How does one diagnose and evaluate ED

The diagnosis (identification of the cause or presence of a medical problem or disease) and evaluation of ED require a thorough history, complete physical examination, and possibly some laboratory testing. At first, your doctor will want to establish that the problem truly is ED and not some other form of sexual dysfunction (see Question 68). Your doctor may start the visit out by first paraphrasing the definition of ED— the consistent inability to achieve and/or maintain an erection satisfactory for the completion of sexual performance—to make sure that you are both discussing the same problem. Your doctor will also need a history, which will involve asking a number of questions about your medical, social, and sexual background. Some of these questions might be uncomfortable or embarrassing, but you should answer them as honestly as possible because this is probably the most important part of the diagnostic process, allowing the physician to identify common risk factors for both organic (having a physical origin) and psychogenic (originating from the mind or psyche) erectile dysfunction.

What questions might the doctor ask me during my initial visit?

Questions such as the following will help evaluate the cause and the magnitude of the erectile dysfunction:

• How long have you been experiencing ED?

• Was the onset abrupt or a slow, progressive deterioration in function?

• Can you identify a precipitating event?

• Is the problem constant or intermittent?

• Does it occur with only one partner or with all partners if there are multiple partners?

• Do you achieve any erection with stimulation, and do you notice nocturnal or evening erections?

• Do you get an erection that is rigid enough for penetration?

• Does your erection last long enough for completion of sexual performance?

• Is there any penile pain or curvature associated with erections?

• What medical conditions do you have?

• Have you had any prior surgery?

• Do you take any medications?

• Do you use any recreational drugs?

• Do you feel stressed or depressed?

• Is the ED causing you to feel stressed or depressed?

• Is your partner interested in restoring your sexual relationship?

Often, your physician may ask you to complete a questionnaire: the International Index of Erectile Function, or IIEF (see Appendix A), an abbreviated questionnaire called the Brief Sexual Function Inventory (BSFI), or the Sexual Health Inventory for Men (SHIM), an abbreviated IIEF that contains five questions (see Appendix A). These questionnaires are helpful in assessing your problem and also may help assess your response to therapies.

What is the doctor looking for during the physical examination?

The physical examination looks for clinical signs of several disorders including hypertension, cardiovascular disease, renal or liver disease, peripheral vascular disease, thyroid problems, and neurologic problems that may be causing your ED. It is a head-to-toe examination in which your doctor will look at:

• Your heart rate and blood pressure to determine whether there might be a vascular problem.

• Your head and neck to rule out yellow sclera (liver failure) and to check for thyroid enlargement and swollen lymph nodes.

• Your chest to see how well your lungs and heart are working and to look for gynecomastia (tender or enlarged breasts in males, which can be a sign of a pituitary problem).

• Your abdomen, which will be examined by palpation (feeling with the hand or fingers, by applying light pressure), to rule out enlarged liver or kidneys, abdominal masses, or tenderness.

• Your genitalia (external sexual organs) to make sure that there are no plaques or abnormalities of the penis; the doctor will also check the testes to make sure that both are present, of normal size, and have no tumors and will check secondary sex characteristics, such as pubic hair.

• Your femoral pulse, located in your thigh, and pulses in your feet to rule out peripheral vascular disease.

• Your penile sensation, reflexes, and rectal tone. This may be uncomfortable: the doctor will check the bulbocavernosus reflex by inserting a finger in your rectum, squeezing the tip of penis, and noting a contraction of the anus at time of squeezing penis.

Why is my doctor checking my testosterone level? There are several reasons why your doctor will check a testosterone level during your initial evaluation. First, rare benign pituitary tumors can lower testosterone production and cause decreased libido and ED. These tumors are treatable, and the sexual side effects are potentially reversible. Second, if you have decreased libido, the doctor is attempting to determine whether supplemental testosterone can improve poor libido. There is no other way of assessing your testosterone level besides the blood test because neither libido nor testis size is a good gauge of testosterone levels. Clearly, if you have a decrease in your libido and your testosterone level is low, then supplemental testosterone will enhance your libido. However, in some patients with ED, who fail oral therapy and have a low normal serum testosterone, the use of supplemental testosterone may enhance the response to oral therapy, despite having normal libido.

What happens after the history, physical examination, and laboratory tests have been carried out?

In most cases, once possible causes have been identified and evaluated, your doctor may discuss lifestyle changes and possible therapies with you. This goal-oriented approach centers around the doctor and patient discussing possible origins of the problem and then making a decision about therapy (Figure 31). In select cases, when

Evaluation and Treatment of Men with Erectile Dysfunction

Evaluation and Treatment of Men with Erectile Dysfunction

Dissatisfaction with result

Patient's preference or sildenafil contraindicated

Refer to urology department

Vacuum constriction device or

Transurethral therapy or

Intracavernous injection

Dissatisfaction with result

Refer to urology department

Vacuum constriction device or

Transurethral therapy or

Intracavernous injection

Penile vascular surgery or penile implant

Figure 31 Approach to the evaluation and treatment of erectile dysfunction.

