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Erectile dysfunction — ABIM Board MCQ

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ModerateWomen's Health/Men's HealthErectile dysfunctionABIM Board

A 58-year-old man with a 15-year history of type 2 diabetes mellitus and distal symmetric polyneuropathy reports 18 months of gradually worsening difficulty attaining and maintaining an erection. The problem occurs in all settings, and nocturnal and morning erections have become infrequent. His libido is unchanged. He has no depression, penile pain or curvature, pelvic or urinary symptoms, or antipsychotic use. Examination shows decreased vibration sensation in both feet and diminished pedal pulses. Serum testosterone and prolactin concentrations are normal. Which of the following is the most likely underlying cause of his erectile dysfunction?

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Correct answer: E — Diabetic vascular disease with autonomic neuropathy

The correct answer is E. Gradual, persistent erectile dysfunction with loss of morning erections indicates an organic disorder. Long-standing diabetes can impair erection through endothelial and arterial dysfunction as well as diabetic autonomic and peripheral neuropathy. Diminished pedal pulses and distal sensory loss support these concurrent vascular and neurologic mechanisms. Hyperprolactinemia is unlikely without dopamine-blocking medication and with a normal prolactin level. Prostatitis typically causes pelvic or perineal pain and urinary symptoms. Peyronie disease causes a palpable fibrous plaque, penile curvature, and sometimes painful erections. Primary testicular failure would cause low testosterone, often accompanied by reduced libido and abnormal testicular findings, rather than the normal testosterone and preserved libido described here.

Reference: National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes, Sexual, & Bladder Problems, section: Erectile dysfunction. Last reviewed June 2018. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/sexual-bladder-problems%C2%A0