Erectile Dysfunction: Causes and Risk Factors (2025)

Erectile Dysfunction

Organic and psychogenic causes of erectile dysfunction differ in their factors.
An organic cause is favored by gradual onset, lack of morning erection, and normal libido.
A psychogenic cause is favored by sudden onset, decreased libido, good quality spontaneous or self-stimulated erections, major life events, relationship problems, previous psychological problems, and a history of premature ejaculation.

Risk Factors for Erectile Dysfunction

Increasing age
Cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidemia, metabolic syndrome, hypertension, smoking.
Alcohol use
Drugs like SSRIs and beta-blockers

Investigations for Erectile Dysfunction

Lipid profile
Serum HbA1c or fasting blood glucose
Fasting serum free total testosterone (between 9-11 am).
If free testosterone is low or borderline, repeat with follicle-stimulating hormone, luteinizing hormone and prolactin levels.
Refer abnormal results to endocrinology for assessment.
Clinical Knowledge Summaries (CKS) recommend calculating all men's 10-year cardiovascular risk

Management of Erectile Dysfunction

Prescribe PDE-5 inhibitors like sildenafil ("Viagra") if there are no contraindications.
Contraindications include hereditary degenerative retinal disorders, history of non-arteritic anterior ischemic optic neuropathy, recent myocardial infarction or stroke, systolic blood pressure below 90 mmHg, recent unstable angina, and sickle-cell anemia.
Sildenafil should be avoided in patients prescribed nitrates or nicorandil, but can be purchased over-the-counter.
Vacuum erection devices are recommended as first-line treatment for those who can't/won't take a PDE-5 inhibitor.
People with erectile dysfunction who cycle for more than three hours per week should be advised to stop.

Priapism

A persistent penile erection lasting longer than 4 hours, not associated with sexual stimulation.
Can be ischemic or non-ischemic.

Causes of Priapism

Idiopathic
Sickle cell disease or other hemoglobinopathies
Erectile dysfunction medication (e.g., Sildenafil and other PDE-5 inhibitors), including intracavernosal injected therapies
Other drugs (antihypertensives, anticoagulants, antidepressants, etc.)
Recreational drugs (cocaine, cannabis, ecstasy)
Trauma

Presentation of Priapism

Persistent erection lasting over 4 hours
Pain localized to the penis
History of hemoglobinopathy or relevant medications
Rarely, non-painful or not fully rigid erection, suggesting non-ischemic priapism
History of genital or perineal trauma may suggest non-ischemic priapism

Investigations for Priapism

Cavernosal blood gas analysis differentiates between ischemic (low pO2 and pH, high pCO2) and non-ischemic.
Doppler or duplex ultrasonography assesses blood flow in the penis as an alternative to blood gas analysis.
A full blood count and toxicology screen can assess for underlying causes.
Diagnosis is largely clinical, with investigations categorizing ischemic vs. non-ischemic and assessing underlying cause

Management of Priapism

Ischemic priapism is a medical emergency.
Delayed treatment can lead to permanent tissue damage and long-term erectile dysfunction.
First-line treatment for priapism lasting over 4 hours is aspiration of blood from the cavernosa, combined with a saline flush
If aspiration and injection fails, intracavernosal injection of a vasoconstrictive agent like phenylephrine is used repeatedly at 5-minute intervals.
Surgical options are considered if medical therapy fails.
Non-ischemic priapism is not a medical emergency and is normally suitable for observation as a first-line option.

Ejaculation Problems

Ejaculation problems are common sexual problems in men
The 3 main types of ejaculation problems: premature ejaculation, delayed ejaculation and retrograde ejaculation.

Premature Ejaculation

It is a common ejaculation problem.
Occasional episodes are not a cause for concern, but if it's a problem, it might need treatment.

Physical Causes of Premature Ejaculation

Prostate problems
Thyroid problems (hypo or hyper)
Using recreational drugs

Psychological Causes of Premature Ejaculation

Depression
Stress
Relationship problems
Anxiety about sexual performance (particularly at the start of a new relationship, or when a man has had previous problems with sexual performance)
Possible causes include conditioning, traumatic sexual experiences, and strict beliefs about sex.

