Erectile dysfunction (ED) is defined as the inability to achieve or maintain a penile erection, resulting in difficulty to perform penetrative sexual intercourse. Local penile factors and systemic diseases, including diabetes, cardiac disease, and neurologic disorders, can cause ED. Diagnosis is via physical exam and history. Management is guided by clearly discussing patient expectations after explaining the benefits and risks. Treatment includes conservative management with lifestyle modifications, oral medications, and injectables. Invasive surgical penile implants may be considered when conservative measures fail. Ultimately, both the patient and partner must be in tune with the treatment modalities to optimize their overall satisfaction.
Erectile dysfunctionErectile DysfunctionErectile dysfunction (ED) is defined as the inability to achieve or maintain a penile erection, resulting in difficulty to perform penetrative sexual intercourse. Local penile factors and systemic diseases, including diabetes, cardiac disease, and neurological disorders, can cause ED. Erectile Dysfunction (ED) is the recurrent failure to achieve or maintain consistent rigid penile erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy for satisfactory sexual intercourse.
Clinical importance:
Very common, but complex disorder with significant qualityQualityActivities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.Quality Measurement and Improvement of life implications
May be the initial symptom for underlying cardiovascular disease
Epidemiology[1,3,4]
Globally, at least 150 million men suffer from ED:
In the United States, 52% of men between 40 and 70 years of age are affected.
By 40 years of age, about 40% of men experience ED, whereas, about 70% of men report ED by 70 years of age.
PrevalencePrevalenceThe total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time.Measures of Disease Frequency of ED is closely related to increased age and presence of other systemic comorbiditiesComorbiditiesThe presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival.St. Louis Encephalitis Virus.
Etiology[1–4]
Erectile dysfunctionErectile DysfunctionErectile dysfunction (ED) is defined as the inability to achieve or maintain a penile erection, resulting in difficulty to perform penetrative sexual intercourse. Local penile factors and systemic diseases, including diabetes, cardiac disease, and neurological disorders, can cause ED. Erectile Dysfunction is a multifactorial disease process with many contributing factors. There are many factors that can be prevented or adjusted to improve the ability to obtain or maintain erections:
Organic:
Peripheral arterial disease (PAD)
Aortoiliac occlusive disease
AtherosclerosisAtherosclerosisAtherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis and coronary arteryCoronary ArteryTruncus Arteriosus disease (CAD)
Sleep apneaSleep apneaRepeated cessation of breathing for > 10 seconds during sleep and results in sleep interruption, fatigue, and daytime sleepiness.Obstructive Sleep Apnea
DiabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus mellitus (DMDMDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus)
LiverLiverThe liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy disease
Hyperlipidemia (HLD)
HypogonadismHypogonadismHypogonadism is a condition characterized by reduced or no sex hormone production by the testes or ovaries. Hypogonadism can result from primary (hypergonadotropic) or secondary (hypogonadotropic) failure. Symptoms include infertility, increased risk of osteoporosis, erectile dysfunction, decreased libido, and regression (or absence) of secondary sexual characteristics.Hypogonadism
Alcohol use disorderAlcohol use disorderAlcohol is one of the most commonly used addictive substances in the world. Alcohol use disorder (AUD) is defined as pathologic consumption of alcohol leading to impaired daily functioning. Acute alcohol intoxication presents with impairment in speech and motor functions and can be managed in most cases with supportive care. Alcohol Use Disorder
Stroke
Spinal cord injuriesSpinal cord injuriesSpinal cord injuries are complex injuries that involve damage to the neural tissue within the spinal canal. Spinal cord injuries are commonly the result of trauma. Clinical presentation varies depending on the site of injury and on whether the injury is complete or incomplete. Spinal Cord Injuries
Sickle cell anemiaSickle cell anemiaA disease characterized by chronic hemolytic anemia, episodic painful crises, and pathologic involvement of many organs. It is the clinical expression of homozygosity for hemoglobin S.Sickle Cell Disease
CKDCKDChronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities.Chronic Kidney Disease
Genital trauma
Peyronie’s disease
Post prostatectomyProstatectomyComplete or partial surgical removal of the prostate. Three primary approaches are commonly employed: suprapubic – removal through an incision above the pubis and through the urinary bladder; retropubic – as for suprapubic but without entering the urinary bladder; and transurethral (transurethral resection of prostate).Benign Prostatic Hyperplasia
