History
In assessing a patient with erectile dysfunction (ED), the first step is to gather the following information:
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Sexual history
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Medical and surgical history
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Medication and nonprescription drug history
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Psychological history
ED is a sensitive topic, and the clinician must be aware of the patient’s comfort level. Taking the history provides an opportunity for the physician to initiate patient and partner education about ED and its treatments and to facilitate communication. It also allows the physician to establish a rapport with the couple, which assists in treatment. Formal questionnaires may be valuable in this setting.
Sexual history
Even clinicians who are not comfortable dealing with ED should inquire into the sexual aspect of the patient’s health. A simple way to do this is simply to ask, “How’s your sex life? Everything working all right?” This type of inquiry should elicit a clear, quick, direct “Everything’s fine” from the patient. Any other response or even just a delay in answering should suggest potential ED in that patient.
If ED is a possibility, questioning should be aimed at determining which part of the sexual response is abnormal. A clear description of the problem is vital. The following information should be elicited:
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Whether the patient has difficulty obtaining an erection
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Whether the erection is suitable for penetration
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Whether the erection can be maintained until the partner has achieved orgasm
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Whether ejaculation occurs
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Whether both partners experience sexual satisfaction
Taking the sexual history also allows the clinician to begin forming an objective opinion regarding the interpersonal relationship between the patient and his sexual partner.
Premature (early) ejaculation generally occurs in men younger than 40 years. This problem can place a great deal of stress on the couple’s relationship. A history of premature ejaculation can be obtained from many men who present in later years with erectile difficulty. Effective treatments, including selective serotonin reuptake inhibitor (SSRI) medications and sex therapy, are available to remedy this condition. (See Premature Ejaculation.)
The sexual history may include specific questions such as the following:
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Are you ever able to obtain an erection suitable for penetration, even momentarily?
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Is your ED getting worse or stable?
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How long have you had trouble attaining or maintaining an erection?
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How hard is the erection, on a scale of 0-100?
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Is maintaining the erection a problem?
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Have you ever had a traumatic sexual experience?
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Are you able to achieve orgasm and ejaculation?
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Approximately how long are able to have intercourse before ejaculating?
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Do you use any type of contraceptives, such as condoms?
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Do you experience nocturnal or morning erections?
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Does pain or discomfort occur with ejaculation?
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Do you have premature (early) ejaculation?
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Is penile curvature (Peyronie disease) a problem?
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How frequently do you have sexual activity? Is it typically spontaneous or planned?
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If your erections were functional, what would be your preferred frequency of intercourse? Do you and your sexual partner agree on this issue?
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Is adequate foreplay occurring? Is your sexual partner satisfied with the sexual experience?
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Have you already tried any treatments? If so, what were they? Are you interested in trying a particular treatment first? Are you opposed to trying a particular type of therapy?
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To what degree do you wish to proceed in determining the cause of the ED? How important is this to you?
Medical and surgical history
Information should be obtained about any previous surgical procedures or other medical disorders. In particular, in addition to general medical information, any history of pelvic surgery, trauma, previous prostate surgery, or irradiation of the prostate should be elicited.