Adapted with permission from N EnglJ Med 2000;342:1807. Copyright © 2000, The Massachusetts Medical Society.

the patient wants to know more about the cause of the ED—is it really an artery problem or a vein problem?— then further investigation is required. Young men with no identifiable medical conditions or risk factors should undergo further evaluation because these individuals are the best candidates for penile vascular surgery.

If there appears to be a significant psychological component to the ED then it may be appropriate to seek consultation with a psychiatrist, psychologist, or sex therapist. Although organic problems account for 80 to 90% of the cases of ED, realistically, in many men there is some psychological overlay. Treating the ED may resolve psychological problems related to ED, but if there are significant psychological stressors, then psychological counseling at the same time as medical therapy may be more beneficial than medical therapy alone.

It is important to identify possible causes of your ED so that you and your doctor can find the best method of treating it. The success rates of many therapies have been subdivided based on the causes and the degree of ED. Knowing where your problem comes from will allow you to determine the likelihood of success of a given therapy and to avoid falsely elevated expectations.

It is often very helpful if your partner can participate in the evaluation and treatment process. Realistically, an intervention is unlikely to succeed if your partner is not interested in resuming sexual relations. For example, if your partner is a postmenopausal woman, she might suffer from atrophic vaginitis, which stems from lower estrogen levels that cause the vaginal mucosa to become thin, dry, and prone to irritation. If this is the case, she may find intercourse uncomfortable—and you may not

It is often very helpful if your partner can participate in the evaluation and treatment process.

have a supportive partner to help you through the therapy for your ED. This might be an opportunity to address both problems; discomfort from atrophic vaginitis can be improved by using lubricants during intercourse. In addition, the use of topical estrogen cream helps restore the vaginal mucosa in women for whom such agents are appropriate, so your partner may want to discuss with her primary care provider or gynecologist the risks and benefits of topical estrogen therapy for atrophic vaginitis.

What laboratory tests are performed? The laboratory evaluation of ED is limited in most cases. If you are treated by a primary care provider on a regular basis, such information as a fasting blood sugar test, kidney function tests, liver function tests, and lipid profile are often available. If you have experienced unexplainable weight gain or loss and/or other signs or symptoms of abnormal thyroid function, then thyroid function tests may be performed. All men with ED should have a serum testosterone level checked. Because the testosterone level varies throughout the day and tends to be highest in the morning, it is best to have the testosterone level checked in the morning. In some men, such as obese men and those with liver disease, the total testosterone level may be low, but the free testosterone level (the active form of testosterone) is normal. If the testosterone level is low, then a prolactin level should be checked to rule out a pituitary adenoma (a benign brain tumor).

Do I need any specialized tests?

In most cases, the history, physical examination, and blood testing allow the physician to identify possible causes of your ED, but in some cases, a more advanced evaluation may be required. In men who seem to have a psychogenic basis for their problem, the doctor might order nocturnal penile tumescence (NPT) studies to confirm this theory. (Tumescence is the state of being swollen, in this case referring to having an erection.) This test involves wearing a specialized device around the penis at night on several occasions when sleeping. The device records whether you have erections during your sleep, which is both normal and common; if you do, it would suggest that the ED could be psychogenic in origin, which can help determine the correct treatment strategy. However, NPT studies have limitations, and it has been suggested that sleep-related erections may not be the same as sexually induced erections.

If your doctor wishes to evaluate your penile vasculature and obtain a preliminary assessment of the arterial and venous function therein, the best initial test is Doppler ultrasonography in conjunction with injection therapy. In ultrasound studies, internal organs are visualized by measurement of reflected sound waves. In this particular study, you are injected with a chemical that causes smooth muscle relaxation and increases penile blood flow, usually 10 |ig of alprostadil (Caverject, Edex), but other agents, such as trimix/triple P (prostaglandin E1, papaverine, and phentolamine), may be used. After injection, sequential blood flow studies are performed. The rate at which blood is flowing through the caver-nosal artery on each side of the penis (the peak systolic velocity) can be determined. A peak systolic velocity over 25 to 30 mL/sec is considered normal. The Doppler ultrasound also allows the diameter of the cavernosal arteries to be measured. In addition, the function of the penile veins can be assessed by measuring the end-diastolic velocity (venous resistance). The Doppler ultrasound study may be affected by patient anxiety and may require stimulation to achieve the maximum

Doppler ultrasonography

Use of a Doppler probe during ultrasound to look at flow through vessels.

