Absent night or morning erection

Specialty: Nephrology and urology.

• absence of morning erections
• loss of spontaneous nocturnal erections

Why it occurs

• Erectile dysfunction of organic origin (the loss of involuntary erections during the REM sleep phase is a highly reliable indicator of vascular, arterial or veno-occlusive structural damage, pudendal neuropathy or deep endothelial dysfunction)
• Severe hypogonadism (critically low total and free testosterone levels that do not reach the threshold to maintain spontaneous nocturnal erectile function)
• Generalized diabetic or autonomic neuropathy (damage to the pelvic afferent and efferent nerve pathways)
• Antiandrogen pharmacological treatments or chronic use of estrogens
• Advanced cardiovascular disease or generalized atherosclerosis of the pudendal and iliac arteries

Initial workup

Determination of levels of total and free testosterone, LH, FSH, prolactin, TSH, complete lipid profile and glycosylated hemoglobin (HbA1c); nocturnal penile tumescence test (seal test or RigiScan device, which objectively monitors the number and stiffness of nocturnal erections during sleep to differentiate organic from psychogenic causes); Dynamic Doppler ultrasound of cavernous arteries after pharmacological injection.

Standard management

• Tadalafil — 5 mg daily orally continuously at night, or Sildenafil 50-100 mg as needed; phosphodiesterase-5 inhibitors - PDE-5 - which facilitate the entry of blood flow to the corpus cavernosum by maintaining high levels of cGMP; absolutely contraindicated if the patient takes nitrates such as nitroglycerin or isosorbide dinitrate due to the risk of severe fatal hypotension
• Hormone replacement with testosterone gel or injections if underlying hypogonadism is confirmed
• Optimization of cardiovascular risk factors.