Summary
Erectile dysfunction is the most common presentation of sexual dysfunction in males and is characterized by an inability to maintain an adequate erection for sexual intercourse that lasts at least 6 months. The causes may be psychological, vascular, neurological, or hormonal. Diagnosis is made based on a detailed medical history and physical exam, relevant blood tests (e.g., testosterone, sexual hormone-binding globulin), and objective measurement of the remaining erectile function (nocturnal penile tumescence testing). Treatment includes counseling and, in cases with an organic cause, potentially mechanical vacuum pump therapy, medical therapy with phosphodiesterase-5 inhibitors, or surgery (penile prosthesis implant).
Premature ejaculation is characterized by an inability to delay ejaculation during penetration and is often accompanied by significant psychological distress. Proposed etiologies include penile hypersensitivity and psychological disorders such as depression and anxiety. The diagnosis is made with a medical history of short ejaculation latency time, inability to delay or control ejaculation, and psychological strain. Treatment consists of SSRIs and local topical anesthetics with sex therapy and other psychotherapy as needed.
See “Male sexual response” in “Male reproductive organs” for physiological erection.
Erectile disorder
Definition
- Erectile dysfunction (impotentia coeundi): inability to achieve or sustain an erection sufficient in rigidity or duration for sexual intercourse which is present for a minimum of ∼ 6 months [1]
- See “Infertility” and “Recurrent pregnancy loss.”
Epidemiology
- Most common sexual disorder in men
Etiology
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Organic (most common)
- Vascular: hypertension, diabetes mellitus, cardiovascular disease, hyperlipidemia, smoking
- Neurogenic: stroke, brain or spinal cord injury, dementia, Parkinson disease, multiple sclerosis
- Endocrine: hypogonadism, hyperprolactinemia, thyroid disorders
- Medications
- Antihypertensives (beta-blockers, thiazide diuretics)
- Antidepressants (SSRIs)
- Dopamine antagonists (e.g., antipsychotics): increased prolactin secretion (anterior pituitary) → decreased GnRH secretion (hypothalamus) → decreased LH secretion (anterior pituitary) → decreased testosterone production (Leydig cells) → hypogonadotropic hypogonadism
- Nitric oxide reductase inhibitors
- Iatrogenic: surgery or radiotherapy (radical prostatectomy, pelvic radiation)
- Trauma: pelvic fracture and urethral injury
- Alcohol abuse, cannabis abuse
- Peyronie disease
- Psychogenic: depression, anxiety (performance-related), relationship issues, trauma from prior experiences, stress
- Mixed organic and psychogenic
Diagnosis [2]
- Largely a clinical diagnosis
- Detailed patient history and clinical exam
| Diagnostic criteria (according to DSM V) | |
|---|---|
| A | |
| B |
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| C |
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| D |
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- Further tests to exclude organic disorders [3]
- Endocrinological laboratory analysis: ↓ testosterone, ↑ SHBG, ↑ prolactin, ↓ LH, ↓ FSH, ↑ TSH, ↑ fasting glucose or hemoglobin A1C, abnormal lipid profile
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Nocturnal penile tumescence measurement (phallography): measurement of spontaneous nightly erections in erectile dysfunction (primarily performed in a sleep laboratory) to differentiate between organic from psychogenic erectile dysfunction.
- Lack of nocturnal erections suggests an organic etiology (neurogenic or vascular)
- Normal testing suggests a psychogenic etiology
- Duplex Doppler ultrasound or arteriography to identify suspected arterial inflow or venous leaks after injection of vasodilatory agent
Treatment
It is important to identify the underlying etiology to manage lifestyle risk factors and initiate appropriate therapy.
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Psychotherapy
- Counseling
- Sensate focus exercises for performance anxiety
- Group psychotherapy
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Medical therapy
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Phosphodiesterase-5 inhibitors are considered the only first-line therapy: tadalafil, sildenafil, vardenafil.
