Approach
Since the introduction of orally available agents for the treatment of erectile dysfunction (ED), primary care providers have become vital to the screening, evaluation, and initial management of uncomplicated ED. The aetiology of ED is multifactorial and differentiating between organic versus non-organic ED may be less relevant when considering that physical, psychological, and social factors interact.[16] A patient-centred approach is recommended to identify the nature of the problem, as well as any serious or modifiable underlying comorbidities, with specialised testing and evaluation as necessary to guide management.[51]
History of erectile dysfunction
Attention to the history is probably the most important aspect of evaluating a man with ED.
Specific questions regarding the timing of onset of the problem and the quality of the erection, and distinguishing between the ability to obtain versus maintain an erection, may clarify the nature of the dysfunction.
The presence of morning erections and the ability to obtain an erection in the context of self-stimulation may suggest relationship tensions or a psychogenic cause.
Further aspects of the sexual history that require attention include the quality of the man's libido, genital sensation (pain, numbness), and the presence of associated sexual dysfunctions (premature/delayed ejaculation, Peyronie's disease, orgasmic disorders).
Degree of partner satisfaction, relationship and fertility problems, and major life events are important factors.
Interviewing the partner should be considered.
Risk factors
Underlying risk factors that may warrant treatment or help to direct therapy include:
Cardiovascular (hypertension, coronary artery disease, hyperlipidaemia, peripheral vascular disease)
Diabetes mellitus
Depression
Obesity
Alcohol use
Medicine use (antihypertensives, antidepressants, anti-androgenic agents)
History of pelvic surgery/trauma/radiation
Neurological diseases
Endocrinopathies (hyper/hypothyroidism, hypogonadism, corticosteroid use)
Lower renal tract symptoms due to benign prostatic hyperplasia.
In addition to identifying the risk factors, assessing the impact that these comorbid conditions have on the quality of life and ability to perform activities of daily life, including exercise tolerance, is important.[52]
Features distinguishing organic from psychogenic aetiology
Organic aetiology:
Gradual in onset
Occurs in all sexual scenarios (i.e., with partner, nocturnal erections, self-stimulation)
Follows a constant clinical course
Associated with poor non-coital erections
Leads to secondary psychosexual problems, relationship distress, anxiety and/or fear.
Psychogenic aetiology:
Often acute in onset
Varies by situations
Variable in its course
Pre-existing psychosexual disorder is often present and may be related to relationship problems or anxiety and fear
Non-coital erections are usually preserved.
Standardised questionnaires
Standardised questionnaires are an important research tool and clinically can be used before the face-to-face encounter or to quantify the degree of dysfunction.[51]
The most widely used questionnaire is the International Index of Erectile Dysfunction.[53] It addresses all domains of male sexual dysfunction (ED, orgasmic function, sexual desire, ejaculation, intercourse, and overall satisfaction). It is composed of 15 questions.
An abbreviated format of five questions called the Sexual Health Inventory for Men is more commonly used.[54] Questions 3 and 4 address the ability to obtain an erection sufficient for intromission and completion of intercourse, respectively, and have been used in assessing therapeutic endpoints during treatment.[53][54]
Physical examination
The goal of the physical examination is to identify cardiac, vascular, neurological, and hormonal disturbances.
A focused genital examination should include palpation of the penis for abnormalities, such as plaques, deformities, and angulation.
Peyronie's disease is an inflammatory condition characterised by the formation of fibrous, non-compliant nodules in the tunica albuginea, which can impede tunical expansion during penile erection, leading to deformity and bending.[55] Erections may or may not be painful.
The testes are examined for size and abnormalities.
The degree of androgenisation is assessed (hair pattern, gynaecomastia).
Digital rectal examination is not required for evaluation of ED, but benign prostatic hyperplasia is a common comorbidity and should be considered and managed.[51]
Initial diagnostic testing
Laboratory examination should be tailored to individual patient history, to rule out suspected underlying diseases. Routine laboratory testing may include fasting blood glucose to screen for diabetes, haemoglobin A1c in those known to have diabetes, fasting lipid profile, and thyroid-stimulating hormone. Use of hormonal evaluation is controversial and may be considered in cases of suppressed libido. It is performed by testing serum testosterone and followed, if testosterone is low, by follicle-stimulating hormone, luteinising hormone, and prolactin. Investigation of other conditions, such as hyper/hypothyroidism and hypogonadism, should be directed only by clinical suspicion or findings.
Specialised tests and consultant referral
Consultation should be considered in cases where standard therapies are contraindicated, or if there are abnormal findings on examination. Certain scenarios benefit from more specialised investigations due to a concurrent problem or unusual aetiology requiring other intervention.
Patients with indeterminate or increased cardiac risk should receive comprehensive cardiac evaluation to determine the appropriateness of ED-specific therapy, to address modifiable risk factors, and to treat the underlying cardiac disease when present.
Men who have Peyronie's disease may respond to oral agents to improve rigidity of erection, but the penile curvature, unless surgically corrected, may prohibit satisfactory intercourse.
In cases of pelvic, perineal, or genital trauma, Doppler ultrasonography should be considered before proceeding with penile implant, and a pelvic/penile angiography may be required to evaluate for an arteriovenous fistula or arterial obstruction, which may require surgical penile revascularisation.
Men who have purely psychogenic ED may benefit from referral to rule out treatable pathology. Additionally, involvement of a sexual medicine consultant for intensive sexual therapy may be helpful.
Use of this content is subject to our disclaimer