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Erection and ejaculation disorders

Last updated: August 2, 2021

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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 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 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.

See “Male sexual response” in “Male reproductive organs” for physiological erection.

Definition

Epidemiology

  • Most common sexual disorder in men

Etiology

Diagnosis [2]

Diagnostic criteria (according to DSM V)
A
  • ≥ 1 of the following occur during ≥ 75% of all sexual encounters:
B
  • Lasts for a minimum of ∼ 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

It is important to identify the underlying etiology to manage lifestyle risk factors and initiate appropriate therapy.

Diagnostic criteria (according to DSM V)
A
  • Persistent or recurrent ejaculation that occurs within ∼ 1 minute of 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
  • Epidemiology: Incidence increases with age ≥ 50 years. [5]
  • Etiology: psychological stress (e.g., childhood abuse, sexual trauma)
  • Diagnosis [2]
    • 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
  • Definition: fibroproliferative disorder that affects the tunica albuginea of the penis, causing abnormal curvature of the penis
  • Pathogenesis: repeated penile microtrauma during sexual intercourse or athletic activity followed by abnormal wound healing → fibrous plaque formation [6]
  • Classification
    • Active phase
      • Acute or inflammatory phase
      • Characterized by progressive penile deformity and painful erection
    • Stable phase
      • Chronic phase
      • Characterized by the absence or lack of progression of penile deformity and pain
  • Clinical features
    • Penile pain
    • Penile nodules/indurations on the affected side of the penis
    • Erectile dysfunction due to abnormal curvature of the penis
    • Possibly associated with psychological conditions; (e.g., anxiety, depression) [7]
  • Differential diagnosis
  • Treatment
    • Active phase: oral NSAIDs or oral pentoxifylline for 3 months
      • No symptomatic improvement: intralesional collagenase injections
      • Symptomatic improvement: observation or continuation of oral pentoxifylline for another 6 months
    • Stable phase
      • Observation: patients with a mild penile curvature (< 30°) and no erectile dysfunction
      • Intralesional collagenase injections: patients with penile curvature (> 30°) and erectile dysfunction
      • Surgical repair: patients unresponsive to treatment, with severe penile deformity, and/or with extensive calcifications

  1. T F Lue. Peyronie's disease: an anatomically-based hypothesis and beyond. Int J Impot Res. 2002; 14 (5): p.411-413. doi: 10.1038/sj.ijir.3900876 . | Open in Read by QxMD
  2. Terrier JE, Nelson CJ. Psychological aspects of Peyronie's disease.. Translational andrology and urology. 2016; 5 (3): p.290-5. doi: 10.21037/tau.2016.05.14 . | Open in Read by QxMD
  3. Di Sante S, Mollaioli D, Gravina GL, et al. Epidemiology of delayed ejaculation.. Translational andrology and urology. 2016; 5 (4): p.541-8. doi: 10.21037/tau.2016.05.10 . | Open in Read by QxMD
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). undefined. 2013 . doi: 10.1176/appi.books.9780890425596 . | Open in Read by QxMD
  5. Crowdis M, Nazir S. Premature Ejaculation. StatPearls. 2020 .
  6. Elhanbly S, Elkholy A, Elbayomy Y, Elsaid M, Abdel-gaber S. Nocturnal penile erections: the diagnostic value of tumescence and rigidity activity units. Int J Impot Res. 2009; 21 (6): p.376-381. doi: 10.1038/ijir.2009.49 . | Open in Read by QxMD
  7. Carson C, Gunn K. Premature ejaculation: definition and prevalence.. Int J Impot Res. undefined; 18 Suppl 1 : p.S5-13. doi: 10.1038/sj.ijir.3901507 . | Open in Read by QxMD