Erectile dysfunction

Medicine > Cardiovascular

Differential Diagnosis Schema 🧠

Vascular Causes

Atherosclerosis: Most common cause of erectile dysfunction (ED) in older men, due to reduced arterial blood flow to the penis
Hypertension: Long-standing high blood pressure can lead to vascular damage and ED
Diabetes mellitus: Contributes to both vascular and neuropathic components of ED
Peripheral vascular disease: Associated with generalized vascular insufficiency affecting penile blood flow
Smoking: Major risk factor for atherosclerosis and vascular ED
Hyperlipidemia: High cholesterol levels contribute to plaque formation in arteries, reducing blood flow

Neurological Causes

Diabetic neuropathy: Nerve damage due to long-standing diabetes affects penile innervation
Multiple sclerosis: Demyelination in the central nervous system can affect sexual function
Spinal cord injury: Damage to the spinal cord can disrupt the neural pathways involved in erection
Stroke: Depending on the area affected, stroke can impair erectile function
Parkinson’s disease: Neurodegenerative changes can lead to ED as part of autonomic dysfunction
Pelvic surgery: Procedures like prostatectomy can damage nerves and blood vessels supplying the penis

Endocrine Causes

Hypogonadism: Low testosterone levels can lead to reduced libido and erectile dysfunction
Hyperprolactinemia: Elevated prolactin levels can suppress testosterone and cause ED
Thyroid disorders: Both hyperthyroidism and hypothyroidism can contribute to ED
Cushing’s syndrome: Chronic exposure to high cortisol levels can lead to ED
Diabetes mellitus: Also a major endocrine cause of ED due to its vascular and neuropathic effects

Psychological Causes

Depression: A common cause of reduced libido and erectile dysfunction
Anxiety: Performance anxiety and generalized anxiety disorder can contribute to ED
Stress: Chronic stress can interfere with sexual function
Relationship issues: Interpersonal conflict or lack of sexual intimacy can lead to psychogenic ED
Sexual trauma: Past experiences of sexual trauma can lead to difficulty achieving or maintaining an erection
Psychiatric disorders: Schizophrenia and other major mental illnesses can impair sexual function

Key Points in History 🥼

Symptom Characteristics

Onset and duration: Sudden onset may suggest psychogenic causes, while gradual onset suggests organic causes
Consistency of ED: Persistent ED is more likely to be organic, while intermittent ED may suggest psychogenic factors
Morning erections: Presence suggests psychogenic causes, while absence may indicate organic causes
Erection during masturbation: Intact function during masturbation but not with a partner may suggest a psychogenic cause
Associated symptoms: Libido changes, ejaculatory function, and other systemic symptoms (e.g., fatigue, weight changes)
Impact on quality of life: Assess the psychological and social impact of ED on the patient

Background

Past medical history: Diabetes, hypertension, cardiovascular disease, and neurological disorders
Medication history: Use of antihypertensives, antidepressants, antipsychotics, and recreational drugs
Family history: Consider familial predisposition to vascular or endocrine disorders
Social history: Smoking, alcohol use, and level of physical activity, which can affect vascular health
Sexual history: Details of sexual orientation, practices, and any relationship issues
Psychosocial factors: Assess for stress, anxiety, depression, and relationship dynamics
Surgical history: Particularly urological or pelvic surgeries

Possible Investigations 🌡️

Laboratory Tests

Serum testosterone: To assess for hypogonadism
Lipid profile: To evaluate for hyperlipidemia, a risk factor for vascular ED
Fasting glucose/HbA1c: To assess for diabetes or poor glycemic control
Thyroid function tests: To rule out thyroid disorders contributing to ED
Prolactin levels: To assess for hyperprolactinemia if hypogonadism is suspected
Liver function tests: Particularly if there is a history of alcohol use or suspected liver disease
Renal function tests: To assess for chronic kidney disease contributing to ED
PSA (Prostate-Specific Antigen): In older men or those with symptoms suggestive of prostatic disease

Imaging and Specialist Tests

Penile Doppler ultrasound: To assess penile blood flow and identify vascular causes of ED
Nocturnal penile tumescence testing: To differentiate between psychogenic and organic causes of ED
Neurophysiological testing: If a neurological cause is suspected, such as in diabetic neuropathy or after pelvic surgery
Dynamic infusion cavernosometry and cavernosography (DICC): Specialized tests to assess venous leak in severe cases
MRI of the pelvis: Consider if there is suspicion of neurogenic causes, particularly after trauma or surgery
Psychological assessment: Referral to a psychologist or psychiatrist if psychogenic ED is suspected

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