Red Flag Symptoms - Erectile dysfunction

Dr Tillmann Jacobi examines the myriad possible causes for erectile dysfunction.

Prostate surgery can cause ED (Photograph: SPL)
Prostate surgery can cause ED (Photograph: SPL)

Erectile dysfunction (ED) is when an erection is either entirely absent or does not last to enable sexual intercourse. About 50 per cent or more of all men in western societies between 40 and 70 years experience a degree of ED, but it may also occur in younger patients. The physical and emotional impact varies between individuals depending on their social situation and other factors.

Research over recent years has shown that 80 per cent of presentations of ED have an organic component. This finding is important because other symptoms of causative systemic conditions may not be obvious at that point. Signs indicating organic ED include a gradual onset with deterioration and absence of night-time or early morning erections.

Possible Causes
  • Atherosclerosis
  • Diabetes
  • Hypertension
  • Depression
  • Trauma
  • Hypogonadism
  • Drug side-effects
  • Sickle cell disease
  • Prostate cancer

The possible medical causes for ED are vast and include neurological (for example, epilepsy, multiple sclerosis, Parkinson's disease); metabolic (alcoholism, uraemia); urological (prostate cancer); hormonal (abnormal testosterone and cortisol levels, diabetes, thyroid problems); and cardiovascular (hypertension, systemic atherosclerotic disease, peripheral vascular disease, hyperlipidaemia) conditions.

Other causes include trauma (prostate surgery, mechanical trauma), or side-effects of medications, such as antihypertensives and psychotropic medication. Recreational drug use may also be a cause.

Some patients with sickle cell disease have a history of priapism due to the vascular damage through the affected blood cells, which can eventually lead to structural ED.

Primary ED (absence of any conscious erections) is rare and may be due to anatomical problems or psychological reasons, like conflicts regarding sexual identity or sexual preferences. Suspected primary ED warrants a direct specialist referral.

Evaluation of the patient includes taking a history of drug and alcohol use and smoking as well as a review of current medications including OTC medicines. Consider (psycho-) sexual dysfunction in the patient or their partner (atrophic vaginitis, depression) and explore previous and current sexual relationships.

Use a questionnaire, such as the 'international index for erectile function'. Complete a full cardiovascular risk assessment. Examine the genitalia for signs of hypogonadism or Peyronie's disease. Look for signs of gynaecomastia and check the prostrate gland for abnormalities.

Add a neurological examination guided by any other symptoms. Blood tests that may be required include FBC, renal and liver function, lipids and cholesterol, fasting sugar, thyroid function, testosterone levels and PSA.

Keep a low threshold regarding a specialist opinion; most patients present only when their ED has already been going on for some time. For every patient with established ED, consider screening for all possible underlying conditions.

  • Dr Jacobi is a salaried GP in York

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