Psychogenic:
Major depressive disorderMajor depressive disorderMajor depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders.Major Depressive Disorder
Generalized anxietyAnxietyFeelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders.Generalized Anxiety Disorder disorder
Performance anxietyAnxietyFeelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders.Generalized Anxiety Disorder
Acute stress disorderAcute stress disorderAcute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Acute Stress Disorder
Medications:
Beta blockers
Antidepressants
Antipsychotics
SpironolactoneSpironolactoneA potassium sparing diuretic that acts by antagonism of aldosterone in the distal renal tubules. It is used mainly in the treatment of refractory edema in patients with congestive heart failure, nephrotic syndrome, or hepatic cirrhosis. Its effects on the endocrine system are utilized in the treatments of hirsutism and acne but they can lead to adverse effects.Potassium-sparing Diuretics
KetoconazoleKetoconazoleBroad spectrum antifungal agent used for long periods at high doses, especially in immunosuppressed patients.Azoles
CimetidineCimetidineA histamine congener, it competitively inhibits histamine binding to histamine h2 receptors. Cimetidine has a range of pharmacological actions. It inhibits gastric acid secretion, as well as pepsin and gastrin output.Antihistamines
The penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy is made of cylindrical structures (paired corpus cavernosa and corpus spongiosumCorpus spongiosumPenis: Anatomy):
Contains the urethraUrethraA tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm.Urinary Tract: Anatomy, surrounded by sinusoidsSinusoidsLiver: Anatomy
Vascular supply to penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy is supplied by the internal iliac artery:
Internal pudendal artery becomes the common penile artery, which has 3 branches:
Cavernosal artery: gives off helicine arteriesArteriesArteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology that supply the corpora cavernosaCorpora cavernosaPenis: Anatomy
Bulbourethral artery: supplies the corpora spongiosum
Venous drainage of corporal bodies via emissary veinsVeinsVeins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: Histology:
Emissary veinsVeinsVeins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: Histology connect to the deep dorsal vein of the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy.
Rapid drainage of venous blood results in detumescence (flaccid penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy).
Male reproductive system:
Structures of the male reproductive system include the testes, epididymis, penis, and the ducts and glands that produce and carry semen. Sperm exit the scrotum through the ductus deferens, which is bundled in the spermatic cord. Seminal vesicles and prostate gland add fluids to the sperm to create semen.
Image: “Male reproductive system” by OpenStax College. License: CC BY 4.0
Normal erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy[1,2]
Sexual stimuli initiate a downstream cascade of complex neuronal and molecular pathways.
Cholinergic neuronal fibers stimulate the cavernosal endothelial cells to produce NO.
NO is the predominant neurotransmitter of erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy, synthesized by NO synthase
NO stimulates guanylate cyclaseGuanylate cyclaseAn enzyme that catalyzes the conversion of GTP to 3.Diarrheagenic E. coli (GC) in the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy.
↑ cGMPcGMPGuanosine cyclic 3.Phosphodiesterase Inhibitors promotes protein kinaseProtein kinaseA family of enzymes that catalyze the conversion of ATP and a protein to adp and a phosphoprotein.Interferons G-dependent smooth-muscle relaxation by decreasing intracellular calciumCalciumA basic element found in nearly all tissues. It is a member of the alkaline earth family of metals with the atomic symbol ca, atomic number 20, and atomic weight 40. Calcium is the most abundant mineral in the body and combines with phosphorus to form calcium phosphate in the bones and teeth. It is essential for the normal functioning of nerves and muscles and plays a role in blood coagulation (as factor IV) and in many enzymatic processes.Electrolytes → penile erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy
ErectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy is a balance between arterial blood inflow and venous drainage.
Penile corpora cavernosal bodies are cylindrical structures that fill with blood during an erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy.
Relaxation of sinusoidal smooth musclesSmooth musclesUnstriated and unstriped muscle, one of the muscles of the internal organs, blood vessels, hair follicles, etc. Contractile elements are elongated, usually spindle-shaped cells with centrally located nuclei. Smooth muscle fibers are bound together into sheets or bundles by reticular fibers and frequently elastic nets are also abundant.Muscle Tissue: Histology allows for rapid blood filling and expansion.