Inquiries should be made regarding cardiovascular risk factors, such as hypertension, diabetes, obesity, dyslipidemia, and family history of cardiac disease. For example, there is an established link between obesity and ED in men. [60]
The Princeton Consensus Conference is a multispecialty collaborative tradition dedicated to optimizing sexual function and preserving cardiovascular health. It has the following two primary objectives:
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To focus on evaluating and managing cardiovascular risk in men with ED and no known cardiovascular disease (CVD), with a particular emphasis on identifying those who may require additional cardiologic workup
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To focus is on reevaluating and modifying previous recommendations for evaluation of cardiac risk associated with sexual activity in men with known CVD
The Second Princeton Consensus suggests that men with ED and no obvious cause are at high risk for subclinical coronary artery disease (CAD) and should undergo, at the least, screening for blood glucose and lipids and blood pressure measurement. [61]
The Third Princeton Consensus focuses on (1) emphasizing the use of exercise ability and stress testing to ensure that each man’s cardiovascular health is consistent with the physical demands of sexual activity before prescribing treatment for ED and (2) highlighting the link between ED and CVD, which may be asymptomatic and may benefit from cardiovascular risk reduction. [8]
ED has been demonstrated to be a harbinger of potential future cardiovascular events. [57] The development of ED has proved to be a precursor to symptomatic CAD in men, with an average lead-time of 38.8 months. [62] Since 2005, several observational studies have shown a strong correlation between ED and CAD, and subsequent large longitudinal studies have demonstrated that men with ED have a 65-85% increased risk of subsequent CAD. [63]
Medication and nonprescription drug history
It is important to obtain a detailed list of all medications taken during the past year, including all vitamins and other dietary supplements. (Patients often neglect to list dietary supplements they have tried in an effort to improve their sexual function.) Numerous prescription medications have been associated with ED, including the following:
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Antihypertensive drugs
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Antiulcer drugs (eg, proton pump inhibitors [PPIs] and cimetidine)
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Lipid-lowering (eg, statins and fibrates) [64]
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5-Alpha reductase inhibitors (eg, finasteride and dutasteride) [65]
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Antidepressants
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Antipsychotic drugs (especially risperidone) [66]
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Testosterone and anabolic steroids
In addition to prescription drug use, tobacco use, alcohol intake, caffeine intake, and illicit drug use should be documented. A smoking history is particularly important, in view of the contribution of smoking to vascular disease.
Psychological history
Factors that give rise to stress factors and tension, whether at work or at home, should be explored. The patient’s psychological state should be assessed, with particular attention to the following:
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Indications of depression
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Loss of libido
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Problems and tension in the sexual relationship
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Insomnia
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Lethargy
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Moodiness
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Stress from work or other sources
It is especially important to have the patient explain his own interpretation of the problem. To this end, questions such as the following may be asked:
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Did the onset of ED coincide with a specific event, such as a major operation or a divorce? Have you experienced the death of a spouse or family member?
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Do you have diminished sexual desire? If so, how long have you had this? Is your diminished sexual desire a primary symptom, or is it a reaction to poor sexual performance?
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Do you have any feelings of performance anxiety?
Pure psychogenic impotence is relatively uncommon. It is characterized objectively by the presence of good nocturnal and morning erections and negative findings on all other tests. However, a psychogenic component often is present in men with organic ED. A history of highly variable erections that can be totally absent one day but virtually normal the next suggests a psychogenic cause. Virtually 100% of men with severe depression have ED.
Use of formal questionnaires
Various formal questionnaires have been developed to gather objective data regarding ED and to assist clinicians in the evaluation of their patients, [67, 68] including the following:
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International Index of Erectile Function (IIEF)
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Sexual Encounter Profile (SEP)
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Global Assessment Question (GAQ)
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Psychological and Interpersonal Relationship Scales (PAIRS)
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Self-Esteem and Relationship (SEAR) questionnaire
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Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS)
The IIEF is a sensitive, specific, and standardized tool that has been validated in several languages. [46] This 15-question instrument evaluates 5 domains: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and global satisfaction. It is used to evaluate pharmacologic and other therapies for the treatment of ED.
A shorter version of the IIEF, termed the IIEF-5, has been developed as a sexual health inventory for men. [45] This tool is helpful in screening patients for ED, a problem that many men are hesitant to discuss. In the IIEF-5, the patient is asked the following 5 questions with respect to the preceding 6 months:
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How do you rate your confidence that you could achieve and maintain an erection?
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When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
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During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?
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During sexual intercourse, how difficult was it to maintain your erection to the completion of intercourse?
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When you attempted sexual intercourse, how often was it satisfactory for you?
The answers to these 5 questions are each scored on a scale of 0-5. A score of 25 is typical for a healthy man; scores of 11 or lower indicate moderate-to-severe ED. After completion of the IIEF or the IIEF-5 and a discussion with the patient, the physician should have a good understanding of the nature and scope of the patient’s problem.
