Erectile dysfunction

Probability diagnosis

Ageing

Drugs esp. excess alcohol

Diabetes (autonomic dysfunction)

Stress/anxiety/depression

Serious disorders not to be missed

Vascular:

• Generalised arteriopathy esp. lower limbs

Infection:

• Generalised: viral, bacterial

Tumours:

• Pituitary fossa

Other:

• Systemic illness

• Chronic kidney disease

Pitfalls (often missed)

Pelvic trauma

Excessive cigarette smoking

Iatrogenic e.g. prostate surgery, drugs

Thrombosis corpus callosum

Rarities:

• Neurological e.g. MS

• Hypogonadism e.g. Klinefelter’s

• Anatomical e.g. tight frenulum, Peyroine’s disease

Masquerades checklist

Depression including drugs

Diabetes

Drugs: various

Thyroid/other endocrine: several (see history)

Spinal dysfunction e.g. spinal cord pathology, cauda equina lesion

Is the patient trying to tell me something?

Consider psychosexual dysfunction incl. marital disharmony, performance anxiety

Key history

• Nature of onset including nature of sexual relationship

• Ask about nocturnal and early morning erections

• Drug history incl. alcohol, nicotine (4 times risk), street drugs (cocaine, cannabis), pharmaceutical agents esp. antihypertensives (beta blockers, diuretics), hypolipidaemic agents, antiandrogens (prostate cancer treatment), antidepressants, antipsychotics, H₂-receptor antagonists

Key examination

Genitourinary, cardiovascular and neurogenic examinations are important. This should include a rectal examination; examination of the vascular and neurological status of the lower limbs; and genitalia esp. the testicles and penis. Check the cremasteric and bulbocavernosus reflexes.

Key investigations

First line:

• glucose

• FBE

• free testosterone (androgen deficiency)

• thyroxine (hypothyroidism)

• prolactin

• LH

• FSH

• Urinalysis

Consider:

• LFTs esp. GGT (alcohol effect) and KFTs

• nocturnal penile tumescence

• Doppler flow studies

Diagnostic tips

Endocrine causes to consider include androgen/testosterone deficiency, hyperprolactinaemia and hypothyroidism. Consider pituitary fossa tumour.