Venous occlusion restricts blood outflow via compressionCompressionBlunt Chest Trauma of venulesVenulesThe minute vessels that collect blood from the capillary plexuses and join together to form veins.Veins: Histology beneath the rigid tunica albugineaTunica albugineaPenis: Anatomy, thereby maintaining penile rigidityRigidityContinuous involuntary sustained muscle contraction which is often a manifestation of basal ganglia diseases. When an affected muscle is passively stretched, the degree of resistance remains constant regardless of the rate at which the muscle is stretched. This feature helps to distinguish rigidity from muscle spasticity.Megacolon.
Structural compartments of the penis during the flaccid (top) and erected (bottom) states: As seen in bottom images (erect: lateral view and erect: transverse view), rapid filling of the sinusoids and subsequent compression of veins and venules maintain penile rigidity.
Image: “The Structural Compartments of the Penis” by School of Information and Communications, Gwangju Institute of Science and Technology, Gwangju, 500-712, Korea. License: CC BY 4.0
Pathogenesis[1,2,4]
Neurogenic:
Intact nervous systemNervous systemThe nervous system is a small and complex system that consists of an intricate network of neural cells (or neurons) and even more glial cells (for support and insulation). It is divided according to its anatomical components as well as its functional characteristics. The brain and spinal cord are referred to as the central nervous system, and the branches of nerves from these structures are referred to as the peripheral nervous system.Nervous System: Anatomy, Structure, and Classification is a key component for initiation of erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy
Any neurologic compromise can inhibit the ability to achieve an erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy:
Peripheral nerve damage (e.g., penile surgery)
Central nerve damage (e.g., spinal cordSpinal cordThe spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injury, multiple sclerosisSclerosisA pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve.Wilms Tumor)
Impaired contractility of cavernosal smooth muscle (seen in defects in neurotransmitters, including NO and cGMPcGMPGuanosine cyclic 3.Phosphodiesterase Inhibitors)
Psychogenic:
Decreased sexual desire or stimulation will cause difficulty in achieving an erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy.
Generalized or performance-related anxietyAnxietyFeelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders.Generalized Anxiety Disorder, depression, and stress can cause ED.
Vascular:
Vascular compromise with arterial insufficiency or venous leak can impair blood flowBlood flowBlood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute).Vascular Resistance, Flow, and Mean Arterial Pressure to the erectogenic tissue.
HypertensionHypertensionHypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, diabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus, HLD, smokingSmokingWillful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand.Interstitial Lung Diseases, and cardiovascular disease can affect local (and systemic) vasculature.
Hormonal:
Low testosteroneTestosteroneA potent androgenic steroid and major product secreted by the leydig cells of the testis. Its production is stimulated by luteinizing hormone from the pituitary gland. In turn, testosterone exerts feedback control of the pituitary LH and FSH secretion. Depending on the tissues, testosterone can be further converted to dihydrotestosterone or estradiol.Androgens and Antiandrogens levels can affect erectile mechanisms, but the exact level corresponding to ED is unknown.
Others: thyroidThyroidThe thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck.Thyroid Gland: Anatomy and adrenal disorders
Biochemical mechanism of erection:
Nitric oxide is released from the cavernous nerves upon sexual stimulation, which leads to the activation of guanylate cyclase within the smooth muscle cells of the penis. Guanylate cyclase facilitates the conversion of guanosine triphosphate to cGMP. Specific protein kinases then are acted on by cGMP, causing a decrease in intracellular calcium levels. General effects are smooth-muscle relaxation, vasodilatation, and tumescence. The active cyclic GMP is converted to inactive 5′-GMP by phosphodiesterase type 5 (PDE-5), allowing intracellular calcium levels to normalize, thereby leading to vasoconstriction and loss of tumescence. Phosphodiesterase type 5 inhibitors are used in the management of erectile dysfunction, resulting in tumescence.
Image by Lecturio.
Clinical Presentation and Diagnosis
Initial encounter
Men of any age complaining of a recurrent inability to sustain an erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy rigid enough for sexual activity
ED is a very sensitive topic and patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may not present with this condition as their main complaint.
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may initially present with vague complaints about their sexSexThe totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism.Gender Dysphoria life or depression.
Diagnosis
Majority of cases are diagnosed based on history and physical examination.
Comprehensive medical and sexual history:[5–7,9,10]
Marital or relationship issues
Performance anxietyAnxietyFeelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders.Generalized Anxiety Disorder
Sexual Health Inventory for Men (SHIM): 5-question abbreviated version of IIEFIIEFErectile Dysfunction
ErectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy Hardness ScaleScaleDermatologic Examination (EHS): self-reported 0 (no engorgementEngorgementMastitis) to 4 (completely rigid)
Depression
Assess for lifestyle factors:
SmokingSmokingWillful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand.Interstitial Lung Diseases
Alcohol use
Illicit drug use
Relevant medical and surgical history
Any prior genitourinary surgeries
CAD
DMDMDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus
PAD
HLD
ED history:
Is the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy hard enough for penetrative sexual activity?
