Erectile DysfunCtion
Differential Overview
❑ Psychological
❑ Drugs
❑ Diabetes mellitus
❑ Androgen deficiency
❑ Aortoiliac occlusion
❑ Hypogastric-cavernous occlusion
❑ Pudendal artery occlusion
❑ Venous leak
❑ Primary gonadal failure
❑ Peyronie disease
❑ Post-prostatectomy
❑ Prolactin excess
❑ Spinal cord lesion
❑ Post-priapism
Diagnostic Approach
The advent of nitric oxide inhibitors has reduced the impetus for the comprehensive evaluation of erectile dysfunction.
Reduced libido (sexual desire for the partner) should be distinguished from dysfunction of hydraulics. If the patient has any full nocturnal or morning erections, it implies that the corpora cavernosa vascular supply and neurological reflex arc are intact. Organic causes may have a gradual onset. Early in the course symptoms may fluctuate, but soon universal erectile dysfunction is present.
A neurologic cause is implied if there is decreased pinprick sensation in the sacral dermatomes. The bulbocavernosus reflex will be normal if rectal tone is normal.
Clinical Findings
Psychological A sudden onset, usually concurrent with life stress or with situational performance anxiety (increasing adrenergic output), is typical. The occurrence of full erections during sleep or on awakening is a helpful sign. Erectile dysfunction also commonly accompanies depression, recognized by mood disturbance, sleep disorder, and anhedonia.
Drugs Many drugs can cause erectile dysfunction, including antihypertensives (beta-blockers, thiazide diuretics, methyldopa, clonidine), H2 blockers, barbiturates, phenothiazines, tricyclics, MAO inhibitors, lithium, levodopa, opiates, alcohol, antihistamines, spironolactone, ketoconazole, cancer chemotherapeutics, metoclopramide, phenytoin, and indomethacin. The diagnosis is made by the reversibility of the symptoms when the drug is discontinued.
Diabetes mellitus When erectile dysfunction occurs, other signs of autonomic neuropathy are usually present, including orthostatic hypotension or retrograde ejaculation.
Androgen deficiency Erectile dysfunction is partial and associated with decreased libido. Testicular atrophy is found with soft testes less than 3.5 cm in length.
Aortoiliac occlusion It presents with thigh pain and quadriceps atrophy combined with a decreased femoral pulse and a bruit.
Hypogastric-cavernous occlusion It should be considered in the setting of atherosclerosis risk factors, other vascular occlusions, prior pelvic radiation therapy, or pelvic trauma.
Pudendal artery occlusion Saddle paresthesia is a sign of pudendal nerve injury adjacent to the artery. It occurs most commonly as a result of chronic trauma from a bicycle seat.
Venous leak A firm erection occurs, which is then unable to be maintained. This is caused by valve incompetence.
Primary gonadal failure Small, soft testes are present.
Peyronie disease A firm induration is felt in the lateral aspect of the penis. The penis bends sideways with erection.
Post-prostatectomy Radical prostatectomy for prostate cancer frequently produces retrograde ejaculation or erectile failure caused by periprostatic nerve interruption.
Prolactin excess Concurrent gynecomastia is a clue.
Spinal cord lesion Decreased genital sensation in addition to the erectile dysfunction should raise suspicion of a cord lesion. The cremasteric reflex (scrotal contraction with stroking the inner thigh) will be absent. Causes include spinal cord trauma, tumor, or a demyelinating lesion.
Post-priapism Variations include scarring of the tunica albuginea with lateral deviation of the erect penis or sinusoidal scarring with erectile failure. Examine the penile shaft for firm scar tissue. Causes of priapism include injury to the upper dorsal spinal cord, leukemia, sickle cell anemia, trauma, and bladder cancer with a urethral growth.
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Impotence
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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