Erectile Dysfunction

BASICS

DESCRIPTION

  • Erectile dysfunction (ED): the consistent or recurrent inability to acquire and/or sustain an erection of sufficient rigidity and duration for sexual intercourse
  • ED was previously assumed to be a symptom of aging in men. It is more often the result of concurrent medical conditions of the patient or from medications used to treat those conditions.
  • Sexual problems are frequent among older men and have a detrimental effect on their quality of life but are infrequently discussed with their physicians.
  • Synonym(s): impotence

EPIDEMIOLOGY

Incidence

In the United States, the incidence is 25.9/1,000 people and increases with age.

Prevalence

Overall prevalence for some degree of ED:

  • 52% in men aged 40 to 70 years
  • Age-related increase ranges from 12.4% in men aged 40 to 49 years to >70% of men over 70.
  • Prevalence is likely underestimated due to underreporting.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Erections are neurovascular events.
    • With stimulation, nitrous oxide is released, which increases production of cyclic guanosine 3′,5′-monophosphate (cGMP).
    • This leads to relaxation of cavernous smooth muscle, increasing blood flow to penis.
    • As cavernosal sinusoids distend with blood, there is passive compression of subtunical veins, which decreases venous outflow, leading to an erection.
  • ED may result from problems with systems required for normal penile erection.
    • Vascular: diseases that compromise blood flow (peripheral vascular disease, diabetes, arteriosclerosis, essential hypertension, and some medications that treat hypertension)
    • Neurologic: diseases that impair nerve conduction to brain or penile vasculature (spinal cord injury, stroke, diabetes)
    • Endocrine: diseases associated with changes in testosterone, luteinizing hormone, prolactin levels
    • Structural: phimosis, lichen sclerosis, congenital curvature
    • Psychological: patients suffering from depression, performance anxiety, premature ejaculation

RISK FACTORS

  • Advancing age
  • Cardiovascular disease (CVD)
  • Diabetes mellitus (DM)
  • Metabolic syndrome
  • Sedentary lifestyle
  • Cigarette smoking
  • Pelvic surgery, radiation, trauma/injury to pelvic area or spinal cord
  • Medications, including SSRIs, β-blockers, clonidine, digoxin, spironolactone, antiandrogens, corticosteroids, H2 blockers, or anticonvulsants
  • Central neurologic and endocrinologic conditions
  • Alcohol, cocaine, opioid, or marijuana abuse
  • Psychological conditions including stress, anxiety, depression, sexual abuse, or relationship problems

GENERAL PREVENTION

  • Lifestyle interventions, including exercise, limiting alcohol, and smoking cessation.
  • Treating the above risk factors.

COMMONLY ASSOCIATED CONDITIONS

  • CVD:
    • There is a documented two-way relationship between ED and CVD. ED has been identified as an independent risk marker for CVD with ED found to confer a 25% increased 10-year risk of CVD in the QRISK model (1). Men with ED have a greater likelihood of having angina, myocardial infarction, stroke, transient ischemic attack, congestive heart failure, or cardiac arrhythmia compared to men without ED.
  • DM and metabolic syndrome
  • Neurologic and psychiatric conditions

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