Year : 2006 | Volume
: 22 | Issue : 3 | Page : 220--224
Investigating a patient with erectile dysfunction: Is it really necessary?
Via Pansini 5, Napoli, Italy
Via Pansini 5, Napoli
The National Institute of Health defined erectile dysfunction as the persistent inability to achieve and/or to maintain an erection for a satisfactory sexual performance. Erectile dysfunction must be considered a public health problem for its high prevalence worldwide. Aetiology of erectile dysfunction can be classified as organic, psychogenic or mixed. Erectile dysfunction must be considered the first sign of many diseases. Thus, a correct diagnostic approach is essential before starting an effective therapeutic regimen. Current guidelines concerning management of erectile dysfunction agree on the great importance of anamnesis as being the basis of a correct diagnosis of erectile deficit. First level diagnostic tests, including anamnesis, validated questionnaire, routine laboratory tests and hormonal profile seem enough to make an aetiological diagnosis of erectile dysfunction and to identify and remove any erectile dysfunction (ED) risk factors in most cases. First level tests should be performed, so than urologists can accurately diagnose ED and prescribe relevant treatment.
Second level diagnostic evaluation includes specialistic instrumental exams that can be helpful for accurate aetiological diagnosis of erectile dysfunction. These exams, including Penile dynamic colour-duplex. Doppler ultrasonography, nocturnal penile tumescence recording, cavernosometry/cavernosography and neurological investigation, should be performed when first level diagnostic assessment is not clear, when the presence of an underlying organic pathology should be excluded in young patients with persistent ED, when veno-occlusive or neurogenic ED is suspected and when a better definition of the disease is needed.
|How to cite this article:|
Mirone V. Investigating a patient with erectile dysfunction: Is it really necessary?.Indian J Urol 2006;22:220-224
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Mirone V. Investigating a patient with erectile dysfunction: Is it really necessary?. Indian J Urol [serial online] 2006 [cited 2019 Sep 21 ];22:220-224
Available from: http://www.indianjurol.com/text.asp?2006/22/3/220/27628
Erectile dysfunction (ED) has been defined as the persistent inability to achieve and/or to maintain an erection for a satisfactory sexual intercourse. This event can occur occasionally without inducing psychological or managerial problems, but frequent ED can lead to emotional and relational disorders which can often reduce self-esteem, reinforcing dysfunctional processes. ED represents a very important public health problem and can strongly compromise both the patient and the couple's quality of life because of a combined presence of organic and psychological aspects and frequent correlation with clinical comorbidities.
Epidemiological data on ED are often altered by the patient's resistance to consult a specialist. However, ED reaches very remarkable proportions worldwide. The Massachusetts Male Ageing Study (MMAS - 1994), the first epidemiological study on a large scale performed on men between 40 and 70 years old, showed an incidence of erectile dysfunction in 52% of men; among these, 10% of the patients suffered severe ED. Prevalence of ED varied from 30-40% in men 40 years old to 70% in men 70 years old. A direct relationship between age and severity of erectile deficit has been demonstrated.. The National Health and Social Life Survey (1999) reported the presence of ED in 18% of men 50 and 59 years old. Lately, Mirone et al (2004), having based his study on a wide Italian population, described an ED incidence variability from 4.6% in men under 25 years old to 37.6% in men over 74 years old, with an overall prevalence of 12.8%.
These data seems to be applicable worldwide, although not dependent on ethnic or racial differences. Even if developing countries have heavy sexual taboos, prevalence of this problem is sometimes strongly underestimated.
Generally, aetiology of ED can be classified as organic or psychogenic. However, this classification doesn't seem to be very clear, with a prevalence of mixed forms, being the organic and psychological factors often interrelated and overlapped.
Organic and psychogenic ED have different for presenting symptoms, severity and association with environmental variables. Psychogenic dysfunction usually appears suddenly with an immediate loss of erection. On the other hand organic dysfunction shows a gradual onset with worsening of underlying pathologies.