Do you wake up in the morning with an erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy?
Any history of prematurePrematureChildbirth before 37 weeks of pregnancy (259 days from the first day of the mother’s last menstrual period, or 245 days after fertilization).Necrotizing Enterocolitis ejaculation?
PainPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways with sexual activity?
Physical examination:[5–8]
Obtain resting vital signs.
Measure waist circumferenceWaist circumferenceMeasure of abdominal obesity and is associated with increased cardiovascular risks.Obesity and BMIBMIAn indicator of body density as determined by the relationship of body weight to body height. Bmi=weight (kg)/height squared (m2). Bmi correlates with body fat (adipose tissue). Their relationship varies with age and gender. For adults, bmi falls into these categories: below 18. 5 (underweight); 18. 5-24. 9 (normal); 25. 0-29. 9 (overweight); 30. 0 and above (obese).Obesity.
Observe the chest for gynecomastiaGynecomastiaGynecomastia is a benign proliferation of male breast glandular ductal tissue, usually bilateral, caused by increased estrogen activity, decreased testosterone activity, or medications. The condition is common and physiological in neonates, adolescent boys, and elderly men. Gynecomastia.
Penile exam to assess for lesions, plaques, or any anomalies
Laboratory tests:[5–7]
Early morning total testosteroneTestosteroneA potent androgenic steroid and major product secreted by the leydig cells of the testis. Its production is stimulated by luteinizing hormone from the pituitary gland. In turn, testosterone exerts feedback control of the pituitary LH and FSH secretion. Depending on the tissues, testosterone can be further converted to dihydrotestosterone or estradiol.Androgens and Antiandrogens levels to establish baseline
Hemoglobin and hematocritHematocritThe volume of packed red blood cells in a blood specimen. The volume is measured by centrifugation in a tube with graduated markings, or with automated blood cell counters. It is an indicator of erythrocyte status in disease. For example, anemia shows a low value; polycythemia, a high value.Neonatal Polycythemia to rule out anemiaAnemiaAnemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types
Hemoglobin A1CHemoglobin A1cProducts of non-enzymatic reactions between glucose and hemoglobin a, occurring as a minor fraction of the hemoglobin components of human erythrocytes. Hemoglobin a1c is hemoglobin a with glucose covalently bound to the terminal valine of the beta chain. Glycated hemoglobin a is used as an index of the average blood sugar level over a lifetime of erythrocytes.Diabetes Mellitus to determine glucoseGlucoseA primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement.Lactose Intolerance status
Ancillary diagnostic testsDiagnostic testsDiagnostic tests are important aspects in making a diagnosis. Some of the most important epidemiological values of diagnostic tests include sensitivity and specificity, false positives and false negatives, positive and negative predictive values, likelihood ratios, and pre-test and post-test probabilities. Epidemiological Values of Diagnostic Tests:
Wrap a ring of stamps around the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy and assess if the stamp breaks in the morning.
Positive erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy = broken stamp
Nocturnal penile tumescence and rigidityRigidityContinuous involuntary sustained muscle contraction which is often a manifestation of basal ganglia diseases. When an affected muscle is passively stretched, the degree of resistance remains constant regardless of the rate at which the muscle is stretched. This feature helps to distinguish rigidity from muscle spasticity.Megacolon (NPTR) test[5,6]
Monitoring device placed around the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy at night
Measures number of erections, tumescence, duration of erections, and maximal rigidityRigidityContinuous involuntary sustained muscle contraction which is often a manifestation of basal ganglia diseases. When an affected muscle is passively stretched, the degree of resistance remains constant regardless of the rate at which the muscle is stretched. This feature helps to distinguish rigidity from muscle spasticity.Megacolon
Should be performed on 2 separate occasions
May help differentiate organic and psychogenic ED (psychogenic typically has normal findings)
Office intracavernous injection (ICI) with prostaglandin (PG) E1E1An aromatized C18 steroid with a 3-hydroxyl group and a 17-ketone, a major mammalian estrogen. It is converted from androstenedione directly, or from testosterone via estradiol. In humans, it is produced primarily by the cyclic ovaries, placenta, and the adipose tissue of men and postmenopausal women.Noncontraceptive Estrogen and Progestins (erectogenic agent) into the corpora cavernosaCorpora cavernosaPenis: Anatomy of the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy:[5–7]
PGE1 produces vasodilationVasodilationThe physiological widening of blood vessels by relaxing the underlying vascular smooth muscle.Pulmonary Hypertension Drugs.
