Impotence/erectile dysfunction

Question 1

A 70 year old man presents with the recent onset of impotence. How would you assess and manage him?

Answer 1

Impression
Erectile dysfunction. May be associated with other features of male sexual dysfunction including diminished libido and abnormal ejaculation.

DDx

• Organic: Vascular (Atherosclerosis, surgery, radiotherapy)
• Neurologic (stroke, MS, spinal chord),
• Endocrine: hypogonadism, hyperprolactinaemia),
• Penile (peurneys disease),
• Iatrogenic: prostate biopsy
• Medications: anti-androgenic drugs
• Drugs (recreational drugs, smoking).
• Psychogenic: performance anxiety, past trauma, relationship problems

Is a common problem for ageing males. Important component to patient management in this case is patient education. Otherwise, would conduct focussed history and examination to determine any underlying causes of the presentation, and institute appropriate management accordingly.

Question 2

Erectile dysfunction - History

Answer 2

History

• sx: ask about nature of sexual dysfunction, onset, severity, difficulty obtaining vs maintaining erection, situations when it occurs (masturbation vs alone), gradual onset and worsening vs paroxysmal, associated psychiatric features
• Consequences: Impact on life, relationship, etc
• CVD risk factors: diabetes, HTN, hyperlipidaemia, CVD, stroke, fam hx, smoking/alcohol - ?vascularpath
• PSHx (Radiation etc), PMHx, medications (GTN, ß-Blockers, anti-androgen [prostate cancer], GTN), allergies

Question 3

Erectile dysfunction - Examination

Answer 3

Examination

• General appearance
• Cardiovascular examination, evidence of PVD.
• genito-urinary: Penis; deformities, curvature, hypogonadism (small testes), DRE for prostate assessment
• Neurological examination (evidence of stroke/other focal neurology)
• MSE for psychogenic causes

Question 4

Erectile dysfunction - Investigations

Answer 4

Investigations

• Bloods: CVD work-up: FBC, UEC, LFT, lipid panel, fasting BSL, HbA1C
• hormones: free test, TSH, FSH/LH, prolactin
• nil imaging indicated

Question 5

Erectile dysfunction - Management

Answer 5

Management
depends on underlying aetiology, patient and partner preferences, etc
- may require referral to urology for definitive management input.

Supportive

• Treat reversible causes (SNAP optimisation, underlying co-morbidities, CVD risk factors, reduce obesity)
• Medications review
• Sexual health counselling, address other psychosocial issues within relationship with appropriate referral to counselling etc. Stress reduction

Definitive:
- Phosphodiesterase inhibitors are first line (viagra - sildenafil, tadalafil). First take as needed, then daily, and refer to urology
o Recent MI or on GTN are contraindications to this medication

Other management options:

• Intracavernosal PDEi injections +/- combination medications
• Vacuum erection device
• Penile implants