Health Assessment
Erectile Dysfunction
Carnel C. Jackson, DNP, RN, FNP-BC
Case Study
Chief Complaint
“Difficulty obtaining an erection, and even when I do it doesn’t last long.”
Patient Profile
Name: Joseph Kennedy
Age: 56
Gender: male
History of Presenting Illness
J.K. is a 56-year-old man who presents with difficulty obtaining and maintaining an erection for the past few months.* He reports that the issue has been gradually worsening,* with erections that are insufficient for satisfactory sexual activity*. He denies morning erections and notes a decline in sexual desire.*
He denies penile pain, Peyronie's disease, or discharge. There are no symptoms of urinary frequency, urgency, hesitancy, or dysuria.* He reports some stress related to work but denies significant anxiety or depression.*
Medical History
Seasonal allergies, nicotine dependence, hypertension, hyperlipidemia, new onset type 2 diabetes mellitus
Medications
- Cetirizine: 10 mg by mouth daily
- Lisinopril: 10 mg by mouth daily
- Atorvastatin: 20 mg by mouth daily
- Olmesartan: 20 mg by mouth daily
- Metformin ER: 500 mg by mouth twice daily, initiated today
Social History
- Electrician
- Daily two-mile walks with his dog.
- Lives in a two-story home with his wife and dog.
- Alcohol use: two or three beers on the weekends.
- Tobacco smoke: 30 pack year history (1 pack per day).*
- Illicit drug use: prior cocaine use, no use in the last 1 year.*
Family History
- Mother: hypertension
- Father: prostate cancer diagnosed at 52 (alive), diabetes mellitus type 2
- Maternal grandmother: hypertension, diabetes mellitus type 2
- Maternal grandfather: hypertension
- Paternal grandfather: hyperlipidemia, hypertension, diabetes mellitus type 2
- Paternal grandmother: unknown
Review of Systems
- Constitutional: Denies chills, fever. Smells of tobacco smoke.
- HEENT: Denies postnasal drip, sore throat, hearing impairment, and blurred vision.
- Respiratory: Denies shortness of breath, cough, wheezing.
- Cardiovascular: Denies chest pain and pedal edema.
- Gastrointestinal: Denies abdominal pain, tenderness, nausea, and emesis. Denies constipation, diarrhea, hematochezia. Denies appetite changes and melena.
- Derm: Denies breaks in the skin, lesions, and rashes.
- GU: no lesions or rash, reported inability to maintain an erection, denies hematuria, dysuria*. Endorsed polyuria.*
- Neurological: Denies headaches, tremors, and dizziness.*
- Hematologic: Denies easy bruising.
Physical Assessment
Vital Signs
- Blood pressure: 146/80 mm Hg
- Heart rate: 76 bpm
- Respiratory rate: 16 bpm
- Temperature: 97.6℉
- Oxygen saturation: 99% on room air
General Survey
- General appearance: Alert, oriented, slender male.
- HEENT: Moist mucous membranes, PERRLA, thyroid exam normal.
- Cardiovascular: Normal rhythm without murmurs, normal s1 and s2. Diminished pedal pulses bilaterally.
- Respirations: Clear to auscultation bilaterally.
- Abdomen: Active bowel sounds x4, nontender to palpation, nondistended.
- Derm: Without abrasion or ulceration, without rash, hyperpigmentation around the lower legs.* Normal body hair distribution, no hair on lower legs.
- Neurological: No focal deficits, no signs of confusion or cognitive impairment. Positive monofilament test of the bilateral lower extremities.* Bilateral lower extremity stasis dermatitis.*
- Musculoskeletal: 5/5 strength in all extremities. Muscle mass appears normal for patient’s age and height.
Diagnostic Testing
- Hemoglobin A1C 11.2, abnormal*
- Urine microalbumin 179, abnormal*
Assessment
Most likely diagnosis: Penile venous insufficiency secondary to diabetes mellitus and/or hypertension.