- Contraindicated in patients taking nitrates due to profound hypotension
- May cause orthostatic hypotension in those taking alpha-adrenergic antagonists (e.g., for BPH) and should therefore be taken at least 4 hours apart
- Testosterone replacement if patient's serum testosterone is low (e.g., in hypogonadism)
- Intracavernous injection therapy or prostaglandin E1 (alprostadil) are second-line therapies if PDE-5 inhibitors are ineffective.
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Phosphodiesterase-5 inhibitors are considered the only first-line therapy: tadalafil, sildenafil, vardenafil.
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Mechanical
- Vacuum pump (hollow cylinder that is placed onto the penis) with penis ring (outflow obstruction of the existing erection) is also considered a second-line therapy if PDE-5 inhibitors are ineffective.
- Often recommended before intracavernous injections as vacuum devices are noninvasive
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Surgical
- Implantation of penile prosthesis
- Generally last resort (can be placed, e.g.g, at time of reconstructive surgery for Peyronie disease when erectile dysfunction is also present)
- Inflatable implants in the cavernous body most commonly used (vs. semi-rigid)
Premature ejaculation
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Epidemiology [2]
- Frequent sexual function disorder of men of all ages (prevalence of up to 30%) [4]
- May occur with erectile dysfunction
-
Etiology: largely unknown
- Psychogenic factors: depression/anxiety, relationship problems, irregular sexual intercourse
- Organic factors: penile hypersensitivity, hyperexcitability of the reflex arc
| Diagnostic criteria (according to DSM V) | |
|---|---|
| A |
|
| B |
|
| C |
|
| D |
|
-
Treatment
- The indication primarily depends on the psychological strain on the affected individual.
- Psychotherapy/behavioral therapy
- Medical therapy
- Local: Topical anesthetics (e.g., lidocaine-prilocaine spray) can also be used in combination with SSRIs and psychotherapy.
- Systemic: SSRIs (e.g., paroxetine ) are first-line treatment.
Delayed ejaculation
- Epidemiology: Incidence increases with age ≥ 50 years. [5]
- Etiology: psychological stress (e.g., childhood abuse, sexual trauma)
-
Diagnosis [2]
- Exclude any underlying organic disorder (e.g., traumatic or iatrogenic injury to any structures involved in the ejaculation process, medication-induced ejaculation disorder)
- Exclude severe relationship stress
| Diagnostic criteria of delayed ejaculation (DSM V) | |
|---|---|
| A |
|
| B |
|
| C |
|
| D |
|
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Treatment
- Psychodynamic psychotherapy
- Other types of therapy depending on the underlying cause of psychological stress
Peyronie disease
- Definition: fibroproliferative disorder that affects the tunica albuginea of the penis, causing abnormal curvature of the penis
- Pathogenesis: repeated penile microtrauma during sexual intercourse; or athletic activity followed by abnormal wound healing → fibrous plaque formation [6]
- Classification
-
Clinical features
- Penile pain
- Penile nodules/indurations on the affected side of the penis
- Erectile dysfunction due to abnormal curvature of the penis
- Possibly associated with psychological conditions; (e.g., anxiety, depression) [7]
-
Differential diagnosis
- Penile fracture (penile injury → rupture of corpora cavernosa → penile curvature)
- Chordee without hypospadias
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Treatment
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Active phase: oral NSAIDs or oral pentoxifylline for 3 months
- No symptomatic improvement: intralesional collagenase injections
- Symptomatic improvement: observation or continuation of oral pentoxifylline for another 6 months
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Stable phase
- Observation: patients with a mild penile curvature (< 30°) and no erectile dysfunction
- Intralesional collagenase injections: patients with penile curvature (> 30°) and erectile dysfunction
- Surgical repair: patients unresponsive to treatment, with severe penile deformity, and/or with extensive calcifications
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Active phase: oral NSAIDs or oral pentoxifylline for 3 months
