Diagnosing Erectile Dysfunction

• Men are frequently reluctant to discuss their sexual problems, particularly erectile dysfunction or ED, and often need to be specifically asked.
• You can assist and initiate this process just by telling your doctor directly that erectile dysfunction is a problem for you. Opening a dialogue allows your doctor to begin the investigation or refer you to a consultant.
• Scheduling enough time with your doctor to conduct a full interview and physical examination is important.
• After performing a full interview, physical examination, and laboratory testing, your doctor can then discuss your particular situation, the most likely cause, and reasonable treatment options.

The first step in the medical management of erectile dysfunction is taking a thorough sexual, medical, and psychosocial history. This is a delicate topic, and your doctor should be sensitive and caring to make you comfortable about sharing these intimate details of your private life.

While conducting a full interview, specific questions like these will probably be asked:

• Your doctor will ask if you have difficulty obtaining an erection, if the erection is suitable for penetration, if the erection can be maintained until the partner has achieved orgasm, if ejaculation occurs, if you have lost interest in sex (libido), and if both partners have sexual satisfaction.
• You will be asked about current medications you are taking, about any surgery you may have had, and about other disorders (eg, history of trauma, prior prostate surgery, radiation therapy).
• The doctor will want to know all medications you have taken during the past year, including all vitamins and other dietary supplements.
• Tell the doctor about your tobacco use, alcohol intake, and caffeine intake, as well as any illicit drug use.
• Your doctor will be looking for indications of depression. You will be asked about libido (sexual desire), problems and tension in your sexual relationship, insomnia, lethargy, moodiness, nervousness, anxiety, and unusual stress from work or at home.
• You will be asked about your relationship with your sexual partner. Does your partner know you are seeking help for this problem? If so, does your partner approve? Is this a major issue between you? Is your partner willing to participate with you in the treatment process?

Your doctor will also want your candid answers to questions like these:

• How long has a problem existed? Did a specific event, such as a major surgery or a divorce, occur at the same time?
• Do you have diminished sexual desire? If so, do you think it is just a reaction to poor sexual performance?
• How hard or rigid are your erections now? Are you ever able to obtain an erection suitable for penetration even momentarily? Is maintaining the erection a problem?
• Can you achieve orgasm, climax, and ejaculation? If so, does it feel normal to you? Does the penis become somewhat rigid at climax?
• Do you still have morning erections?
• Is penile curvature (Peyronie's disease) a problem?
• What would be your preferred frequency of intercourse, assuming the erections were working normally? How would your sexual partner answer this same question? What was your sexual frequency before the erections became a problem?
• Have you already tried any treatments for erectile dysfunction? If so, what were they and how did they work for you? Were there any problems or side effects to their use?
• Are you interested in trying a particular treatment first? Are you against trying any particular type of therapy? If so, what caused you to make this judgment?
• To what degree do you wish to proceed in determining the cause of your erectile dysfunction? How important is this information to you?

A physical examination is necessary. During this examination, your doctor will pay particular attention to the genitals as well as the nervous, vascular, and urinary systems. Your blood pressure will be checked because several studies have demonstrated a connection between high blood pressure and erectile dysfunction.

The physical examination will confirm the information you gave the doctor in your medical history and may help reveal unsuspected disorders, such as diabetes, vascular disease, penile plaques (scar tissue or firm lumps under the skin of the penis), testicular problems, low male hormone production, injury or disease to the nerves of the penis, and various prostate disorders.

Laboratory testing is needed for some men. Tests such as these may be performed:

• Your hormonal status for testosterone (the male hormone) is evaluated, particularly if one of your symptoms is low sexual desire (low libido).
  • Blood tests for testosterone should ideally be taken early in the morning because that is when levels are usually at their highest.
  • Blood may also be tested for other hormones that can affect sexual function (eg, luteinizing hormone, prolactin).
• Your blood may be checked for glucose (sugar), cholesterol, thyroid function, triglycerides, and prostate specific antigen (PSA).
• A urinalysis looking for blood cells, protein, and glucose (sugar) may also be done.

An ultrasound examination of your penis and testicles may be performed. The principle of ultrasound is similar to the sonar used on submarines. Sound waves are reflected back when they contact relatively dense structures, such as fibrous tissue or blood vessel walls. These reflected sound waves are then converted into pictures of the internal structures being studied.

In diagnosing the cause of erectile dysfunction, an ultrasound may be done on the lower abdomen, the pelvis, and the testicles, or it may be restricted to just the penis.

• A duplex ultrasound is a diagnostic technique that uses painless, high frequency sound waves to measure blood flow in structures such as the penis.
• The procedure itself is painless. It is usually performed before and after injection of a smooth muscle relaxing medication into the penis, which should significantly increase the diameter of the penile arteries.
• A duplex ultrasound is most useful in evaluating possible penile arterial disorders. Further studies of the venous drainage system as well as arterial imaging are usually recommended if vascular reconstructive surgery is anticipated.

Following completion of a full interview, physical examination, and laboratory testing, your doctor should be able to determine the general type of dysfunction and the need for any additional testing. Such tests include penile or pelvic blood flow studies, nocturnal penile tumescence testing, penile biothesiometry (nerve testing), and/or more blood tests.

• Numerous devices have been developed to determine if erections occur during sleep. One such example is a snap gauge that is fastened around the penis and opens when an erection occurs.

• One of the most common tests used to evaluate penile function is the direct injection of PGE1 into the penis. PGE1, also called prostaglandin E1 or alprostadil, is a medication that increases blood flow into the penis and normally produces erections.
  • If the penile structure is normal or at least adequate, an erection should develop within several minutes. You and your doctor can judge the quality of the erection.
  • If successful, this test also establishes penile injections as one possible therapy.
• Nocturnal penile tumescence or NPT testing may be useful in distinguishing between psychological causes and physical causes of erectile dysfunction.
  • This test involves the placement of a band around the penis that you would wear during 2 or 3 successive nights.
  • If an erection occurs, which is expected during rapid eye movement (REM) sleep, the force and the duration are measured on a graph.
  • Inadequate or no erections during sleep suggest a physical (or organic) problem, while a normal result may indicate a possibility of emotional, psychological, or mental causes.
• Formal neurological testing is not needed for most men, and specialized nerve conduction studies are only performed in selected cases. However, anyone with a history of nervous system problems, such as loss of sensation in the arms or the legs and those with a history of diabetes, may be asked to undergo further neurological testing.
  • Measuring the sensitivity of the skin of the penis to detect vibrations (called biothesiometry) can be used as a simple office nerve function screening test.
  • This test involves the use of a small vibrating test probe placed on the right and left side of the penile shaft as well as on the head of the penis. The strength of the vibrations is increased until you can feel the probe vibrating.
  • Although this test does not directly measure the erectile nerves, it serves as a reasonable screening for possible sensory loss and is simple to perform.

Your doctor will discuss your results with you (including your partner when possible) and summarize any risk factors (eg, smoking, medications) that may be involved. Your doctor will also review with you the various treatment options that can be considered. Together, you and your doctor will develop a strategy to help you and your partner achieve a satisfactory result.

Once significant systemic diseases, such as diabetes or heart disease, are ruled out, an oral medication, such as Viagra, Levitra, or Cialis, may be prescribed. If these agents are successful, further testing is usually not warranted.