• Clinical science

Erection and ejaculation disorders

Abstract

Erectile dysfunction is the most common presentation of sexual dysfunction in males and is characterized by an inability to maintain an adequate erection for sexual intercourse that lasts at least 6 months. The causes may be psychological, vascular, neurological, or hormonal. Diagnosis is made based on a detailed medical history and physical exam, relevant blood tests (e.g., testosterone, sexual hormone-binding globulin), and objective measurement of the remaining erectile function (nocturnal penile tumescence testing). Treatment includes counseling and, in cases with an organic cause, potentially mechanical vacuum pump therapy, medical therapy with phosphodiesterase-5 inhibitors, or surgery (penile prosthesis implant).

Premature ejaculation is characterized by an inability to delay ejaculation during vaginal penetration and is often accompanied by significant psychological distress. Proposed etiologies include penile hypersensitivity and psychological disorders such as depression and anxiety. The diagnosis is made with a medical history of short intravaginal ejaculation latency time, inability to delay or control ejaculation, and psychological strain. Treatment consists of SSRIs and local topical anesthetics with sex therapy and other psychotherapy as needed.

Physiological erection

References:[1][2]

Erectile disorder

Definition

Epidemiology

  • Most common sexual disorder in men

Etiology

Diagnosis

  • Largely a clinical diagnosis
  • Detailed patient history and clinical exam
Diagnostic criteria (according to DSM V)
A
  • ≥ 1 of the following occur during ≥ 75% of all sexual encounters:
B
  • Lasts at least 6 months
C
  • Causes clinically significant distress in the individual
D
  • Not due to another mental disorder, severe relationship distress, substance abuse, or an organic disorder
  • Further tests to exclude organic disorders:
    • Endocrinological laboratory analysis; : testosterone; , SHBG , prolactin; , LH; , FSH; , TSH, ↑ fasting glucose or hemoglobin A1C; , abnormal lipid profile
    • Nocturnal penile tumescence measurement (phallography): measurement of spontaneous nightly erections in erectile dysfunction (primarily performed in a sleep laboratory) to differentiate between organic from psychogenic erectile dysfunction.
      • Lack of nocturnal erections suggests an organic etiology (neurogenic or vascular)
      • Normal testing suggests a psychogenic etiology
    • Duplex Doppler ultrasound or arteriography to identify suspected arterial inflow or venous leaks after injection of vasodilatory agent

Treatment

  • Important to identify the underlying etiology to manage lifestyle risk factors and initiate appropriate therapy
  • Psychotherapy
  • Medical therapy
  • Mechanical
    • Vacuum pump; (hollow cylinder that is placed onto the penis) with penis ring (outflow obstruction of the existing erection) is also considered a second-line therapy if PDE-5 inhibitors are ineffective.
    • Often recommended before intracavernous injections as vacuum devices are noninvasive
  • Surgical

References:[1][3][4][2][5][6]

Premature ejaculation

  • Epidemiology
  • Etiology: largely unknown, but the following factors have been proposed:
    • Psychogenic factors: depression/anxiety, relationship problems, irregular sexual intercourse
    • Organic factors: penile hypersensitivity, hyperexcitability of the reflex arc
Diagnostic criteria (according to DSM V)
A
  • Persistent or recurrent ejaculation that occurs within ∼ 1 minute of vaginal penetration and before the patient wishes to ejaculate
B
  • Occur during ≥ 75% of all sexual encounters and is present for at least 6 months
C
  • Causes clinically significant distress in the individual
D
  • Not due to another mental disorder, severe relationship distress, substance abuse, or an organic disorder
  • Treatment
    • The indication primarily depends on the psychological strain on the affected individual.
    • Psychotherapy/behavioral therapy
    • Medical therapy

References:[7][4]

Delayed ejaculation

  • Epidemiology: Incidence increases with age ≥ 50 years.
  • Etiology: psychological stress (e.g., childhood abuse, sexual trauma)
  • Diagnosis
    • Exclude any underlying organic disorder (e.g., traumatic or iatrogenic Injury to any structures involved in the ejaculation process; medication-induced ejaculation disorder)
    • Exclude severe relationship stress
Diagnostic criteria of delayed ejaculation (DSM V)
A
  • ≥ 1 of the following occur during ≥ 75% of all sexual encounters:
B
  • Present for at least 6 months
C
  • Causes clinically significant distress in the individual
D
  • Not due to another mental disorder, severe relationship stress, substance abuse, or an organic disorder

References:[1][4][8]