Assesses for erectile response and the ability to maintain an erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy
Used to identify possible veno-occlusive dysfunction or arterial insufficiency
Performed after ICI to stimulate an erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy
Invasive vascular testing, such as pudendal angiographyAngiographyRadiography of blood vessels after injection of a contrast medium.Cardiac Surgery, is rarely used and only indicated for severe vascular disruption arising from pelvic trauma.[5–7]
SHIM questionnaire[8,9]
Image by Lecturio.
Management
The following recommendations are based on US and international guidelines.
Treatment approach[5–7,9]
Patient education
Holistic approach to address the underlying cause:
Medical condition-related ED
Anatomical or surgical correction of factors leading to ED
Psychogenic factors
Proceed from least to maximally invasive options as needed.
There are 2 individuals to keep in mind: patient and partner
Diagnosis and management of erectile dysfunction[6‒8]
HbA1c: hemoglobin A1c
PDE-5: phosphodiesterase-5
Image by Lecturio.
Medical treatment
Lifestyle modifications:[5–7]
Reduce cardiac risk factors.
Adjust anti-hypertensive drug doses as indicated.
Optimize diabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus care.
Decrease alcohol use.
SmokingSmokingWillful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand.Interstitial Lung Diseases cessation
Diet low in saturated fatsFatsThe glyceryl esters of a fatty acid, or of a mixture of fatty acids. They are generally odorless, colorless, and tasteless if pure, but they may be flavored according to origin. Fats are insoluble in water, soluble in most organic solvents. They occur in animal and vegetable tissue and are generally obtained by boiling or by extraction under pressure. They are important in the diet (dietary fats) as a source of energy.Energy Homeostasis
Increase physical exercise.
Phosphodiesterase-5 (PDE-5) inhibitors:[6,7]
SildenafilSildenafilA phosphodiesterase type-5 inhibitor; vasodilator agent and urological agent that is used in the treatment of erectile dysfunction and primary pulmonary hypertension.Phosphodiesterase Inhibitors (25 mg, 50 mg, 100 mg)
Starting dose: 50 mg by mouth as needed 60 minutes prior to sexual intercourse
Onset of action: 30–60 minutes after administration
Efficacy: effects up to 12 hours after administration
Effectiveness reduced after heavy fatty meals
VardenafilVardenafilA piperazine derivative, phosphodiesterase 5 inhibitor and vasodilator agent that is used as a urological agent in the treatment of erectile dysfunction.Phosphodiesterase Inhibitors (2.5 mg, 5 mg, 10 mg, 20 mg)
Starting dose: 10 mg by mouth as needed 60 minutes prior to sexual intercourse (take only once a day)
Onset of action: 15–30 minutes after administration
Efficacy: effects up to 12 hours after administration
Effectiveness reduced after heavy fatty meals
TadalafilTadalafilA carboline derivative and phosphodiesterase 5 inhibitor that is used primarily to treat erectile dysfunction; benign prostatic hyperplasia and primary pulmonary hypertension.Phosphodiesterase Inhibitors (5 mg, 10 mg, 20 mg)
Starting dose: 10 mg by mouth ≥ 30 minutes prior to sexual intercourse (take only once a day)
Onset of action: 30 minutes after administration
Efficacy: effects maintained up to 36 hours
Not affected by food
Available in once-daily dosing (2.5 mg a day) taken without regard to timing of sexual activity
Can also be used for lower urinary tractUrinary tractThe urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra.Urinary Tract: Anatomy symptoms related to benignBenignFibroadenoma prostatic hypertrophyHypertrophyGeneral increase in bulk of a part or organ due to cell enlargement and accumulation of fluids and secretions, not due to tumor formation, nor to an increase in the number of cells (hyperplasia).Cellular Adaptation (2.5–5 mg by mouth once a day)
Oral medications that promote increased levels of cGMPcGMPGuanosine cyclic 3.Phosphodiesterase Inhibitors in the penile vasculature
To be taken before planned sexual activity and must involve sexual stimulation
Contraindicated in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship taking nitratesNitratesNitrates are a class of medications that cause systemic vasodilation (veins > arteries) by smooth muscle relaxation. Nitrates are primarily indicated for the treatment of angina, where preferential venodilation causes pooling of blood, decreased preload, and ultimately decreased myocardial O2 demand.Nitrates, as it may cause an unsafe drop in BP
Adverse reactions:
HeadacheHeadacheThe symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders.Brain Abscess
Rarely may cause priapismPriapismA prolonged painful erection that may lasts hours and is not associated with sexual activity. It is seen in patients with sickle cell anemia, advanced malignancy, spinal trauma; and certain drug treatments.Penile Anomalies and Conditions (erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy lasting > 4 hours)
