Page 3 - Erectile dysfunction

CUA Guidelines on ED

ease, lifestyle factors including illicit drug use, quality • Nocturnal penile tumescence testing (NPTR)
of partners relationship). (Rigiscan)
2. Determine the timing of onset, nature of the prob- • Dynamic infusion cavernosography and caver-
lem, and significance to the partner (if applicable). nosometry (DICC)
The patient (with or without their partner) will guide • Penile and pelvic angiogram
whether treatment is desired.
3. Identify whether a potentially reversible cause to the Diagnosis history
ED exists (medications), stress, depression, hormonal
abnormalities including androgen, thyroid and pitu- Obtaining a diagnostic history is the cornerstone of the eval-
itary, tobacco, excessive alcohol use, drug abuse, and uation of sexual dysfunction and ED. The history will provide
partner-specific issues). Testosterone profile is appro- the likely diagnosis in most cases. 4,6,8 A supportive healthcare
priate at the ED diagnosis if hypogonadism suspected, professional allows the couple to relate their concerns and
but screening is not recommended for all ED patients. express their goals of treatment in an unhurried manner.
4. Establish a likely underlying etiology based on his- A monogamous, heterosexual relationship should not be
tory, physical exam, and lab testing. Obtaining or assumed. Potential etiologies for sexual dysfunction include
confirming recent blood pressure measurements, a wide range of organic and medical factors, but multiple
lipid profile, and glucose/HgBA1C are highly rec- psychological or interpersonal factors (i.e., anxiety, depres-
ommended. sion, relationship distress) can be causal or contributory.
A commonly used schema is:
• Vascular General domains of the history
• Endocrine
• Neurological • Determine specifics related to ED (onset, severity, sig-
• Situational nificance and situations) and desire, arousal, orgasm,
• End organ (penile deformity – Peyronie’s disease or and ejaculation.
trauma) • Sexual desire, relationship issues, stressors at home and
• Mixed (Most cases have an underlying organic cause work.
or causes; similarly most men will subsequently • Genital pain or altered shape.
report anxiety, stress, and depression as a conse - • Lifestyle factors: smoking, substance use/abuse, seden-
quence of ED.) tary lifestyle.
• Comorbid conditions: hypertension, peripheral vascular
Methodology disease, diabetes, obesity, and renal disease.
• Pelvic surgery, radiation or trauma.
1. History and clinical questioning (most important • Medications.
component of the ED evaluation). • Psychiatric illness or conditions.
2. Focused physical examination (directed at anatomic,
vascular and neural systems essential for erections). Questionnaires
3. Use of formalized questionnaire instruments (e.g.,
Sexual Health Inventory for Men [SHIM], Appendix- Use of validated questionnaires may be beneficial. These
http://journals.sfu.ca/cuaj/index.php/journal/article/ tools can be patient self-administered and provide much
view/2699/2022) is recommended but not manda- of the above information in an efficient non-threatening
6
tory, as the questionnaires are useful in establishing manner, while being time-saving and cost-effective. There
baseline function, ED severity, evaluate treatment are validated instruments designed to evaluate sexual and
response, and in most cases questionnaire results do erectile function. The greatest utility of these questionnaires
not add significantly to duration of the doctor-patient may be in establishing a response to therapy and determin-
encounter. ing overall satisfaction with drug use over a specified length
4. Laboratory investigations: serum glucose, lipid pro- of time (i.e., 4 weeks). The most common questionnaire is
file, and in select cases hormonal screening (total the SHIM (Appendix-http://journals.sfu.ca/cuaj/index.php/
testosterone/bioavailable testosterone). journal/article/view/2699/2022). 9
5. Consultation with subspecialists (endocrinology, psy-
chology, cardiology). Physical exam
6. Specialized tests:
• Combined injection and stimulation test (CIS) The aim of a focused physical examination in men with ED is
• Duplex ultrasound with vasoactive penile injection to examine genital anatomy and identify any related abnor-

CUAJ • January-February 2015 • Volume 9, Issues 1-2 25