The SEP is commonly used in clinical trials involving pharmacologic therapies for ED. It is a diary maintained by men after each sexual attempt, consisting of a series of yes/no questions regarding specific aspects of each encounter, as follows [69] :
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Were you able to insert your penis into your partner’s vagina?
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Did your erection last long enough for you to complete intercourse with ejaculation?
The GAQ has also been used in clinical trials. The questions are as follows:
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Has the treatment you have been taking improved your erectile function?
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If yes, has the treatment improved your ability to engage in sexual activity?
Psychosocial questionnaires have been developed, but they are infrequently used in clinical practice. They have been employed in clinical trials for product development.
The PAIRS is a self-administered questionnaire containing 3 domains (sexual self-confidence, time concerns, and spontaneity) related to the broader psychological and interpersonal outcomes associated with ED and its treatment. Patients rate their agreement or disagreement with a specific statement on a scale of 1 (“strongly disagree”) to 4 (“strongly agree”). If more than 50% of data are missing from a domain for any patient at any given visit, then that domain is considered missing for that patient at that visit. [70]
The SEAR questionnaire [71] is a subject-reported measure of psychosocial outcomes in men with ED. It consists of 14 items assessing two domains, as follows:
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Sexual relationship (items 1-8)
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Confidence (items 9-14)
The confidence domain consists of two subscales, as follows:
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Self-esteem (items 9-12)
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Overall relationship (items 13 and 14)
The EDITS is a reliable and validated questionnaire used to assess patients’ satisfaction with their ED treatment. For each question, satisfaction is rated on a scale of 0 (“extremely low treatment satisfaction”) to 4 (“extremely high treatment satisfaction”). [67]
Physical Examination
A physical examination is necessary for every patient, with particular emphasis on the genitourinary, vascular, and neurologic systems. A focused physical examination entails evaluation of the following:
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Blood pressure
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Peripheral pulses
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Sensation
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Status of the genitalia and prostate
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Size and texture of the testes
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Presence of the epididymis and vas deferens
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Any penile abnormalities, such as hypospadias and Peyronie plaques
The physical examination may corroborate history findings or may reveal unsuspected physical findings, such as penile plaques, small testes, evidence of possible prostate cancer, prostate infections, or hypertension.
Several studies have found a strong correlation between hypertension and ED—not surprisingly, given that both are manifestations of a vascular disorder. In a large hypertension clinic, men who also demonstrated ED had a much higher prevalence of complications related to high blood pressure. It has been suggested that hypertensive patients with ED and poor cavernosal artery blood flow as measured during duplex ultrasonography studies should proceed to a full cardiac evaluation because of the high prevalence of associated problems.
A number of studies have shown a correlation between benign prostatic hyperplasia and ED. The cause of this correlation is not yet clear.
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These images depict penile anatomy. Note the sinusoidal makeup of the corpora and thick fascia (ie, Buck fascia) that covers the corpora cavernosa. The major blood vessels to the corpora cavernosa enter through tributaries from the main vessels running along the dorsum of the penis.
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Vascular anatomy of the penis.
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This penile tumescence monitor is placed at the base and near the corona of the penis. It is connected to a monitor that records a continuous graph depicting the force and duration of erections that occur during sleep. The monitor is strapped to the leg. The nocturnal penile tumescence test is conducted on several nights to obtain an accurate indication of erections that normally occur during the alpha phase of sleep.
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The presence of normal skin sensation adequate to produce an erection is measured with this device.
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A vasodilator such as prostaglandin E1 can be injected into one of the corpora cavernosa. If the blood vessels are capable of dilating, a strong erection should develop within 5 minutes.
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Erectile dysfunction. This diagram depicts a cross-section of penile anatomy and is used to instruct patients in the technique of administering intracorporeal medications.
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The Medicated Urethral System for Erections (MUSE) is a small suppository placed into the urethra with this device.