Therefore, this classification can be very helpful for the management of a patient with ED. In the presence of organic ED, the treatment of underlying pathology should be the first step of therapeutic regimen, while a patient with a psychogenic ED should be addressed to adequate counselling representing the principal care for this kind of dysfunction.
DIAGNOSIS OF ED: FIRST LEVEL
Current guidelines for management of ED, sometimes differing in details, agree on the great importance of the anamnesis as basis of a correct diagnosis of ED.,, History taking has been shown more precise if partners are involved in clinical interview, facing the erectile problem within the couple. When it is correctly taken, the anamnesis allows to minimize any further diagnostic test for a complete evaluation of erectile dysfunction.,,
A good anamnesis consists of three aspects, medical, sexual and psychosocial. Medical history should identify the presence of concomitant pathologies and reveal risk factors for ED onset (for example drugs or alcohol abuse, uncompensated diabetes mellitus, previous radiotherapy for cancer, etc.). Only correcting these factors, patients often can benefit. Most chronic pathologies usually are able to cause loss of erection because of both specific organic modification and psychological correlates following ED. Sexual history has the purpose of investigating in detail on which is the real dimension of patient's ED. Sexual history has the purpose of investigating in detail on which is the real dimension of patient's ED. Sexual history should be able to assess if patient presents loss of libido, if ED is prevalent in obtaining or maintaining erection, if erectile dysfunction is associated with other sexual disorders (i.e., ejaculation or arousal disorders), how often this dysfunction happens and should investigate on quality and duration of morning erection. All these information, usually allow the physician to obtain very important elements leading to a correct etiogical diagnosis. Psychosocial history can identify psychological and relational dynamics affecting somehow ED. These conditions could be classified as pre-disposing (inadequate sexual education, uncertain psychosexual role, etc.), precipitating (infidelity, psychiatric diseases, etc.) and maintaining (loss of attraction as regards one's partner, performance anxiety, etc.), based on time when take part in ED genesis.
In evaluation of a patient with ED, the physician can make use of specific validated questionnaires filled in by the patients himself, giving a correct measurement of ED severity. These questionnaires include the International Index of Erectile Function (IIEF), the sexual health inventory for men, the brief male sexual function inventory, the erectile dysfunction inventory for treatment satisfaction and the sexual encounter profile. The IIEF is certainly the most famous and used questionnaire in clinical practice and it showed a high diagnostic specificity and sensibility. It also allows to classify erectile dysfunction into three severity degrees: mild, moderate or severe, based on total score. Validated questionnaires result particularly useful for men who have difficulty in expressing their problems. Nevertheless, in these patients questionnaires should not replace the anamnesis, which remain the most important tool for a correct diagnosis of erectile dysfunction. Moreover the scales for ED assessment represent very effective instruments for long-term evaluation of pharmacological therapy.
An extensive physical examination is not usually request in management of ED. It should confirm results coming out from anamnesis with particular attention at cardiovascular and genito-urinary system.
Laboratory tests can be useful to complete diagnostic evaluation. Each patient suffering ED should perform routine haemato-chemical tests to evaluate general health status (i.e., lipidic profile, glycaemia, haemachrome, transaminase, serum creatinine) and hormonal tests.,, Hormonal assessment appears indispensable in case of ED matched to loss of libido. Other hormonal assays (DHT, FSH, LH, PRL and E 2 ) should be performed when low testosterone serum levels are found. Therefore hormonal tests allow identification of endocrine alterations that can be promptly corrected setting up an hormone replacement therapy. This substitutive treatment can resolve erectile problems in most of patients.
When first level diagnostic tests are performed in a right way, urologist can make accurate diagnosis and can prescribe adequate treatment in a large number of patients with ED.
