Summary

Erectile Dysfunction (ED) is the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance. ED can be psychogenic (Sudden onset, Situational, Morning erections preserved) or organic (Gradual onset, Progressive, Vascular, Neurogenic, Hormonal, Drug-induced). The most common cause is vascular disease, making ED a "Canary in the Coalmine" – It often precedes symptomatic coronary artery disease by 3-5 years (Penile arteries are smaller than coronary arteries and affected earlier). Assessment includes cardiovascular risk evaluation, hormonal screening (Testosterone), and psychological assessment. Management involves lifestyle modification (Smoking cessation, Weight loss, Exercise), treatment of underlying conditions, and PDE-5 Inhibitors (Sildenafil, Tadalafil) as first-line pharmacotherapy. PDE-5 Inhibitors are contraindicated with Nitrates (Risk of severe hypotension).

Key Facts

• Definition: Inability to achieve/maintain erection sufficient for sex.
• Prevalence: ~40% of men aged 40; ~70% aged 70.
• Psychogenic vs Organic: Sudden vs Gradual onset. Morning erections present vs absent.
• "Canary in the Coalmine": ED predates MI/Stroke by 3-5 years.
• First-Line Treatment: PDE-5 Inhibitors (Sildenafil, Tadalafil).
• Contraindication: Nitrates + PDE-5 Inhibitors = Severe Hypotension.

Clinical Pearls

"ED Before MI": Erectile dysfunction is often the first sign of systemic vascular disease. Consider CV risk assessment.

"Morning Erections = Psychogenic": If morning/nocturnal erections are preserved, the cause is likely psychogenic.

"Nitrates + Sildenafil = Hypotension": NEVER co-prescribe. 24-48 hour washout required.

"Check Testosterone in ED": Low testosterone is common and treatable.

Why This Matters Clinically

ED is extremely common and often under-reported. It is an important marker for cardiovascular disease and significantly impacts quality of life.

Psychogenic ED

Organic ED

Causes of Organic ED

History

Examination

ED as a Cardiovascular Marker

• ED often precedes coronary artery disease by 3-5 years.
• Artery size hypothesis: Penile arteries (1-2mm) affected before coronary arteries (3-4mm).

CV Risk Stratification (Princeton Consensus)

Key Guidelines

Scenario 1:

• Stem: A 55-year-old diabetic man presents with gradual onset ED and absent morning erections. What is the likely cause and first-line treatment?
• Answer: Organic ED (Likely vascular/neurogenic from Diabetes). First-line: PDE-5 Inhibitor (e.g., Sildenafil or Tadalafil).

Scenario 2:

• Stem: A man on Sildenafil for ED develops chest pain. Why is GTN contraindicated?
• Answer: PDE-5 Inhibitors + Nitrates = Severe Hypotension. Risk of CV collapse.

Scenario 3:

• Stem: What screening should be done in a 50-year-old presenting with new ED?
• Answer: Cardiovascular risk assessment (QRISK, Lipids, Glucose, BP) and Testosterone level.

What is Erectile Dysfunction?

ED is when a man cannot get or keep an erection firm enough for sex. It is very common and becomes more frequent with age.

What causes it?

• Physical causes: Poor blood flow (Diabetes, Heart disease, Smoking), Nerve damage, Hormone problems.
• Psychological causes: Stress, Anxiety, Depression, Relationship issues.

How is it treated?

• Lifestyle changes: Stop smoking, Lose weight, Exercise.
• Tablets: Sildenafil (Viagra), Tadalafil (Cialis) – Increase blood flow.
• Other treatments: Injections, Vacuum devices, Implants (Rare).

Key Counselling Points

1. It's Common: "ED is very common – you are not alone."
2. Check Your Heart: "ED can be an early sign of heart disease – Get your heart checked."
3. Don't Take with Nitrates: "If you take GTN spray for angina, you MUST NOT take Sildenafil."