Editing Evaluation and Management of Erectile Dysfunction (section)

== Diagnosis and Evaluation ==

=== UrologySchool.com Summary ===
{| class="wikitable"
|
|'''2018 AUA'''
|'''2021 CUA'''
|-
|'''Mandatory'''
|
## '''History and physical exam'''
## '''Diabetes screen (fasting glucose or HbA1c)'''
## '''Serum testosterone'''
|
## '''History and physical exam'''
|-
|'''Recommended'''
|
## '''Questionnaire'''
|
## '''Diabetes screen (fasting glucose AND HbA1c)''' '''in patients with either suspected vasculogenic or idiopathid ED'''
## '''Fasting lipids in patients with either suspected vasculogenic or idiopathid ED'''
## '''Serum testosterone in patients with symptoms of testosterone deficiency or failure of PDE5 inhibitor'''
|-
|'''Optional'''
|
## '''Fasting lipids'''
## '''Specialized testing'''
## '''Serum BUN/Cr'''
|
## '''Questionnaire'''
|}

=== History and Physical Exam ===

* '''History (medical, sexual, and psychosocial)'''
** May identify the medical condition and also specify reversible or treatable factors associated with ED
*** See Campbell's 11th edition Tables 27-2 and 27-3
** '''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)'''
** '''Onset of symptoms''' (the timing of specific symptoms should be ascertained in relation to the onset of ED as these symptoms may be primary causes of ED or secondary effects of the ED condition), '''symptom severity, degree of bother, whether symptoms have been stable or are progressive''' (worsening symptoms may suggest progressive underlying comorbidities, particularly cardiovascular comorbidities)
** '''Changes in libido, orgasm, ejaculation, genital pain and penile morphology''' (possible presence of Peyronie’s disease)
** '''Situational factors''' (e.g., occurring only in specific contexts, only when with a partner, only with specific partners), circumstances that facilitate or hinder erectile function
** '''Presence of nocturnal and/or morning erections''' (suggests, but does not confirm, a psychogenic component to ED symptoms that would benefit from further investigation), '''masturbatory erections'''
** '''Prior use of erectogenic therapy'''
** '''Evaluation of psychological factors (i.e., depression, anxiety, relationship conflict, stressors at home or work) and psychosexual issues''' addresses psychogenic contributions to clinical presentations. Men may not appreciate that depression, anxiety, stress, and relationship conflicts can interfere with the physiological processes necessary for erectile function. Thoughtful discussion of these issues with men and their partners is a key component of patient education and can promote acceptance of incorporating a mental health/sexuality expert into the treatment plan.
*** In situations in which sudden or severe ED is likely to develop (e.g., men considering definitive therapy for pelvic cancers) early inclusion of psychosexual expertise on the treatment team is critical to development of an effective and feasible treatment plan
** '''Comorbid medical conditions''': hypertension, peripheral vascular disease, diabetes, obesity, and renal disease
** '''Comorbid sexual conditions:''' premature ejaculation, anorgasmia, low libido, and Peyronie's
** '''Pelvic surgery, radiation or trauma'''
** '''Medications'''
** '''Lifestyle factors''': smoking, substance use/abuse, sedentary lifestyle
** Because of the complexity of sexuality and the impact of a sexual relationship on a man’s life, '''it is strongly advised that a male’s partner''' be invited to participate in this process whenever possible and clinically appropriate.
** '''Questions that may help to differentiate psychogenic from organic erectile dysfunction (5):'''
**# Presence of nocturnal erections?
**#* Psychogenic ED: often present
**#* Organic ED: reduced
**# Presence of erection during masturbation or with alternate partners?
**#* Psychogenic ED: often present
**#* Organic ED: reduced
**# Significant recent psychosocial stress?
**#* Psychogenic ED: strong impact
**#* Organic ED: minimal impact
**# Feelings of performance anxiety around sexual activity?
**#* Psychogenic ED: strong impact
**#* Organic ED: minimal impact
**# Situational variability of erectile dysfunction (improved while on vacation)?
**#* Psychogenic ED: potential for wide variability
**#* Organic ED: minimal variability
* '''Physical exam'''
** '''Vitals''' '''(hypertensive may contribute to ED)'''
** '''Body habitus''' (waist circumference, BMI)
** '''Signs of testosterone deficiency''' (e.g., gynecomastia, virizilation (under-developed facial/pubic/axillary hair))
** '''Genital exam'''
*** Penile length and girth, presence of penile plaques, phimosis, frenular tether, meatal stenosis,
**** Examination of the penis for occult deformities or plaque lesions should occur with the penis held stretched and palpated from the pubic bone to the coronal sulcus.
** '''Scrotal exam'''
*** General assessment of the scrotal skin
*** Palpation of the testicles to assess for size, consistency, and location.
** '''Groin exam'''
*** Quality of femoral pulses
** '''Digital rectal examination is NOT required for evaluation of ED'''; however, BPH is a common comorbid condition in men with ED and may merit evaluation and treatment.

