CUA GUIDELINE: ERECTILE DYSFUNCTION (2015)
*****2018 AUA Guideline Notes more comprehensive and includes all of the information below*****
See ED Evaluation and Management Chapter Notes
Definition of erectile dysfunction: persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity for at least 3 months
Diagnosis and Evaluation of erectile dysfunction
- A commonly used schema is:
- Vascular
- Endocrine
- Neurological
- Situational
- End organ (penile deformity – Peyronie’s disease or trauma)
- Mixed (Most cases)
- History (mandatory)
- Determine that the problem is erectile dysfunction versus other aspects of the sexual response cycle (desire, ejaculation, orgasm) or from other causes (Peyronie’s disease, lifestyle factors including illicit drug use, quality of partners relationship).
- Determine specifics related to ED (onset, severity, significance and situations) and desire, arousal, orgasm, and ejaculation
- Relationship issues, bother to partner, stressors at home and work
- Genital pain or altered shape
- Comorbid conditions: hypertension, peripheral vascular disease, diabetes, obesity, and renal disease
- Pelvic surgery, radiation or trauma
- Medications
- Lifestyle factors: smoking, substance use/abuse, sedentary lifestyle
- Psychiatric illness or conditions
- Physical exam (mandatory)
- Ensure testes/testis presence and examine consistency of the testicle (i.e., atrophy, hypogonadism).
- The identification of penile deformities may be best achieved in the erect state, but is most commonly examined by stretching the penis to make the Peyronie’s plaque(s) more pronounced.
- Questionnaires (recommended)
- The most common questionnaire is the SHIM (Sexual Health Inventory for Men)
- Components of SHIM: Confidence, Penetration, Maintenance, Completion, Satisfaction
- The greatest utility of these questionnaires may be in establishing a response to therapy and determining overall satisfaction with drug use over a specified length of time (i.e., 4 weeks).
- Laboratory testing
- Assessment for occult diabetes should be performed with either a fasting glucose or HbA1c
- Lipid screen is optional
- A morning total testosterone or bioavailable testosterone is indicated in men with (5): Interestingly, Viagra and Volume Delay Diabetes
- Decreased sexual Interest
- Failure of PDE5-inhibitor treatment
- Reduced ejaculatory volume
- Delayed ejaculation
- Men with ED and diabetes
- Calculated bioavailable testosterone (requires a morning total testosterone, albumin and sex-hormone binding globulin) is an acceptable substitute for measured bioavailable testosterone if it is not available or cost-prohibitive. Free testosterone measurements have significant intra-assay variability which limits their clinical utility in Canada and is not recommended.
- Optional testing such as thyroid-stimulating hormone (TSH), luteinizing hormone (LH) and follicle-stimulating hormone (FSH), prolactin, complete blood count (CBC), and urinalysis are added when dictated by clinical context.
Specialized testing
- Nocturnal penile tumescence and rigidity testing is a minimally invasive means to measure and record nighttime erectile events (nocturnal penile tumescence), but has limited availability in Canada and costs are not covered by most provinces.
- Penile duplex cavernous artery flow determination after corporal injection of vasoactive agents is commonly performed. Use of ultrasound to localize and measure the size and flow through the cavernous vessels, pre- and post-vasoactive injection allow a more refined assessment of penile circulation.
- Dynamic infusion cavernosography and cavernosometry aims to define how well the penile blood-trapping mechanism (the veno-occlusive mechanism) works.
- Arteriography is the most invasive diagnostic test and is reserved generally for cases of high-flow priapism or planned vascular bypass.
Treatment options
- Stepwise progression from oral agents through second- and third-line therapies occurs as needed.
- First line: oral therapy (on-demand or daily dosing). The choice of which initiating PDE5-inhibitor may be influenced by several factors (See Table 1 from Original Guideline), including timing or frequency of intercourse, and interactions with food or alcohol
- Testosterone replacement therapy in men with documented hypogonadism is an option. Testosterone may be used alone for hypogonadism, or in combination with oral PDE5-inhibitor therapy when ED is present. Once treatment with exogenous testosterone is initiated, ongoing follow-up is mandatory.
- Sexual counselling (this may represent a spectrum of approaches from a simple open discussion with the PCP to psychologist, sexual therapists and/or psychiatrists).
- Second line: local therapy (intracavernous or intraurethral agents) or vacuum erection device therapy
- Third line: surgery
- Penile implant
- Peyronie’s surgical repair
- Vascular bypass procedure (generally reserved for young men after traumatic arterial penile vascular injury).
Questions
See 2018 AUA Erectile Dysfunction Guideline Notes