Overview
Erectile dysfunction (ED) is the persistent inability to achieve or maintain an erection sufficient for sexual activity. It is common, and importantly is often an early marker of cardiovascular disease.
Causes
- Organic (the majority):
- Vascular — atherosclerosis, diabetes, hypertension, smoking (the commonest)
- Neurogenic — diabetes, spinal cord disease, pelvic surgery
- Endocrine — hypogonadism, hyperprolactinaemia
- Drugs — beta-blockers, thiazides, SSRIs, antipsychotics
- Psychogenic — anxiety, depression, relationship factors
Assessment
- History distinguishing organic (gradual, persistent, loss of nocturnal erections) from psychogenic (sudden, situational, preserved nocturnal erections)
- Examine for signs of vascular disease and hypogonadism
- Investigations: fasting glucose/HbA1c and lipids (cardiovascular risk), morning testosterone (and prolactin if low)
Management
- Treat the cause and modify risk factors; review culprit drugs
- PDE5 inhibitors (e.g. sildenafil) are first-line — contraindicated with nitrates (risk of profound hypotension)
- Address cardiovascular risk; treat hypogonadism if confirmed
- Psychosexual therapy for psychogenic ED
MRCP-specific traps
- Never co-prescribe a PDE5 inhibitor with nitrates — a dangerous, exam-favourite interaction.
- New ED warrants cardiovascular risk assessment — it can precede ischaemic heart disease.
- Preserved nocturnal erections point away from an organic cause.
Summary
ED is usually organic (vascular/diabetic) and a marker of cardiovascular disease; a psychogenic pattern is sudden, situational and spares nocturnal erections. Assess cardiovascular risk and testosterone; treat with PDE5 inhibitors — never alongside nitrates.
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