Treatment for Premature Ejaculation

Antidepressants (SSRIs; paroxetine, sertraline, fluoxetine) and clomipramine can delay ejaculation.
Improvement may occur after a few days, but full effects may take 1-2 weeks.
Dapoxetine (Priligy) is an SSRI specifically designed for premature ejaculation, licensed in the UK
It acts faster than other SSRIs and can be used "on demand", 1-3 hours before sex, but not more than once a day.
Patient response is reviewed after 4 weeks (or 6 doses), and then every 6 months.
Dapoxetine is not suitable for some men with heart, kidney and liver problems.
Common side effects: headaches, dizziness, feeling sick

Other Treatments for Premature Ejaculation

Phosphodiesterase-5 inhibitors may help
Topical anesthetics (lidocaine or prilocaine) and condoms can help but may cause decreased sensation, especially in the vagina
Psychosexual counseling can help explore relationship issues and use techniques to "unlearn" the habit of premature ejaculation, like the "squeeze" and "stop-go" techniques.
The squeeze technique involves stopping masturbation before ejaculating and squeeze the head of the penis for 10–20 seconds, and then repeating.
The stop-go technique is similar, but without squeezing the penis; stopping and starting during sex may be more confident.
Useful advice includes: masturbating an hour or 2 before sex, using a thick condom, and having the partner on top.

Delayed Ejaculation

(male orgasmic disorder) is classed as either: Experiencing a significant delay before ejaculation, Being unable to ejaculate at all, even though the man wants and his erection is normal.

Causes of Delayed Ejaculation

Possible psychological causes similar to those of premature ejaculation like relationship problems, stress or depression.
Physical causes include Diabetes, Spinal cord injuries, Multiple sclerosis, Surgery to the bladder or prostate gland, Increasing age.
Many medicines are known to cause delayed ejaculation, including Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), Medicines to treat high blood pressure, such as beta-blockers, Antipsychotics.

Treatment of Delayed Ejaculation

Sex therapy is a form of counseling that uses a combination of psychotherapy and structured changes in sex life: increase feeling of enjoyment and make ejaculation easier.
Switching medicine May be several medicines that can be used if it's thought SSRIs are responsible, These include: amantadine - originally designed to treat viral infections, bupropion - usually prescribed to help people quit smoking, yohimbine - originally designed to treat erectile dysfunction
These help block some of the chemical effects of SSRIs that may contribute towards delayed ejaculation.
Alcohol and drugs Alcohol misuse and recreational drug use can be separate underlying causes of delayed ejaculation, so addressing these problems may help.
Pseudoephedrine tablets may be tried, but these will need to be prescribed "off-label". This means the medicine shows promise in treating delayed ejaculation.
Midodrine Is significantly better than with pseudoephedrine and ephedrine, however, the prportion of patients with antegrade ejaculation after midodrine treatment remains low (18%). Midodrine is usually given in flexible doses, starting with 7.5 mg and 15 mg.

Retrograde Ejaculation

A rarer condition where semen travels backwards into the bladder instead of through the urethra.

Symptoms of Retrograde Ejaculation

Include producing no semen, or only a small amount, during ejaculation while men experience orgasm.
May include, producing cloudy urine (because of the semen in it) when you first go to the toilet after having sex

Causes of Retrograde Ejaculation

Include Prostate gland surgery, Bladder surgery, Diabetes, Multiple sclerosis,, Class of medicines known as alpha blockers

Treatment for Retrograde Ejaculation

Most men do not need treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life, and the condition does not have adverse effects on their health. But if treatment is required for medical reasons
For example, pseudoephedrine has proved effective in treating retrograde ejaculation caused by diabetes or surgery. If retrograde ejaculation is caused by using a certain medicine, then normal ejaculation will usually return once medicine is stopped.
If retrograde ejaculation has been caused by significant muscle or nerve damage, treatment may not be possible.
Men who want to have children can have sperm taken from their urine or testicles for use in intrauterine insemination or in-vitro fertilisation (IVF).

Haematospermia

The most common causes are: Iatrogenic for example following a recent urological procedure, Urogenital infection (the most common cause in men under 40 years of age), Sexually transmitted infections such as chlamydia, gonorrhoea and herpes simplex, Organisms associated with UTI such as Escherichia coli, Proteus mirabilis and Enterobacter.