Treatment Plan
- Treat or manage overarching cause
- Lifestyle changes
- Consider urology or vascular surgery referral
- Phosphodiesterase type 5 (PDE5) inhibitors
- Penile dorsal vein ligation
Review Questions
Click the arrow to expand the section and view the correct answers.
- What is the most common type of ejaculatory disorder?
- Erectile dysfunction
- Decreased libido
- Premature ejaculation
- Anejaculation
Answer:
C) Premature ejaculation. Feedback: Premature ejaculation is the most common male ejaculatory disorder that affects up to 30% of males. The second most common is erectile dysfunction, which affects 18% of men ages 50 to 59 years and 37% of men ages 70 to 75.
- When interviewing this patient, he asks what the risk factors for erectile dysfunction are. Which of the following are risk factors for erectile dysfunction? Select all that apply?
- Vascular disease
- Prolonged bicycle riding
- Trauma
- Chronic atopic dermatitis
- Alcoholism
Answer:
A) Vascular disease, prolonged bicycle riding, trauma, alcoholism. Feedback: Some of the risk factors of erectile dysfunction include diabetes mellitus type 2, smoking history, prolonged bicycle riding, hypertension, venous insufficiency, direct trauma, depression, anxiety, recreational drug use and medication side effects. This list is not all inclusive.
- When interviewing this patient, you ask about social risk factors that may exacerbate his symptoms. Which social factor is likely the greatest cause of his erectile dysfunction?
- Tobacco smoke
- Physical activity
- Alcohol consumption
- Work-related exposure
Answer:
A) Tobacco smoke. Feedback: Smoking damages blood vessels, reducing blood flow to the penis. Quitting smoking improves circulation and can significantly help with erectile function.
- Which of the following questions may assist the clinician in differing between psychological and pathologic causes of erectile dysfunction?
- Are you currently taking any medications that could affect erectile function?
- When did you first notice symptoms of erectile dysfunction?
- How often are you able to achieve and maintain an erection during sexual activity?
- Do you experience morning erections?
Answer:
D) Do you experience morning erections?. Feedback: The presence of erections in the morning suggests that the cause of erectile dysfunction may be psychological rather than physical. The absence of them may be a sign of vascular or neurological etiology.
- You are completing the physical exam on this young man and notice that his femoral and pedal pulses are thready (+1). This finding suggests which cause of erectile dysfunction?
- Depression and/or anxiety
- Vascular disease
- Impotence
- Relationship concerns
Answer:
B) Vascular disease. Feedback: The absence of thready femoral and pedal pulses suggests vascular insufficiency, which may cause penile venous sufficiency.
- Erectile dysfunction in diabetic men is frequently associated with which other microvascular or macrovascular complications? Select all that apply:
- Diabetic neuropathy
- Diabetic retinopathy
- Chronic kidney disease
- Hyperthyroidism
Answer:
A), B), C) Diabetic neuropathy, diabetic retinopathy, and chronic kidney disease. Feedback: ED often coexists with other microvascular complications (neuropathy, retinopathy, nephropathy).
Clinical Pearls
* All areas with asterisks are highlighted for a patient with this chief complaint.
Erectile dysfunction and diabetes mellitus type 2
- 30% to 70% of men with diabetes experience some form of erectile dysfunction
- ED is common and treatable
- Lifestyle modifications can improve glycemic control and manage symptoms of erectile dysfunction
Causes:
- Endothelial dysfunction: decreased blood flow
- Peripheral and autonomic neuropathy
- Hormonal
- Psychogenic
Questions to ask:
- Onset, duration, severity, libido, new medications, hematuria, depression? Stress?
Physical exam:
- Pubic hair distribution, penile plaques, peripheral neuropathy, ankle-brachial index
Diagnostics:
- Testosterone, hemoglobin A1C, cholesterol panel, renal function, prostate-specific antigen, urinalysis
References
Raymond, C., & Martin, K. A. (2024). Epidemiology and etiologies of male sexual dysfunction. In K. A. Martin (Ed.), UpToDate. UpToDate. https://www.uptodate.com/contents/epidemiology-and-etiologies-of-male-sexual-dysfunction
scar tissue forms within the penis that causes a curvature and pain during erections
