Erectile Dysfunction: Diagnosis and Treatment

Diagnosis

A careful medical and sexual history is essential for diagnosis. Sexual history should include onset of symptoms, presence of spontaneous erections (ie, morning erections), and risk factors for impotence (eg, cigarette smoking, diabetes mellitus, hypertension, drug abuse, obesity). A psychiatric interview and questionnaire may reveal psychological factors, such as depression and anxiety. In some cases, it may be helpful to interview the patient's sexual partner.

Physical examination can provide clues to systemic problems, such as neurologic abnormalities (eg, visual field defects that occur with pituitary tumor), vascular abnormalities (eg, decreased peripheral pulses), and developmental abnormalities (eg, abnormal secondary sex characteristics, penile curvature, gynecomastia).

Laboratory evaluation may include serum testosterone, prolactin, and thyroid function tests to evaluate for hormonal abnormalities. Nocturnal penile tumescence testing can be used to quantify the number, tumescence, and rigidity of erectile episodes during sleep, which can rule out psychological etiologies and can help identify men who might benefit from corrective vascular surgery. Doppler ultrasound or angiography of the penile arteries may be indicated to identify arterial obstruction or venous leak.

Treatment

Treatment is aimed at restoring the capacity to acquire and sustain penile erections and reactivating the libido.

The most commonly used class of medications is phosphodiesterase-5 inhibitors (eg, sildenafil, vardenafil, tadalafil). These medications are contraindicated in men taking nitrates. Hormonal therapy with testosterone may be effective, but is only recommended in a small number of patients with documented hypogonadism. Yohimbine may improve erections and increase libido by stimulating the parasympathetic nervous system.¹

Treatment of comorbid psychiatric disorders may improve sexual functioning. Between 20% and 50% of men with impotence have symptoms of depression, which may contribute to erectile dysfunction. Self-esteem may also suffer as a result of erectile dysfunction. Individual or couples psychotherapy may be a helpful part of impotence treatment.²

Penile injections, intraurethral therapies (eg, alprostadil), and vacuum devices may be beneficial. Surgical interventions may include reconstruction of blocked arteries and implantable prostheses.