After all that we asserted, invasive specialistic diagnostic test could be reserved only for primary erectile disorder (not caused by organic disease or psychogenic disorder), for young patients who have always had difficulty, for men with a history of genital trauma who could benefit from potentially curative vascular surgery, for men with abnormality at physical examination, for patient's or his partner's request, for medico-legal reasons or when the initial screening tests have indicated a significant abnormality.,
DIAGNOSIS OF ED: SECOND LEVEL
Second level diagnostic evaluation uses specialistic instrumental exams that can be helpful for accurate aetiological diagnosis of ED.
Penile dynamic colour-duplex Doppler ultrasonography allows direct visualization of penile vessels and evaluation of possible strictures and dysfunctions. Using Doppler methodology urologists are able to study both arterial and venous flow velocity, assessing erectile haemodynamics as a whole. This exam is performed after injection of alprostadil (PGE 1 ) 10 or 20 mg in order to induce erection and reduce false positive; some authors reported that oral administration of sildenafil seems to be as effective than PGE1 in inducing erection, but less invasive and more capable of reducing false positive venous leakage diagnosis. If full rigidity is not obtained after a period of privacy and self-stimulation, a second injection (alprostadil 10 mg plus phentolamine 1-2 mg) should be performed in order to achieve the best erection and get over anxiety-induced failures.
Ultrasonoghrapy is performed 5-10 minutes after injection, using high-frequency linear transducers (7.5-13 MHz). When it's possible, Power Doppler technique should be used because of better definition of vascular details and less dependence on transducer position.
During exam, parameters which could be mainly considered are the Peak Systolic Velocity (PSV), the End Diastolic Velocity (EDV) and the Resistance Index (RI= (PSV-EDV)/PSV); the last one can predict venous leak probability in patients suffering ED.
Dynamic ultrasonography also allows to value anatomical aspects of penile circulation (for example strictures, high-speed jets, duplication of the cavernosal artery, cross-communications between the two cavernosal arteries, etc.) and corpora cavernosa, especially after vasoactive drugs injection.
Men with normal erectile function present a PSV value > 30 cm/s and an EDV value 0.85. As the PSV decreases with ageing, the PSV cut-off value should be calculated as following in order to increase test predictivity: PSV = 6.73 + (0.7 * age).
Patients showing normal PSV value and complete erectile response can be considered as normal subjects; patients showing low PSV value but normal erection probably suffer arterial insufficiency, offset by effective veno-occlusive system (RI > 0.85).
In patients showing normal PSV value associated with incomplete erectile response and RI value under 0.85, a probable veno-occlusive mechanism alteration should be considered as cause of erectile dysfunction. Nevertheless, penile dynamic colour-duplex Doppler ultrasonography is not sufficient to make diagnosis of venous leak because of its low specificity due to incomplete rigidity of corpora cavernosa and persistence of diastolic flow. In order to formulate a correct diagnosis of venous leak gold standard remain the cavernosometry/cavernosography.
Role of penile Doppler ultrasonography has been discussed because it provides operator dependent information and, considering currently available therapy for ED (especially PDE5-inhibitors), rarely alters following patient management.
Some evidences open new diagnostic possibilities for penile dynamic colour-duplex Doppler ultrasonography. A statistically significant correlation between PSV decrease and ischemic heart disease was found, probably due to a greater sensibility of penile vessels towards atherosclerosis promoting factors.
Thus ultrasonography could become a non-invasive screening test in order to value coronary risk. Moreover penile dynamic colour-duplex Doppler ultrasonography conserves a very important role in investigating patients refractory to PDE5-inhibitors therapy (especially in detecting arterio-venogenic disorders).