Vacuum erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy device:[6,7]
Good choice for well-informed older patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with infrequent intercourse and comorbid conditions that preclude them from medical or surgical interventions
Mechanical pumpPumpACES and RUSH: Resuscitation Ultrasound Protocols used to generate negative pressure around the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy and sustain erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy
Causes dilation of the cavernous spaces of the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy
ErectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy maintained with a constrictive ring/band placed at the base of the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy
ContraindicationsContraindicationsA condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks).Noninvasive Ventilation:
Men on long-term anticoagulantsAnticoagulantsAnticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are at increased risk of bleeding or bruising.
Unexplained priapismPriapismA prolonged painful erection that may lasts hours and is not associated with sexual activity. It is seen in patients with sickle cell anemia, advanced malignancy, spinal trauma; and certain drug treatments.Penile Anomalies and Conditions
Adverse reactions:
HematomaHematomaA collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue.Intussusception if over-pressurized
EcchymosisEcchymosisExtravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia.Orbital Fractures if constrictive band left on for too long
Also known as Medicated Urethral System for ErectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy (MUSE)
Administered via urethral meatus
Dissolves into the corpus spongiosumCorpus spongiosumPenis: Anatomy and increases cAMPcAMPAn adenine nucleotide containing one phosphate group which is esterified to both the 3′- and 5′-positions of the sugar moiety. It is a second messenger and a key intracellular regulator, functioning as a mediator of activity for a number of hormones, including epinephrine, glucagon, and acth.Phosphodiesterase Inhibitors levels in smooth musclesSmooth musclesUnstriated and unstriped muscle, one of the muscles of the internal organs, blood vessels, hair follicles, etc. Contractile elements are elongated, usually spindle-shaped cells with centrally located nuclei. Smooth muscle fibers are bound together into sheets or bundles by reticular fibers and frequently elastic nets are also abundant.Muscle Tissue: Histology
Leads to corporal smooth-muscle relaxation and erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy
ContraindicationsContraindicationsA condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks).Noninvasive Ventilation:
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with urethral strictureStricturePrimary Sclerosing Cholangitis disease, hypospadiasHypospadiasA birth defect due to malformation of the urethra in which the urethral opening is below its normal location. In the male, the malformed urethra generally opens on the ventral surface of the penis or on the perineum. In the female, the malformed urethral opening is in the vagina.Penile Anomalies and Conditions, urethritisUrethritisInflammation involving the urethra. Similar to cystitis, clinical symptoms range from vague discomfort to painful urination (dysuria), urethral discharge, or both.Urinary Tract Infections (UTIs)
Sickle cell diseaseSickle cell diseaseSickle cell disease (SCD) is a group of genetic disorders in which an abnormal Hb molecule (HbS) transforms RBCs into sickle-shaped cells, resulting in chronic anemia, vasoocclusive episodes, pain, and organ damage.Sickle Cell Disease or hematologic disorders
Not to be used with a pregnant partner, as it may induce labor
Adverse reactions:
Penile painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
Urethral burning or irritation
PriapismPriapismA prolonged painful erection that may lasts hours and is not associated with sexual activity. It is seen in patients with sickle cell anemia, advanced malignancy, spinal trauma; and certain drug treatments.Penile Anomalies and Conditions possible, but rare
ICI therapy:[6–8]
Direct PGE1, papaverine, phentolaminePhentolamineA nonselective alpha-adrenergic antagonist. It is used in the treatment of hypertension and hypertensive emergencies, pheochromocytoma, vasospasm of raynaud disease and frostbite, clonidine withdrawal syndrome, impotence, and peripheral vascular disease.Antiadrenergic Drugs combination administered as a penile injection into the corpora cavernosaCorpora cavernosaPenis: Anatomy:
PGE1 increases cAMPcAMPAn adenine nucleotide containing one phosphate group which is esterified to both the 3′- and 5′-positions of the sugar moiety. It is a second messenger and a key intracellular regulator, functioning as a mediator of activity for a number of hormones, including epinephrine, glucagon, and acth.Phosphodiesterase Inhibitors levels in the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy.