Other causes for Haematospermia

Trauma for example, coital trauma or injury of the pelvis, perineum or genitals.
Malignant tumours of the prostate, bladder, urethra, testes/epididymis, or seminal vesicles.
Prostatic conditions acute/chronic prostatitis, BPH.
Testicular or epididymal conditions such as orchitis or epididymitis.
Seminal vesicle/ejaculatory duct conditions such as cysts or calculi, seminal vesiculitis, or ductal obstruction.Systemic disorders such as severe HTN, bleeding disorders, lymphoma, leukaemia, amyloidosis and severe liver disease. Medications such as anticoagulants.
Vascular malformations (rare).

Management of Haematospermia

If under 40 years old, and no cause identified: Reassure, Return if the problem recurs, Refer the person a genitourinary medicine (GUM) clinic if a STI is suspected
If a urinary tract infection is suspected, treat with antibiotics.
If acute or chronic prostatitis is suspected: treat with antibiotics.
See Also
Complicated contraception: Prescribing in women over 40 Page 4 | Underactive thyroid and pregnancy | Mumsnet
Men of any age with signs and symptoms suggestive of prostate cancer and Refer using a suspected cancer pathway referral (for an appointment within 2 weeks).
All men aged over 40 years with no identifiable cause found in primary care, Who have recurrent or persistent
Reassure the person that most causes of haematospermia have no effect on fertility, Reassure men who have had a recent prostate procedure that any associated haematospermia should resolve within three to four weeks.

Scrotal Swelling

Inguinal hernia: If inguinoscrotal swelling; cannot 'get above it' on examination, Cough impulse may be present, May be reducible, PPT factor: chronic cough – chronic constipation.
Testicular tumors: Risk factors include: infertility – cryptorchidism - family history - Klinefelter's syndrome - mumps orchitis, Often discrete painless testicular nodule (may have associated hydrocele), Commonly young male (20-30 years), Systemic symptoms or Symptoms of metastatic disease may be present, USS scrotum and serum AFP and HCG required
Acute epididymo-orchitis: Often history of dysuria and urethral discharge, Swelling may be tender and eased by elevating testis, Most cases due to Chlamydia, may be associated with underlying structural abnormality
Hydrocele: Painless, soft fluctuant swelling, Often possible to 'get above it' on examination, Usually contain clear fluid; Will often transilluminate, May be presenting feature of testicular cancer in young men, Management: infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years / in adults a conservative approach
Testicular Torsion: Severe, sudden onset testicular pain, Risk factors include abnormal testicular lie, Typically affects adolescents and young males, On examination testis is tender and pain not eased by elevation, Urgent surgery is indicated
Varicocele: Varicosities of the pampiniform plexus, classically described as a 'bag of worms', Typically occur on left (because testicular vein drains into renal vein, May be presenting feature of renal cell carcinoma

Uroflowmetry

Qmax = Maximum flow rate
Qave = Average flow rate
Vvoid = Voided volume
Bell shaped curve indicates Normal flow
Tall bell curve indicates Quick to reach Qmax and Short flow time
Plateau shape indicates Low Qmax, Long flow time and Fixed obstruction
Sawtooth shape indicates Interrupted flow

CKD & eGFR Calculation

Risk factors: diabetes, hypertension, previous episode of acute kidney injury, cardiovascular disease,structural renal tract disease, recurrent renal calculi or prostatic hypertrophy multisystem diseases with potential kidney involvement gout, family history of end-stage renal disease or hereditary kidney disease, incidental haematuria or proteinuria.
Diagnosis Abnormal U&E > 3 months; eGFR < 60 ml/min/1.73m2 or ACR ≥3 mg/mmol;
Avoid meat for 12 hours before the test, Blood sample should be processed within 12 hours.
Measured using CKD-EPI or Modification of Diet in Renal Disease (MDRD) equation, Variables uses includes; serum creatinine – age – gender – ethnicity)
Inaccurate if: (Factors which may affect the result) Abnormal muscle mass, Pregnancy, Age < 18 years, Age > 75 years, Obesity, Severe malnutrition.

Kidney Failure Kisk Equation

The number of times per year by filtration rate and albumin creatinine ratio can be given by, a 5-year risk of needing renal replacement therapy of greater than 5%
Accelerated progression of chronic kidney disease (CKD), defined as a sustained decrease in eGFR of: 25% or more within 12 months and a change in CKD category.
A urinary albumin: creatinine ratio (ACR) of: 70 mg/mmol or more, unless proteinuria is known to be associated with diabetes mellitus and is managed appropriately.
/= 30 mg/mmol or more together with persistent haematuria, after exclusion of a urinary tract infection (UTI).
Hypertension that remains uncontrolled despite the use of at least four antihypertensive drugs, A known or suspected rare or genetic cause of CKD, such as polycystic kidney disease Suspected renal artery stenosis.

