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Erectile dysfunction

Definition
ED is a male sexual dysfunction characterized by an inability to achieve or maintain a penile erection sufficient for sexual satisfaction.
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Pathophysiology
ED is caused due to endocrine (reduced serum testosterone levels), psychogenic (stress, depression, anxiety), nonendocrine (spinal cord injury, multiple sclerosis, traumatic brain injury, diabetes, hypertension, dyslipidemia, radical pelvic surgery, medications) factors.
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Disease course
Clinical manifestations of ED may include gynecomastia, a decrease in beard and body hair due to hypogonadism, tachycardia, arterial bruit, bradycardia, arrhythmia, Peyronie disease, phimosis, frenulum breve, in addition to comorbidities (hypertension, diabetes, obesity).
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Prognosis and risk of recurrence
ED is not associated with increased mortality.
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Key sources
The following summarized guidelines for the evaluation and management of erectile dysfunction are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023; 2022), the Italian Society of Andrology and Sexual Medicine (SIAMS 2023), the American Urological Association (AUA/SMSNA 2022), the Italian Society of Endocrinology (SIE/SIAMS 2022), the European Society for Sexual Medicine (ESSM 2022), the Canadian Urological Association (CUA 2022), the American Urological Association (AUA 2021; 2018; 2015; 2014), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the European Academy of Andrology (EAA 2020), the Canadian Neurological Sciences Federation (CNSF 2019), and the European Huntington's Disease Network (EHDN 2019).
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Guidelines

1.Screening and diagnosis

Indications for screening
Assess sexual function and screen for ED in all patients with any of the following:
obesity
A
diabetes mellitus
A
arterial hypertension,
A
including taking certain antihypertensive agents
B
dyslipidemia
A
low testosterone
A
taking antidepressants or antipsychotics
A
history of pelvic surgery for malignancies
A
gout
B
systemic diseases, especially in patients with organ failure.
B
Consider assessing sexual functuon and screening for ED in all patients with any of the following:
COPD and obstructive sleep apnea
C
central and peripheral neurological diseases potentially affecting male sexual response
C
endocrine conditions, such as thyroid, adrenal, and pituitary diseases
C
chronic prostatitis/chronic pelvic pain syndrome
C
Peyronie's disease
C
young patients with a history of previous treatment with drugs affecting the serotoninergic pathway or the conversion of testosterone to dihydrotestosterone
C
couple infertility, particularly when undergoing assisted reproduction techniques.
C
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2.Classification and risk stratification

Severity assessment: use validated questionnaires to assess the severity of ED.
E

3.Diagnostic investigations

History and physical examination: as per EAU 2023 guidelines, elicit a comprehensive medical and sexual history in all patients with ED. Take into consideration psychosexual development, including life stressors, cultural aspects, and cognitive/thinking style of the patient regarding their sexual performance.
A
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  • Doppler ultrasound

  • Nocturnal penile tumescence and rigidity monitoring

  • Laboratory tests

  • Screening for CVD

  • Screening for BPH

4.Medical management

Avoidance of drugs affecting erectile function
Consider prescribing drugs with the lowest impact on sexual function.
C
Avoid using β-blockers as first-line therapy in patients with newly diagnosed arterial hypertension in the absence of specific cardiological indications.
D

More topics in this section

  • PDE5 inhibitors

  • Testosterone replacement therapy

5.Nonpharmacologic interventions

Lifestyle modifications
As per EAU 2023 guidelines:
Offer lifestyle changes and risk factor modification before or at the same time as initiating ED treatments.
A
Treat a curable cause of ED first, when found.
B

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  • Dietary supplements

  • Erection rehabilitation

  • Vacuum erection devices

  • Psychosocial interventions

6.Therapeutic procedures

Intraurethral alprostadil: as per EAU 2023 guidelines, offer topical/intraurethral alprostadil as an alternative first-line therapy in well-informed patients not wishing or not suitable for oral vasoactive therapy, not wishing to have intracavernous injections, or in patients preferring a less invasive therapy.
B

More topics in this section

  • Intracavernous injections

  • Extracorporeal shock wave therapy

7.Surgical interventions

Penile vascular surgery
Consider performing penile arterial reconstruction in young patients with ED and focal pelvic/penile arterial occlusion in the absence of documented generalized vascular disease or veno-occlusive dysfunction.
C
Do not perform penile venous surgery for the treatment of ED.
D

More topics in this section

  • Penile prosthesis implantation

8.Specific circumstances

Patients with obesity, indications for bariatric surgery: consider offering bariatric surgery to decrease ED in patients with morbid obesity.
C

More topics in this section

  • Patients with obesity (after bariatric surgery)

  • Patients with hypogonadism

  • Patients with hyperprolactinemia

  • Patients with Peyronie's disease (surgical management)

  • Patients with other endocrine disorders

  • Patients with Peyronie's disease (PDE5 inhibitors)

  • Patients with Peyronie's disease (penile prosthesis)

  • Patients with BPH

  • Patients with premature ejaculation

  • Patients with urethral injury

  • Patients with Parkinson's disease

  • Patients with Huntington's disease

9.Patient education

Counseling before arterial embolization for priapism: inform patients with non-ischemic priapism that embolization carries a risk of ED.
B

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  • Counseling before radical prostatectomy

  • Counseling before Intracavernous injections

10.Preventative measures

Counseling before anti-androgenic therapy: inform all patients treated with antiandrogenic agents about possible negative effects on erectile function.
B

11.Follow-up and surveillance

Assessment of treatment response: as per EAU 2023 guidelines, assess for inadequate/incorrect information about the mechanism of action and the ways the drugs are taken as they are the main causes of a lack of response to PDE5 inhibitors.
B

More topics in this section

  • Management of iatrogenic priapism