Erectile Dysfunction in Men

Essentials of Diagnosis

The DSM-IV-TR criteria for the diagnosis of male erectile disorder (MED) are:

1. Persistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate erection.
2. The disturbance causes marked distress or interpersonal difficulty.
3. The erectile dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effect of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Again, MED should also be diagnosed according to subtypes: Generalized vs. situational; lifelong vs. acquired; due to psychological factors vs. due to combined factors.

General Considerations

The prevalence of problems with erections is 1–9% below the age of 40 years, increasing to as high as 20–40% after the age of 60 years. Major correlates of erectile problems include age, depression, smoking, diabetes, and hypertension

Causes

Major depressive disorder, social anxiety, and posttraumatic stress disorder may be associated with MED. Embarrassment and apprehension about possible erectile failure in the future after an initial episode of erectile failure are felt to be involved in the genesis of psychogenic erectile disorder. After an episode of failure, a negative cognitive set and unwitting self-distraction from erotic cues may perpetuate the problem.

A variety of disease including diabetes mellitus, multiple sclerosis, and hypogonadism may be associated with organic erectile problems. Various medications, (namely, antihypertensives and psychiatric) may be associated with erectile problems.

Signs & Symptoms

The major symptom of MED is the failure to obtain erections in a situation in which they were anticipated. This is usually accompanied by embarrassment, self-doubt, and loss of self-confidence..

Laboratory Testing

Standard laboratory testing includes serum free testosterone and serum prolactin, especially if complaints of libido are also present. Other commonly ordered screening laboratory examinations include fasting glucose and lipids. Nocturnal penile tumescence (NPT) testing is sometimes used to differentiate psychogenic from organic impotence. Some clinicians have employed waking erections to erotic audiovisual material to try to distinguish between MED due to psychological factors and MED due to a general medical disorder. However, both of these procedures are used infrequently because of the lack of specificity. Evaluation of erection after intracavernosal injection of erectogenic drugs is sometimes used as a general screening procedure. However, the specificity of this procedure is also unclear. Specialized assessment of vascular function involves dynamic infusion cavernosography, duplex Doppler penile ultrasound, and arteriography. Specialized neurological testing might include dorsal nerve conduction latency and bulbocavernous reflex latency testing.

Course of Illness

Brief episodes of erectile failure in sexually inexperienced males frequently remit without intervention. A small number of cases of chronic psychogenic erectile dysfunction will remit without intervention.

Differential Diagnosis

The major issue in differential diagnosis is to establish whether the disorder is due to another Axis I disorder or is exclusively a substance induced disorder or exclusively due to a general medical condition. Although a variety of laboratory assessments are available, the most important element in the differential diagnosis is a careful psychiatric evaluation including a sexual history. If the erectile problem is part of the symptomatic presentation of a major depressive disorder, one would diagnose it as an Axis I disorder. The next major element in the differential diagnosis is to rule out a substance-induced disorder. Many drugs such as antidepressants and antipsychotics have been reported to be associated with erectile dysfunction. If the history establishes that the disorder began after a drug was administered or after a dose adjustment, a trial off the suspected drug is in order. Erectile dysfunction may be associated with hyperprolactinemia or hypogonadism, both of which can be detected by laboratory assays. In general, these causes of erectile dysfunction are also associated with a complaint of decreased libido. By history one would establish the presence or absence of diseases likely to cause erectile problems. For example, erectile dysfunction is common in diabetes mellitus and multiple sclerosis. It also can be a result of pelvic surgery or radiation therapy.

Cases with a situational or lifelong pattern are suggestive of a psychogenic etiology. Most organic etiologies are global and acquired. The presence of erections under any circumstances, especially erections upon awakening, is suggestive of a psychogenic etiology. Since the advent of safe oral therapies, extensive laboratory examinations to determine the etiology of erectile complaints are uncommon.

Treatment

Psychopharmacological Treatment

First line pharmacological interventions include sildenafil, tadalafil, and vardenafil, all phosphodiesterase type 5 inhibitors. These agents have been used both in psychogenic and organic impotence with success. In psychogenic impotence, indications for the use of oral vasoactive drugs include (1) failure of psychotherapy, (2) low self-confidence, (3) chronicity, (4) alexithymia, and (5) a coexisting contributing biological factor.

Psychotherapeutic Treatment

Psychological treatment is usually behavioral and involves graduated sexual homework assignments, a temporary cessation of attempts at coitus, modification of unrealistic expectations and cognitions, and supportive psychotherapy. The preferred technique is conjoint couple behavioral psychotherapy.

Other Treatment

Vacuum erection devices, intracavernosal and intraurethral prostaglandins E1 have been used in men with both psychogenic and organic impotence. As a last resort, vascular surgery or microsurgery, or penile prosthesis implantation can be employed.

Complications/Adverse Outcomes of Treatment

Phosphodiesterase type 5 inhibitors may have the following side effects: Priapism, facial flushing, nasal stuffiness, visual disturbances, dyspepsia, and syncope. These drugs are contraindicated with the use of nitrates and should be used in caution in individuals with unstable angina or who are on multiple antihypertensive drugs.

Both intraurethral and intracavernosal prostaglandins E1 can be associated with pain at the site of injection as well as the risk of priapism. There are operative risks with penile prosthesis implantation including hemorrhage and infection.

Prognosis

The prognosis in acquired psychogenic erectile dysfunction is excellent. The prognosis in lifelong global erectile dysfunction is poor. In organic problems of mild to moderate severity, the prognosis is good with the use of oral agents. In MED with combined psychological and organic features, the prognosis for return of sexual activity is less promising unless psychotherapy is combined with pharmacotherapy.