Penile Disorders

Case 2. VK is a 19-year-old foreign exchange student. He reports that since starting college, he has experimented with alcohol and nicotine vapes and, more recently, has become sexually active. He says he felt embarrassed when one of his partners commented that most American men are circumcised, as this practice is uncommon in his home country. Since then, he has had difficulty achieving an erection with another person present. He denies pain or difficulty with erection or ejaculation when masturbating. A chaperoned physical examination reveals a tight foreskin hood that does not easily retract over the glans but is otherwise unremarkable.

The American Urological Association (AUA) defines erectile dysfunction (ED) as the inability to achieve or maintain an erection sufficient for satisfactory sexual activity.¹ The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision, criteria for ED include difficulty maintaining an erection during sexual activity or to complete sexual activity, distress from the symptoms, and presence of symptoms for 6 months or longer.²

ED affects approximately 50% of men ages 40 to 70 years³ (Figure 1⁴). Prevalence figures for ED are subject to reporting bias and vary by disease severity, study, and country. Late-onset hypogonadism can further confound the relationship between sexual dysfunction and aging.⁵ Although patients with ED may report normal libido and ability to reach orgasm, difficulty with the arousal phase of the sexual cycle often causes emotional distress and interpersonal conflict for patients and their partners.^6,7,8–10

Erection of the penis is a parasympathetic process. It occurs when smooth muscle relaxation allows for increased blood flow into the two cylinders of spongy tissue in the penile shaft. Compromised blood flow, inadequate release of nitric oxide (which assists with vasodilation), and impaired nerve impulses can contribute to the pathophysiology of ED.^3,11

Vasculogenic disease is the most common organic cause of ED.³ (Table 1^12,13). Risk factors include sedentary lifestyle, smoking tobacco, and obesity.^11,12 Aging is an independent risk factor.¹¹ Hypertension and type 2 diabetes are common comorbid conditions.¹² Because ED can be an early indicator of cardiovascular disease, men with ED should be considered at risk until proven otherwise.^1,12