=== Labs ===

* '''2018 AUA'''
** '''All men (2):'''
**# '''Fasting glucose or hemoglobin A1c''' (screen for occult diabetes)
**# '''Morning total testosterone'''
** '''Optional'''
*** '''Fasting lipids'''
*** '''Serum BUN/Cr'''
*** Other: 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.
* '''2021 CUA'''
** '''Fasting glucose or hemoglobin A1c in patients with either suspected vasculogenic or idiopathid ED'''
** '''Fasting lipids''' '''in patients with either suspected vasculogenic or idiopathid ED'''
** '''Morning total testosterone if (2):'''
**# '''Symptoms of testosterone deficiency'''
**# '''Failure of phosphodiesterase type-5 inhibitors'''
* '''Serum testosterone''' (Campbell's 11th edition)
** '''Typical range for total testosterone measurement is 250 to 1000 ng/dL'''
*** Because of individual variability, the normal range for which replacement therapy should be initiated remains unknown
** '''If the testosterone level is below or at the low limit of normal, blood draw should be repeated for confirmation'''; a mildly abnormal testosterone level might be found to be normal in 30% of patients on repeat testing. '''When proceeding with a second total testosterone determination, assessment of LH and prolactin should also be included.''' Measurement of serum gonadotropin will help to localize the source of the hypogonadism.
*** Elevated serum LH and FSH releases are appropriate pituitary responses to the low serum testosterone levels, which is consistent with testicular failure (primary hypogonadism).
*** Normal or low serum LH and FSH releases in the setting of low serum testosterone levels indicate an inappropriate response and suggest a central disorder (secondary hypogonadism).
*** '''Hyperprolactinemia''' '''causes hypogonadism by suppression of gonadotropin-release hormone from the hypothalamus''', '''which impairs the pulsatile LH secretion required for serum testosterone production by the gonads'''.
**** Suspicious of hyperprolactinemia is raised in the patient with low serum testosterone and low or inappropriately normal LH.
**** Identifying and addressing the underlying cause of hyperprolactinemia may improve ED
**** '''A prolactin-secreting adenoma should be treated radiologically and if necessary surgically. Bromocriptine, a dopamine agonist that lowers prolactin level and restores testosterone to normal, serves to reduce the size of the tumour.''' Neurological ablation becomes necessary if the therapeutic response to medication does not occur or visual effects are noted in association with optic-nerve compression.
**** Generally accepted guidelines provide indications for pituitary imaging: cases of severe central hypogonadism (testosterone <150 ng/dL) and suspicion of pituitary disease (i.e. panhypopituitarism, persistent hyperprolactinemia, or symptoms of tumor mass effect).

=== Validated questionnaires ===

* '''Uses (3)'''
*# '''Assess severity of ED'''
*# '''Measure treatment effectiveness'''
*#* Greater improvements in IIEF-EF score necessary for satisfactory results in patients with more severe ED
*# '''Guide future management'''
* '''Options (3)'''
*# '''Erection Hardness Scale (EHS)'''
*#* Self-reported assessment of penile hardness on a scale of 0 (no engorgement) to 4 (complete rigidity)
*# '''Sexual Health Inventory of Men (SHIM)'''
*#* Five questions that provide a score out of 25 for the subjective patient-reported assessment of erectile dysfunction
*# '''International Index of Erectile Function (IIEF)'''
*** '''Consists of 15 questions that quantify 5 domains (follows typical sequence):'''
***# '''Sexual desire'''
***# '''Erectile function'''
***# '''Intercourse satisfaction'''
***# '''Ejaculatory/orgasmic function'''
***# '''Overall sexual satisfaction'''
** Validated in heterosexual population, but has been shown to be efficacious in then men who have sex with men (MSM) population
* '''2018 AUA: recommended'''
* '''2021 CUA: can be useful'''