Papaverine is a non-specific PDE inhibitor that increases cAMPcAMPAn adenine nucleotide containing one phosphate group which is esterified to both the 3′- and 5′-positions of the sugar moiety. It is a second messenger and a key intracellular regulator, functioning as a mediator of activity for a number of hormones, including epinephrine, glucagon, and acth.Phosphodiesterase Inhibitors and cGMPcGMPGuanosine cyclic 3.Phosphodiesterase Inhibitors levels.
PhentolaminePhentolamineA nonselective alpha-adrenergic antagonist. It is used in the treatment of hypertension and hypertensive emergencies, pheochromocytoma, vasospasm of raynaud disease and frostbite, clonidine withdrawal syndrome, impotence, and peripheral vascular disease.Antiadrenergic Drugs is an alpha-1 adrenergic blocker that reduces sympathetic tone in the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy.
ContraindicationsContraindicationsA condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks).Noninvasive Ventilation:
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship unable to tolerate penile injections
Penile painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
Bruising
HematomaHematomaA collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue.Intussusception
PriapismPriapismA prolonged painful erection that may lasts hours and is not associated with sexual activity. It is seen in patients with sickle cell anemia, advanced malignancy, spinal trauma; and certain drug treatments.Penile Anomalies and Conditions
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship should not increase the dose without approval and must proceed to emergency for reversal therapy if the erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy persists > 4 hours (priapismPriapismA prolonged painful erection that may lasts hours and is not associated with sexual activity. It is seen in patients with sickle cell anemia, advanced malignancy, spinal trauma; and certain drug treatments.Penile Anomalies and Conditions)
Surgical treatment[5–8]
Must 1st undergo comprehensive diagnosis and medical management
Indicated for failed non-surgical management
Obtain cardiac and medical clearance for safe sexual activity:
Ability to undergo general anesthesiaGeneral anesthesiaProcedure in which patients are induced into an unconscious state through use of various medications so that they do not feel pain during surgery.Anesthesiology: History and Basic Concepts and surgery
Fluid from the intraabdominal reservoirReservoirAnimate or inanimate sources which normally harbor disease-causing organisms and thus serve as potential sources of disease outbreaks. Reservoirs are distinguished from vectors (disease vectors) and carriers, which are agents of disease transmission rather than continuing sources of potential disease outbreaks. Humans may serve both as disease reservoirs and carriers.Escherichia coli connects to tubing to the pumpPumpACES and RUSH: Resuscitation Ultrasound Protocols in the scrotumScrotumA cutaneous pouch of skin containing the testicles and spermatic cords.Testicles: Anatomy.
Associated with infectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease, as these implants are foreign bodies (usually requires the removal of device and treatment with antibiotics)
Device malfunction
Urethral injury during insertion of the implant
Device crossover, where penile cylinder may encroach on the contralateral side
Penile or scrotal painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways due to device placement
Penile prosthesis: semi-rigid prosthesis in the surgical treatment of Peyronie’s disease
Image: “Semirigid prosthesis” by MEDAS Medical Center, Bucharest, Romania. License: CC BY 2.0
Penile prosthesis: post-surgical result
Image: “Post operatory result” by MEDAS Medical Center, Bucharest, Romania. License: CC BY 2.0
Clinical Relevance
Peyronie’s disease: a condition caused by a fibrous-tissue disorder of the tunica albugineaTunica albugineaPenis: Anatomy that results in penile deformityDeformityExamination of the Upper Limbs, painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways, and ED. Diagnosis is based on history and physical examination. Ultrasound can help define the fibrotic tissue. Medical treatments include intralesional collagenase Clostridium histolyticumClostridium histolyticumA species of gram-positive, strongly proteolytic bacteria in the family clostridiaceae. It contains several forms of collagenase whose action can lead to gas gangrene in humans and horses.Gas Gangrene(breaks up fibrousFibrousFibrocystic Change substances), verapamilVerapamilA calcium channel blocker that is a class IV anti-arrhythmia agent.Pulmonary Hypertension Drugs, or interferon alpha-2b injection. Surgical therapy (e.g., plication, grafting, or penile prosthesis) is an option for patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship refractory to medical therapy.
