoscrotal hyposadias (ectopic external urinary meatus at penoscrotal

junction)

Congenital chordee without hypospadias (fixed bending of the penis).

Mechanical causes
Morbid obesity

Huge bilateral hydrocele or inguinal hernia

Elephantiasis of penis & scrotum.

Peyronie’s disease

(a noncancerous condition resulting from fibrous scar tissue that

develops on the penis and causes curved, painful erections)

Carcinoma of the penis

Endocrinal causes
Hypogonadal androgen deficiency, e.g., Klinefelter's syndrome,
mumps orchitis, trauma, castration and male climacteric (weak
desire and performance due to aging process).

Abnormalities of hypothalamopituitary function, e.g.

panhypopituitrism ,isolated gonadotropin deficiency, and
hyperprolactinaemia

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 Adrenal cortical dysfunction especially when there is excess secretion of
female hormones, e.g. feminizing adrenal tumors

Hypo- and hyperthyroidism

Metabolic causes
1. Diabetes mellitus

2. Hemochromatosis.

3. Alcoholism.

4. Sickle cell disease

5. Hepatic failure

6. Renal failure

💡 Metabolic syndrome is the name for a group of risk factors

(overweight, obesity, elevated triglycerides, dyslipidaemia, elevated
blood pressure and elevated fasting glucose) that increase the
chance for heart disease, diabetes, stroke and erectile dysfunction.

Neurogenic causes (problem in mintaining)

Cortical lesions as temporal lobe epilepsy, general paresis of insane
and cerebral atherosclerosis.

Spinal cord lesions as tabes dorsalis & syringomyelia (the

development of a fluid-filled cyst (syrinx) within spinal cord)

Pyramidal tract lesions as hemiplegia and paraplegia

Peripheral neuropathies

Cauda equina lesions

Multiple sclerosis

Vasculogenic causes (problem in attaining)

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 Any lesion decreasing the arterial inflow or enhancing the venous
outflow, e.g.

Atherosclerosis of hypogastric-cavernous arterial bed

Leriche syndrome (obstruction of the terminal aorta)

Pelvic steal syndrome (unilateral obstruction of internal iliac artery)

Trauma to blood vessels (blunt perineal trauma, fracture pelvis).

Arteriovenous malformations.

Iatrogenic causes
1. Surgery

injury of mechanism of erection, e.g. thoracolumbar sympathectomy,

radical prostatectomy & abdominoperineal resection of rectum.

2. Drugs

BB & H2 blockers e.g.Cimetidine

Antihypertensive e.g. clonidine, methyldopa & reserpine

Antiandrogens, e.g. cyproterone acetate.

Major tranquilizers as phenothiazines

Exercise intolerance (General diseases with a bad general

condition)
Pulmonary insufficiency & emphysema

Ischemic heart disease

Severe anemia.

Myasthenia gravis

Diagnosis ?

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 Sexual, Medical & Drug history

To differentiate organic from psychogenic

impotence
Onset, course & duration: organic impotence is of insidious onset &
there is progressive loss of erectile capacity in all sexually arousing
situations.

Presence of morning, nocturnal, psychogenic & reflex erections (defective

in organic impotence).

To determine the etiology

History of systemic disease, e.g., diabetes, hypertension, peripheral
neuropathy, or organ failure

Risk factors for atherosclerosis such as smoking, hypertension &

hyperlipidaemia

History of marital troubles, drug intake, trauma, or surgery.

Examination
General examination
Male secondary sexual characters (signs of hypoandrogenism,
gynecomastia).

Pulse, blood pressure, sensation & reflexes

Scars from previous surgery or trauma.

Local examination
Penis: size, meatus, scars, plaques, pulses

Scrotum: testicular size and sensation

Rectal examination of prostate and seminal vesicles

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 Investigations
Fasting blood sugar &Post prandial

Serum prolactin

Serum Testosterone

Serum Cholesterol

PSA

Invasive investigations
Injection of vasoactive substance (ICI)

Monitoring of nocturnal erections that occur during rapid eye movement

sleep to differentiate organic from psychogenic impotence. This is done
by Rigiscan device examination.

Penile-brachial pressure index.

Benign genital reflexes : Cremastric , Internal&external anal reflexes

Cavernosometry & Cavernosography to study the venous drainage

system of the penis (the veno-occlusive mechanism of the corpus
cavernosum)

Doppler studies Evaluation of the blood vessels by Doppler ultrasound

examination to determine the blood flow, blood pressure and imaging the
defects in penile blood vessels. This is done before and after
intracavernosal injection of vasoactive agents.

Neurologic evaluation of afferent and efferent pathways of erection:

electromyography, nerve conduction studies, thermal or vibratory
threshold & bulbocavernosus latency

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 Treatment ?
1. Counseling Such counseling is useful, even if the sexual dysfunction has a
strictly organic basis

2. Avoiding risk factors, e.g., drugs, smoking, and alcohol. & weight reduction

3. Treatment of underlying causes e.g. hypogonadism, surgical correction of

correctable causes, control of diabetes, hypertension etc.

4. Psychogenic erectile dysfunction: Psychotherapy, behavior modification

therapy

5. Organic erectile dysfunction

Hormonal pharmacotherapy

1. Androgens hypogonadism is the principal indication.

2. Bromocriptine if erectile impotence secondary to hyperprolactinemia

Non-hormonal pharmacotherapy

1. Phosphodiesterase 5 inhibitors e.g sildenafil, vardenafil and tadalafil.

These drugs inhibit phosphodiesterase 5 intracellular enzyme that
degrades cGMP in the smooth muscle cells. Accumulation of cGMP
inside smooth muscle cells of the penis by the action of these drugs
leads to good penile erection.

2. Systemic therapy: yohimbine (alpha 2-adrenergic blocking agent)

3. Intracorporal pharmacotherapy: induction of artificial erection can be

done, in selected cases, by injection of vasoactive drugs into corpora
cavernosa to induce vasodilatation & erection. Papaverine, phentolamine
& prostaglandin E1 are commonly used for intracorporal injection.

4. Multivitamin + Antioxidants

6. Surgical

Arterial reconstructive surgery

Venous reconstructive surgery.

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 Penile prosthesis: Penile implants are reserved for erectile impotence that
is not amenable to any other form of therapy. They are divided into inflatable
& noninflatable devices. Noninflatable devices include rigid rods & malleable
devices

vacuum-constriction devices & electrostimulation therapy.

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