If suspect of veno-occlusive dysfunction arises during penile dynamic, next diagnostic level is represented by cavernosometry/cavernosography. However, there is no gold standard in literature on whether to perform cavernosometry alone or with cavernosography, which flow values (induction or maintenance) should be measured, which drug should be used, whether a standard cavernous pressure of rigidity exists or does it change from case to case and whether the examination can indicate an effective therapeutic choice. Even if cavernosometry is a reliable test in the evaluation of patients with vascular erectile dysfunction, it should not be used alone to decide treatment. In these cases the therapeutic management is difficult, since the alternatives (high pharmacological doses, drug combinations, venous surgery, prosthesis implants) are serious for the patients. Cavernosometry could be useful to select patients for surgical therapy and during follow-up of patients not responding to venous surgery alone or with pharmacotherapy.
Among second level test it is included also NPTR (RigiScan), which offers an objective and quantitative evaluation of nocturnal erections. Nocturnal penile erections physiologically occur 3-5 times during sleep, usually in conjunction with R.E.M. phase.
When this test is performed in men without sleep disorders which can alter NPTR, it allows to distinguish between organic and psychogenic ED in the majority of patients.
RigiScan is performed by applying two elastic rings placed at the basis and the tip of the penis connected to RigiScan recorder placed on one leg. Nocturnal erections must be recorded at least for two consecutive nights. RigiScan criteria for ED are the following: less than 60% of tip and base rigidity, less than 2 cm increase of tip tumescence, less than 3 cm increase of base tumescence, less than three full erections during night and less than 10 min of full erection during night. Patients suffering organic ED present at three of these criteria, while patients suffering psychogenic ED have normal erections.
Although many studies confirmed that NPRT is the best non-invasive diagnostic test for differentiating psychogenic from organic dysfunction, others claimed that NPRT effectiveness is limited by anxiety and sleep disorders. Moreover, NPTR parameters are closely related to androgen levels and advanced age. Additionally, there are no standard evaluation criteria of NPTR and different studies have adopted different criteria.
As showed in many clinical trials, RigiScan sensibility in distinguishing between organic and psychogenic ED varies from 82 to 98%. In order to obtain a certain etiological diagnosis of ED, other test (penile dynamic colour-duplex Doppler ultrasonography, cavernosometry) are needed, because NPRT can differentiate psychogenic from organic ED, but it is not able to identify causes of organic dysfunction (arterial, venous, neurogenic).
Rarely specific neurological alterations involving both central and peripheral nervous system can determinate ED. If urologist suspects a neurological aetiology, he can perform specific tests investigating penile and genital conduction effectiveness. These tests include biothesiometry, speed of conduction of the dorsal penile nerve, bulbocavernous reflex, somatosensorial evoked potential and perineal electromyography. In most cases, careful anamnesis and neurological physical exam allow to detect neurological condition underlying ED, limiting the use of more specific diagnostic tools to selected patients.
ED must be considered a public health problem. Its prevalence in the male population worldwide seems to be very high, leading to the important worsening of life quality among patient and his partner. In the majority of patients, an organic, psychogenic or more frequently, mixed organic/pshycogenic aetiology can be recognized for erectile deficit. A good anamnesis and a good relationship between patient and physician, based on mutual confidence, are needed for correct management of men suffering erectile problems. Finding out, underlying ED conditions is an essential factor for an adequate olistic approach to patient care, even if this may not seem to modify the initial therapeutic choices. Oral PDE5-inhibitors currently represent therapeutic cornerstone for most patients suffering erectile dysfunction, showing high effectiveness, very good compliance and low rate of adverse events in this subjects.
Therefore good anamnesis, correct approach to patients and his problems, issue of validated questionnaire, routine laboratory tests and hormonal profile seem to be enough in most cases to make an aetiological diagnosis of erectile dysfunction and to identify and remove ED risk factors (smoking, hypertension, drugs or alcohol abuse, hypercholesterolemia, hypertriglyceridemia, hormonal alterations, psychiatric diseases, etc.).
So second level diagnostic test can be limited to patients in whom the first level diagnostic assessment had not given clear results, to young patients with persistent ED when the exclusion of the presence of an underlying organic pathology is necessary, to patients with suspected veno-occlusive or neurogenic ED and to all patients when a better characterization of disease is needed.
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