=== Specialized testing ===

* Can be used to differentiate between organic and non-organic causes of ED when the patient’s history is conflicting and in medico-legal cases
* '''2021 CUA: rarely required in the routine assessment of patients with ED'''
* '''2018 AUA: For some men with ED, specialized testing and evaluation may be necessary to guide treatment. Specialized testing should only occur if findings will affect management'''
* '''Situations that may require more detailed evaluation include men with ED who are'''
*# Young
*# Strong likelihood of primary psychogenic etiology
*# Strong family history of cardiac illness
*# Concomitant PD
*# History of pelvic trauma
*# Failed prior ED therapies
*# Lifelong ED
* '''Nocturnal Penile Tumescence and Rigidity (NPTR) testing'''
** '''Quantifies the number, duration, and rigidity of nocturnal erections'''
** Involves placement of two strain gauges on the penile shaft to measure radial rigidity during sleep; the device is used over several nights’ sleep
** Historically used to '''differentiate psychogenic from organic causes of ED''', with the presumption that men with psychogenic ED would have preservation of nocturnal penile erections. However, '''test is prone to false negatives and may be less useful in men with impaired sleep schedules.'''
** '''Recommended criteria for normal NPTR include:'''
**# '''4-5 erectile episodes per night'''
**# '''Mean duration >30 minutes'''
**# '''Increase in circumference >3cm at the base and >2cm at the tip'''
**# '''Maximal rigidity >70% at both base and tip'''
** Limited availability in Canada and costs are not covered by most provinces
* '''Audiovisual and vibratory stimulation'''
** Erotic stimulation by explicit videotape material with monitoring has been used as a reliable as well as a time- and cost-effective alternative to NPTR to '''differentiate psychogenic from organic causes of ED'''
* '''In-office testing (3)'''
*# '''Intracavernosal injection (ICI)'''
*#* An erectogenic agent (e.g., prostaglandin E1, papaverine, and/or phentolamine) is injected into the corpora cavernosa of the penis. Erectile response is assessed 5-10 minutes post injection and typically after sexual stimulation (e.g. masturbation, exposure to audiovisual sexual stimulation). The erectile response is observed and rated by an independent assessor.
*#* The test is designed to bypass neurologic and hormonal influences involved in the erectile response and '''evaluates veno-occlusive function of penis. A normal test,''' based on the assessment of a sustainably rigid erection, '''signifies normal erectile hemodynamics'''. Alternative diagnoses of psychogenic, neurogenic, or endocrinogenic ED may then be considered.
*#* For some men, the sympathetic tone and '''anxiety''' involved with in-office penile '''injection may override the injection agent’s activity, leading to a false positive diagnosis of ED'''. '''Repeat dosing is recommended in such cases.'''
*#* In addition to providing information on penile vascular status, ICI may be useful to assess for penile deformities such as Peyronie’s disease
*# '''Penile duplex ultrasound'''
*#* '''Currently the gold-standard (most reliable, least invasive) in penile vascular evaluation'''
*#* '''Evaluates both cavernous arterial inflow and the veno-occlusive capacity of the penis'''
*#* Used to localize and measure the size and flow through the cavernous vessels, pre- and post-vasoactive injection which allow a more refined assessment of penile circulation. The test '''adds an''' '''imaging dimension and a quantification component to the evaluation of blood flow in the penis, distinct from the ICI evaluation, which relies on the assessor’s judgment alone'''
*#* Uses (4):
*#*# Differentiation of primary psychogenic versus organic etiology for ED
*#*# Identification of men with severe veno-occlusive dysfunction resulting in ED who are unlikely to respond to medical therapy
*#*# Identification of young men who may be candidates for penile revascularization procedures
*#*# Assessment of arterial function in men who may warrant assessment by a cardiologist (i.e., men with predominantly vascular ED)
*#* '''Key parameters derived from penile duplex ultrasound include peak systolic velocity ([PSV],''' cavernosal artery blood flow rate at start of systole) '''and end diastolic velocity ([EDV],''' cavernosal artery blood flow rate at the end of diastole)
*#** '''PSV <25-30 cm/s is considered evidence of arterial insufficiency''' (arteriogenic or vascular ED)
*#*** PSV consistently > 35 cm/s defines normal cavernous arterial inflow
*#** '''EDV >5 cm/s is consistent with veno-occlusive dysfunction''', though different cut-points have been applied.
*#** '''Resistive Index''' (PSV – EDV) / PSV) '''<0.80 is indicative of veno-occlusive dysfunction'''
*# '''Biothesiometry''' (not mentioned in CUA guidelines)
*#* Non-specific term for testing intended to assess for peripheral neuropathies
*#* Has been applied to the penis, most commonly by applying a device that administers vibrations of controlled and consistent intensity
* '''Invasive testing (2)'''
** '''Cavernosometry and cavernosography'''
*** '''Cavernosometry quantifies intracorporal pressure after ICI''' '''and is useful primarily for establishing a diagnosis of veno-occlusive dysfunction.'''
*** '''Typically, cavernosometry is performed in conjunction with cavernosography''' (intracorporal installation of radio-opaque dye''') which''' '''permits detailed localization of any area(s) of leak'''
*** '''Previously used in select patients who were suspected of having a site-specific vasculogenic leak''' resulting from perineal or pelvic trauma or who have had lifelong ED (primary ED). '''Rarely performed in the modern era since surgery for veno-occlusive dysfunction is not recommended''', making anatomical localization from cavernosography largely irrelevant.
** '''Selective internal pudendal angiography'''
*** '''Accurately defines the arterial inflow of the penis'''
*** '''Commonly reserved for'''
***# '''Young patient with ED secondary to a traumatic arterial disruption or the patient with a history of penile compression injury, who is being considered for penile revascularization surgery'''
***# '''Non-ischemic priapism'''