Erectile Dysfunction (History, Examination, Investigations)

Definition

consistent or recurrent inability to attain and/ or maintain a penile erection sufficient for sexual intercourse

Epidemiology

• 52 % of men aged 40-70 y (17% mild, 25% moderate, 10% severe) 
• Increases with age (40% of men in their 80’s)

Aetiology 

• Psychogenic causes
• Organic causes 

History 

• Sexual 
• Onset 
• Duration
• Erections (nocturnal, early morning, spontaneous)
• Ability to maintain erections 
• Loss of libido 
• Relationship issues (Frequency of intercourse, sexual desire)
• Questionnaire 
• IIEF 5
• Medical/ Surgical 
• Diabetes 
• Cardiovascular disease (Intermediate/high risk needs treatment before treating ED) 
• hypertension 
• Peripheral vascular disease 
• Endocrine disorders 
• Neurological disorders 
• Pelvic and penile surgery 
• Radiotherapy 
• Trauma 
• Psychosocial 
• Social stresses 
• Anxiety
• Depression
• Coping problems 
• Patient expectations 
• Relationship details 
• Drugs 
• Current medications 
• ED treatments already tried 
• Social 
• Smoking 
• Alcohol consumption

Examination 

• Full physical examination
• Cardiovascular 
• Abdomen
• Neurological 
• BP
• DRE
• Secondary sexual characteristics
• External genitalia (phimosis, penile deformities (peyronie’s plaques))
• Testicles (presence, size, location) 
• The bulbocavernosus reflex (integrity of S2-4) (glans squeeze —> anal sphincter contraction) 

Investigations 

• Blood tests 
• Fasting glucose 
• Serum (free) testosterone (8-11 am) 
• Fasting lipid profile 
• SHBG; U&E; LH/FSH; prolactin; PSA; Thyroid function test (selective cases) 
• Nocturnal penile tumescence and rigidity testing 
• Rigiscan device 
• number, duration, rigidity of nocturnal erections 
• useful for diagnosing psychogenic ED 
• Penile colour doppler Uss: 
• Arterial peak systolic and end diastolic velocities pre and post PGE1 injection
• Cavernosography:
• Measurement of penile blood flow after intracavernosal injection of contrast and artificial erection (to identify venous leaks) 
• Penile arteriography 
• Pudendal arteriography before and after erection to identify those needing arterial bypass surgery
• MRI
• Assess penile fibrosis and severe cases of Peyronie’s disease