CKD (Chronic Kidney Disease) Management

Chronic kidney disease managing proteinuria using diabetes in adults
The kidney failure risk equation is a well-validated risk prediction tool for a kidney therapy in the next two or five years

Acute Bacterial Prostatitis

Isolated pathogen is Escherichia coli
Obstructive voiding, Pain with Bogginess. Fever and Rigors maybe present
Management, Ciprofloxacin 500mg BD for 14 days, or if unsuitable than trimethoprim 200mg BD for 14days

Chronic Prostatitis

Suspect in men who present with symptoms for at least 3 months, that include Pain or discomfort
LUTS Voiding symptoms for example straining, hesitancy and weak stream, Storage symptoms as urinary urgency nocturia & Dyauria or Sexual dysfunction symptoms e.g erectile dysfunction Pain or discomfort during or after ejaculationPremature ejaculation & Decreased libido, Psychosocial symptoms examples are Anxiety or stress

LUTS or Lower Urinary Tract Symptoms (prostate)

voiding, weak intermittent flow, straining, dribbling incomplete emptying
Storage; urgency frequency incontinence nocturia. Post-micturition dribbling
In the assessment consider PSA

Benign Prstatic Hyperplasia (BPH) factors

Ethnicity black then white then Asian

Management for Prostate

watchful waiting if mild voiding symptoms (IPSS 8) with Alpha-1 antagonists: Decreases muscle tone of the prostate bladder
Alpha-1 antagonist adverse effect can be dizziness, hypertension an dry mouth5 Alpha reducatase inhibitors: - indicated patient is high progession- risk

Prostate (Cancer) factors

Increasing age and obesity

Prostate treatment methods

watchful waiting. alpha 1 antagonist (doxazosin). 5alpha-reductase inhibitors (finasteride)
Prostate specific antigen (PSA)
The traditional investigation for prostate cancer was a transrectal ultrasound guided (TRUS) biopsy. However, recent guidelines from NICE have now advocated the increasing use of multiparametric MRI as a first-line investigation; the results are reported using a 5-point Likert scale

Balanitis features:

Causative:Acute or chronic: Candiddiasis. Ussaly Occurs After InterCourse, With ItCH (Winnie - YTH). Dermatarous
Candidiasis: Usually occurs after intercourse and associated with itching and white non-urethral discharge
Dermatitis (Contact or allergic): Itchy- area: affected
Bacterial: Painful and a yellow urethral with the -sep
Anaerobic: May be itchy but is most associated with Yellow Urethral
Lichen Planus: May be italic dignostic is that of the white line

Scrotal Malignancy: Penile Intrepita

Pinea Pinea is rare, pre-cancus disease in our skin layer is the Pious, in stages it can cause pain urine with difficulty passing urine
manage with a skin bobpsy

AKI or Acute Kidney Injury definition

Serum creatinine rises by ≥ 26 µmol/L within 48 hours or, Serum creatinine rises ≥ 1.5-fold from the reference value., Oliguria or Urine.(AKI):
It occurs in 3 stages.
Stage one of Renal causes also exist.

Nephrotic Medications

Very bad medications can range from the medication we safe to patients to use safely
Arrange hospital mission; if a person has an underlying UTI- or hypocalciums

Kidney issues due to acute medical

Liaise with a nephrologist is presents if needed, for example stage 4-5, a renal transplant - The most common problem
Persistent.Manage and temporarily stop or adjust treatmentHaematuria or glomerular:
Is nephropathy known: Berger's, most of it is presented, for example a male with the recentrespity or in a minority if patients

Kidney Post-streptoccal

Most are due to streppytocci infection and children are affected.. Headeacahe and has a bad premonition:

Kidney Primary and Causes:

minimal change disorder or glomerous are also an issue by drugs:

Change minimises

change is the or renial diseases
Mostly genetic and not idiopathic

Kidney Diseases

What kidney diseases are genetic

They is a disorder in kidneys
Some reasons for haemotuia

What are the signs of kidney or blatter

kidney stone of the bladder etc.

Autonomic kidney symptoms

There some extra renal which could occur

kidney cell cancer

smoking

kidney cell the 3 triads
pain abondaomenal

testicular cancer

is common amoung men
most cell tumors are divided into