Definition and Diagnosis
Erectile dysfunction is the persistent or recurrent inability to attain or maintain a penile erection sufficient for satisfactory sexual performance, causing significant distress or interpersonal difficulty, for a minimum duration of approximately six months.
Epidemiology
Prevalence increases steadily with age, affecting a small minority of men in their twenties and thirties but rising to affect a majority of men over 70. Milder degrees of erectile difficulty are even more common, and the condition is frequently under-reported due to embarrassment.
Risk Factors
Risk factors include cardiovascular disease, diabetes mellitus, obesity, smoking, sedentary lifestyle, and certain medications such as antihypertensives and antidepressants. Psychological contributors include performance anxiety, relationship difficulties, depression, and chronic stress.
Symptoms and Subtypes
The core feature is consistent difficulty achieving or sustaining an erection adequate for penetration, sometimes accompanied by reduced sexual desire or difficulty with ejaculation. Onset can be gradual, suggesting an organic cause, or sudden and situational, suggesting a psychological contributor.
Diagnosis
Evaluation includes a detailed sexual and medical history, assessment of cardiovascular and endocrine risk factors, and screening for depression or relationship distress. Laboratory tests such as testosterone, glucose, and lipid panels help identify contributing medical conditions, and validated tools like the International Index of Erectile Function are often used.
Treatment
First-line treatment is typically an oral phosphodiesterase-5 inhibitor such as sildenafil or tadalafil, alongside management of underlying cardiovascular or metabolic risk factors. Second-line options include vacuum erection devices, intracavernosal injections, and psychosexual therapy, with penile prosthesis reserved for refractory cases.
Prognosis
Outcomes are generally favorable, particularly when an underlying medical cause is identified and treated, or when psychological factors are addressed through therapy. Because erectile dysfunction can be an early marker of cardiovascular disease, evaluation of overall vascular health is an important part of management.
Reference
Sadock, B. J., Sadock, V. A., & Ruiz, P. Kaplan & Sadock's Synopsis of Psychiatry (11th ed.); American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.).