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This image depicts a vacuum device used to produce an erection (also see next image). In this image, the elements are shown. They include the cylinder, a pump to create a vacuum, and a constriction ring to be placed at the base of the penis after an erection has been obtained in order to maintain the erection.
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This image demonstrates the vacuum device in place (see previous image). Note the presence of the constricting ring at the base of the penis.
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This is one of many types of constricting devices placed at the base of the penis to diminish venous outflow and improve the quality and duration of the erection. This is particularly useful in men who have a venous leak and are only able to obtain partial erections that they are unable to maintain. These constricting devices may be used in conjunction with oral agents, injection therapy, and vacuum devices.
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Two rigid cylinders have been placed into the corpora cavernosa. This type of implant has no inflation mechanism but provides adequate rigidity to the penis to allow penetration.
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This inflatable penile prosthesis has 3 major components. The 2 cylinders are placed within the corpora cavernosa, a reservoir is placed beneath the rectus muscle, and the pump is placed in the scrotum. When the pump is squeezed, fluid from the reservoir is transferred into the 2 cylinders, producing a firm erection. The deflation mechanism is also located on the pump and differs by manufacturer.
Tables
Vascular causes |
Atherosclerosis Peripheral vascular disease Myocardial infarction Arterial hypertension Vascular injury from radiation therapy Vascular injury from prostate cancer treatment Blood vessel and nerve trauma (eg, from long-distance bicycle riding) Medications for treatment of vascular disease |
Systemic diseases |
Diabetes mellitus Scleroderma Renal failure Liver cirrhosis Idiopathic hemochromatosis Cancer and cancer treatment Dyslipidemia Hypertension |
Neurologic causes |
Epilepsy Stroke Multiple sclerosis Guillain-Barré syndrome Alzheimer disease Trauma |
Respiratory disease |
Chronic obstructive pulmonary disease Sleep apnea |
Endocrine conditions |
Hyperthyroidism Hypothyroidism Hypogonadism Diabetes |
Penile conditions |
Peyronie disease Epispadias Priapism |
Psychiatric conditions |
Depression Widower syndrome Performance anxiety Posttraumatic stress disorder |
Nutritional states |
Malnutrition Zinc deficiency |
Hematologic diseases |
Sickle cell anemia Leukemias |
Surgical procedures |
Brain and spinal cord procedures Retroperitoneal or pelvic lymph node dissection Aortoiliac or aortofemoral bypass Abdominal perineal resection Proctocolectomy Transurethral resection of the prostate Radical prostatectomy Cryosurgery of the prostate Cystectomy |
Medications |
Antihypertensives Antidepressants Antipsychotics Antiulcer agents (eg, cimetidine) 5-Alpha reductase inhibitors (eg, finasteride and dutasteride) Cholesterol-lowering agents Methadone |
Treatment |
Advantages |
Disadvantages |
Semirigid or malleable rod implants |
Simple surgery Relatively few complications No moving parts Least expensive implant Success rate of 70-80% Highly effective |
Constant erection at all times May be difficult to conceal Does not increase width of penis Risk of infection Permanently alters or may injure erection bodies Most likely implant to cause pain or erode through skin If unsuccessful, interferes with other treatments |
Fully inflatable implants |
Mimics natural process of rigidity-flaccidity Patient controls state of erection Natural appearance No concealment problems Increases width of penis when activated Success rate of 70-80% Highly effective |
Relatively high rate of mechanical failure Risk of infection Most expensive implant Permanently alters or may injure erection bodies If unsuccessful, interferes with other treatments |
Self-contained inflatable unitary implants |
Mimics natural process of rigidity-flaccidity Patient controls state of erection Natural appearance No concealment problems Simpler surgical procedure than that required for fully inflatable prosthesis Success rate of 70-80% Highly effective |
Sometimes difficult to activate the inflatable device Does not increase width of penis Mechanical breakdowns possible Long-term results not available Risk of infection Relatively expensive Permanently alters or may injure erection bodies If unsuccessful, interferes with other treatments |
