Erectile Dysfunction

Differential Diagnosis

Excessive Alcohol Intake
Relationship Dysfunction
Vascular: Arterial Insufficiency (Arteriopathy) or Excessive Venous Drainage
Iatrogenic (e.g. Prostatic Cancer Treatments, Hypotensives, some Antidepressants)
Anxiety
Depression

Key distinguishing features of the most common diagnoses

	Depression/ Anxiety	Alcohol	Relationship Dysfunction	Vascular	Drugs
TATT/sleep Problem	Yes	Possible	Possible	No	No
Occasional Only	Possible	No	Yes	No	No
Full Morning Erection	Yes	No	Yes	No	No
Reduced Foot Pulses	No	No	No	Yes	No
Taking Medication	Possible	No	No	No	Yes

Likely:Urinalysis.

Possible:Blood sugar or HbA1c, FBC, LFT, endocrine assays (testosterone, prolactin, FSH/ LH, TSH), cholesterol, PSA.

Small Print:Doppler flow studies, angiography, intracorporeal prostaglandin injection test, MRI scanning – all likely to be specialist initiated.

Urinalysis: An essential easy screen for undiagnosed diabetes.
Blood sugar or HbA1c: To confirm diabetes.
FBC and LFT possibly helpful in alcohol excess (raised MCV and possible LFT abnormalities).
Testosterone levels reduced in primary or secondary hypogonadism. Prolactin, FSH/LH and TSH check pituitary function. Erectile dysfunction may be a sign of cardiovascular disease – so in certain patients a cholesterol level would be warranted.
The link between prostate cancer and erectile dysfunction is far from clear. Some guidelines recommend PSA in this situation to assess for possible prostate cancer; judge each case on its merits and according to other symptoms and the man’s wishes.
Doppler flow studies of superficial and deep penile arterial flow assess arterial sufficiency. Angiography may be necessary if symptoms suggest significant lower limb arterial insufficiency associated with impotence.
Intracorporeal prostaglandin injection test: Immediate and prolonged response indicates neurological problems. Good initial response with rapid failure indicates excessive venous drainage.
Possible neurological causes will occasionally require further investigation (e.g. MRI scanning for cord lesions or MS).

Establish whether the patient can get an erection at any time (e.g. early morning). If he can, then the cause is unlikely to be organic. Take a positive approach – many psychological causes are transient.
Don’t be too quick to diagnose anxiety as the underlying problem. This may be the effect, rather than the cause, of the impotence.
Erectile dysfunction is often presented as a ‘by the way’ or ‘while I’m here’ symptom. The temptation is to invite the patient to book a further appointment, but bear in mind that this may represent a lost opportunity to help, as he may not return.
Demonstrate that you are taking the problem seriously – for example, by performing an appropriate examination or by inviting the patient’s partner to attend a subsequent appointment.

Sudden onset of erectile dysfunction with saddle anaesthesia and sphincter disturbance indicates a cauda equina lesion. Refer urgently.
An erection which is consistently lost after a predictable period is likely to be organic – probably vascular – in origin.
Do not forget that alcohol and drug abuse are possible causes. Look in the notes for clues and make specific enquiry, as these problems are unlikely to be volunteered.
Erectile dysfunction may well be a marker for vascular disease elsewhere. Extend your assessment as appropriate.