HypogonadismHypogonadismHypogonadism is a condition characterized by reduced or no sex hormone production by the testes or ovaries. Hypogonadism can result from primary (hypergonadotropic) or secondary (hypogonadotropic) failure. Symptoms include infertility, increased risk of osteoporosis, erectile dysfunction, decreased libido, and regression (or absence) of secondary sexual characteristics.Hypogonadism: a condition characterized by the decreased production of sexSexThe totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism.Gender DysphoriasteroidsSteroidsA group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus.Benign Liver Tumors in the gonadsGonadsThe gamete-producing glands, ovary or testis.Hormones: Overview and Types. In men, hypogonadismHypogonadismHypogonadism is a condition characterized by reduced or no sex hormone production by the testes or ovaries. Hypogonadism can result from primary (hypergonadotropic) or secondary (hypogonadotropic) failure. Symptoms include infertility, increased risk of osteoporosis, erectile dysfunction, decreased libido, and regression (or absence) of secondary sexual characteristics.Hypogonadism can result from primary or secondary testicular failure due to pituitaryPituitaryA small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum.Hormones: Overview and Types or hypothalamic disorders. Symptoms of hypogonadismHypogonadismHypogonadism is a condition characterized by reduced or no sex hormone production by the testes or ovaries. Hypogonadism can result from primary (hypergonadotropic) or secondary (hypogonadotropic) failure. Symptoms include infertility, increased risk of osteoporosis, erectile dysfunction, decreased libido, and regression (or absence) of secondary sexual characteristics.Hypogonadism include ED, decreased libido, and regressionRegressionCorneal Abrasions, Erosion, and Ulcers, or absence of secondary sexual characteristicsSecondary Sexual CharacteristicsPrecocious Puberty.
DMDMDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus: a heterogeneous group of metabolic diseases characterized by chronic hyperglycemiaHyperglycemiaAbnormally high blood glucose level.Diabetes Mellitus. DiabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus mellitus leads to various complications including ED. Poor glycemic control, long duration of diabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus, and the presence of microvascular and cardiovascular diseases correlate with the severity of ED.
Prostate-cancertreatment:ProstateProstateThe prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer is a slow-growing malignancyMalignancyHemothorax affecting the prostateProstateThe prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. gland. Treatment options include radiotherapy and radical prostatectomyRadical ProstatectomyProstate Cancer, both of which are commonly complicated in individuals with ED. Effects of treatments can temporarily or permanently damage the nervous and vascular structures integral for erectionErectionThe state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions.Penis: Anatomy. Nerve-sparing surgery is performed when indicated for better erectile function postoperatively. Medications for ED are also generally effective in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship scheduled for the treatment of prostateProstateThe prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer.
Burnett, A. L., Nehra, A., Breau, R. H., et al. (2018). Erectile dysfunction: AUA guideline. Journal of Urology, 200(3), 633–641. https://doi.org/10.1016/j.juro.2018.05.004
Salonia, A., Bettocchi, C., Boeri, L., Capogrosso, P., et al. (2021). European Association of Urology guidelines on sexual and reproductive health—2021 update: male sexual dysfunction. European Urology, 80(3), 333–357. https://doi.org/10.1016/j.eururo.2021.06.007
Hatzichristou, D., Kirana, P.-S., Banner, L., Althof, S. E., Lonnee-Hoffmann, R. A. M., Dennerstein, L., Rosen, R. C. (2016). Diagnosing sexual dysfunction in men and women: sexual history taking and the role of symptom scales and questionnaires. The Journal of Sexual Medicine, 13(8), 1166–1182. https://doi.org/10.1016/j.jsxm.2016.05.017
Domes, T., Najafabadi, B. T., Roberts, M., Campbell, J., Flannigan, R., Bach, P., Patel, P., Langille, G., Krakowsky, Y., Violette, P. D. (2021). Canadian Urological Association Guideline: erectile dysfunction. Canadian Urological Association Journal, 15(10). https://doi.org/10.5489/cuaj.7572
Rosen, R., Cappelleri, J., Smith, M., Lipsky, J., Peña, B. (1999). Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. International Journal of Impotence Research, 11(6), 319–326. https://doi.org/10.1038/sj.ijir.3900472