Erectile dysfunction

What is it?

Erectile dysfunction (ED) is the persistent inability to achieve or maintain an erection sufficient to allow satisfactory sexual activity.

It is very common and its prevalence increases with age, but it should not be considered simply a normal consequence of aging.

How does an erection occur?

Erection requires adequate interaction between:

• sexual stimulation and the nervous system;
• release of nitric oxide;
• relaxation of the cavernous smooth muscle;
• increased arterial flow to the corpora cavernosa;
• veno-occlusive mechanism that keeps blood within the penis.

For this reason, a vascular, neurological, hormonal, anatomical, or psychological disorder can affect erectile function.

Main associated factors

• age;
• diabetes;
• hypertension;
• obesity;
• dyslipidemia;
• smoking;
• cardiovascular disease;
• neurological diseases;
• certain medications;
• pelvic surgery or radiotherapy;
• hypogonadism;
• psychological and relationship factors.

How is it evaluated?

The initial evaluation is based mainly on:

• medical and sexual history;
• medical background;
• medications;
• physical examination;
• assessment of cardiovascular and metabolic factors;
• selected laboratory tests.

The IIEF-5 questionnaire can be used to assess erectile function and quantify its severity.

Treatment

Modifiable factors should be identified and treated first.

PDE5 inhibitors are usually the initial pharmacological treatment:

• sildenafil;
• tadalafil;
• vardenafil;
• avanafil.

If there is no response or they are contraindicated, the following may be considered:

• vacuum devices;
• intracavernosal treatments;
• penile prostheses.

A concept that goes beyond sexuality

Erectile dysfunction shares many risk factors with cardiovascular disease and can be an opportunity to detect undiagnosed vascular and metabolic factors.