Arteriography

A test for identifying and locating arterial disease in the penis, using injection of contrast into the arteries supplying the penis to look for areas of "blockage."

Cavernosography

A technique used to visualize areas of venous leak. It involves the injection of a cavernous smooth-muscle dilator (e.g., prostaglandin E1 or trimix), followed by placement of a butterfly needle into the corpora, instillation of a contrast agent into the corpora, and X-ray photographs to visualize the sites of venous leak.

response. As with injection therapy, there is a small risk of priapism and penile pain related to the injection or to the medication used. If the Doppler ultrasound study demonstrates an abnormality of the arteries or veins and the patient wishes to be evaluated for possible surgical correction, then further studies would be required. Arteriography, or cavernosography are performed to better assess possible arterial or venous abnormalities. These more invasive tests are not required in all individuals and should be performed in select institutions where penile artery bypass surgery or venous ligation surgery is performed.

What are nocturnal penile tumescence (NPT) studies? Formal nocturnal penile tumescence (NPT) testing requires spending two to three consecutive nights in the sleep laboratory. Men undergoing NPT tests must abstain from alcohol, caffeine, and medications that may affect sleep or erections for 8 hours before the test. Because sleep erections occur primarily during rapid eye movement (REM) sleep, one must assess the quality of REM sleep, which is done through the use of an electroen-cephalographic (EEG) test, an electro-oculographic test, and a submental electromyographic test. To assess penile tumescence, two mercury-in-rubber strain gauges (expandable rubber loops) are placed on the penis, one at the base and the other just behind the glans penis. When the loop circumferences increase, the mercury column is thinned, this increases the electrical resistance through the mercury. Each time there is an increase in the electrical resistance, it is recorded on a tracing. The high point of the deflection on the tracing corresponds to the change in penile circumference. The study also allows one to detect discrepancies between the changes in both loops, meaning that if one loop expands substantially more than the other, the test can detect this. One of the biggest drawbacks of NPTs is that they are measuring nocturnal erections, not erections related to sexual arousal, and each may occur via different mechanisms. Secondly, there can be false-positive NPT results; these more commonly occur in patients with neurogenic ED and pelvic steal syndrome, and false-negative NPT results occur in patients with depression, alcohol use, medication ingestion, and sleep apnea. In addition, the measurements of penile rigidity with NPT studies may be insufficient to differentiate between organic and psychogenic erectile dysfunction. Formal nocturnal penile tumescence testing is also laborious and expensive.

What is the RigiScan?

The RigiScan (Timm Medical Technologies, Eden Prairie, MN) was developed as a portable home device to evaluate the quality and the quantity of nocturnal penile erections. It is used to provide continuous measurements of penile rigidity and tumescence, and it represents an improvement over previous techniques of assessing nocturnal penile tumescence. The RigiScan consists of a portable battery-powered unit that is strapped around the thigh and has two loops that are connected to a direct-current torque motor. One loop is placed around the base of the penis and the other is placed just below the corona (the area of the penis just before the glans penis). To measure tumescence every 30 seconds, the loops tighten and the penile circumference (loop length) is recorded. Fifteen seconds later, a second measurement is taken without active tightening of the loops. If tumescence (measured by the length of the loop) increases by 10 mm or more from the initial measurements, rigidity measurements are taken. Rigidity is

Sleep apnea

A condition in which a person stops breathing for a short period of time during sleep (anywhere from a few seconds to a minute or two), causing him to wake repeatedly and get insufficient sleep.

Axial rigidity is the most important measurement in predicting va, penetration because it is used to assess the ability of the penis to stay straight despite pressure against the tip.

measured every 30 seconds by a slight tightening of the loops. Rigidity is expressed as a percentage, with 100% equaling the rigidity of a noncompressible rubber shaft. Rigidity measurements are discontinued when tumescence decreases to within 10 mm of baseline. The RigiScan can record three uninterrupted 10-hour sessions. The information stored in the device can then be downloaded into a microprocessor, and the nocturnal penile tumescence and rigidity information can be analyzed, displayed, and printed. The RigiScan measures only radial rigidity, that is, rigidity across the width or circumference; it does not measure axial rigidity, or rigidity across the length of the penis. Axial rigidity is the most important measurement in predicting vaginal penetration because it is used to assess the ability of the penis to stay straight despite pressure against the tip.

In most patients, the RigiScan device can distinguish functional from inadequate erections and is helpful in distinguishing psychogenic from organic ED.

Sexhormones

Substances (estrogens and androgens) responsible for secondary sex characteristics (e.g., hair growth and voice change in males).

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