Male Sexual Dysfunction-Erectile Dysfunction

🧔🏽‍♂️ Male Sexual Dysfunction & Erectile Dysfunction (ED)

NP Student Educational Guide

✅ Overview

Male sexual dysfunction refers to problems that interfere with normal sexual activity, including:

1. Erectile dysfunction (ED)

2. Low libido (decreased sexual desire)

3. Ejaculatory disorders (e.g., premature or delayed ejaculation)

4. Orgasmic disorders

The most common type seen in primary care is ED.

🔹 What is Erectile Dysfunction (ED)?

Definition:

The persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance.

• Affects ~30 million men in the U.S.

• Prevalence increases with age, but it's not a normal part of aging.

• Often a symptom of underlying disease.

🧠 Pathophysiology of Erection

Erection involves vascular, neurologic, hormonal, and psychologic systems:

1. Sexual stimulation → triggers nitric oxide release

2. → Smooth muscle relaxation in penile arteries

3. → Increased blood flow into corpus cavernosum

4. → Venous outflow restricted → erection maintained

ED occurs when any part of this system is disrupted.

🧪 Causes of ED (Think "VANISH")

🔍 History & Assessment

🔹 Focused Sexual History

Use the "SAMPLE" approach:

• Sexual activity: partner, orientation, frequency

• Arousal issues: onset (sudden vs gradual)

• Medications: antidepressants, beta-blockers, etc.

• Psych factors: stress, anxiety, depression

• Libido: interest in sex

• Ejaculation/orgasm issues

Ask about:

• Morning/nocturnal erections (suggests psychogenic if still present)

• Relationship issues

• Comorbidities: DM, CAD, obesity, smoking, alcohol use

🔹 Physical Exam

• Vitals: BP, BMI

• GU exam: penis, testicles, prostate (if indicated)

• Signs of hypogonadism: gynecomastia, small testes

• Pulses: femoral and pedal pulses (vascular health)

🔹 Screening Tools

• IIEF-5 (International Index of Erectile Function) – Quick ED questionnaire

🧪 Diagnostic Workup

• Fasting glucose or A1C – screen for diabetes

• Lipid panel – assess cardiovascular risk

• Total testosterone (AM level) – if low libido or suspected hypogonadism

• TSH – rule out thyroid dysfunction

• Prolactin – if low testosterone or concern for pituitary disease

• PSA – if considering testosterone therapy in men over 50

💊 Management of ED

✅ 1. Lifestyle Modifications (first-line for all patients)

• Weight loss, exercise

• Smoking cessation

• Limit alcohol and address drug use

• Manage hypertension, diabetes, and dyslipidemia

✅ 2. Oral Medications – PDE5 Inhibitors

• Sildenafil (Viagra) – short-acting

• Tadalafil (Cialis) – longer-acting, can be daily

• Contraindicated with nitrates (risk of severe hypotension)

• Must have sexual stimulation to be effective

✅ 3. Hormone Therapy

• If low testosterone → consider testosterone replacement therapy (TRT)

  • Avoid if: prostate/breast cancer, severe BPH, high Hct, uncontrolled CHF

✅ 4. Other Treatments

• Vacuum erection devices

• Penile injections (alprostadil)

• Intraurethral suppositories

• Penile prosthesis surgery (last resort)

🧠 Psychological & Relationship Support

• Many cases of ED have psychogenic components—consider:

  • Sex therapy

  • Couples counseling

  • Psychiatric referral for depression/anxiety

👩‍⚕ NP’s Role

• Normalize the discussion – ask about sexual health during routine visits

• Identify underlying causes and risk factors

• Initiate basic workup and management

• Counsel on lifestyle changes and medication options

• Know when to refer to urology, endocrinology, or mental health

📝 Clinical Pearl

A gradual onset of ED is often organic (vascular or metabolic), while sudden onset with preserved morning erections suggests a psychogenic cause.