Evaluation for Erectile Dysfunction
Evaluation for Erectile Dysfunction
What would you suggest as a cost-effective and streamlined evaluation for erectile dysfunction (ED) in a middle-aged male?
Wayne J. G. Hellstrom, MD, FACS
Professor of Urology, Chief, Section of Andrology & Male Infertility, Tulane University School of Medicine, New Orleans, Louisiana
ED in a middle-aged man may signify a serious but treatable medical condition. Easy Internet access to oral erectogenic agents may not be in such a man's best interest. A quick and cost-effective medical evaluation is most appropriate in such circumstances.
All ED patients need to undergo a detailed sexual and medical history, a focused physical examination, and related laboratory testing, including testosterone levels, serum glucose, and lipid profile. The presence of risk factors for vascular disease, such as diabetes mellitus, high blood pressure, serum lipid abnormalities, smoking, and history of ischemic heart disease, should be documented. Furthermore, history of penile trauma, chronic renal failure, previous pelvic or genital surgery, and Peyronie's disease can be obtained by questionnaire.
The introduction of validated sexual-function questionnaires over the past few years complement the initial evaluation. The International Index of Erectile Function (IIEF) and the Sexual Health Inventory for Men (SHIM) are 2 of the better known instruments used. A well-organized, brief sexual history can be an effective diagnostic instrument. Questions should review the phases of male sexual response and focus on problems of desire, arousal/erection, orgasm/ejaculation, and pain.
If there are no contraindications (eg, nitrate use), a trial of oral PDE-5 inhibitors is a reasonable diagnostic (and potentially therapeutic) approach for a middle-aged man with ED. If oral agents don't work or are not medically permitted, an office intracavernosal injection with a vasoactive agent (eg, PGE1) can be an important step to differentiate organic from psychogenic ED. In some clinics, the intracavernosal injection can be combined with penile duplex Doppler sonography to evaluate the vascular system of the penis. Abnormalities in the vascular system usually involve referral to a urologist with special interest in the surgical management of impotence. Normal vascular studies may suggest referral to healthcare professionals proficient in the psychogenic aspects of sexual medicine.
Question
What would you suggest as a cost-effective and streamlined evaluation for erectile dysfunction (ED) in a middle-aged male?
Response from Wayne J. G. Hellstrom, MD, FACS
Wayne J. G. Hellstrom, MD, FACS
Professor of Urology, Chief, Section of Andrology & Male Infertility, Tulane University School of Medicine, New Orleans, Louisiana
ED in a middle-aged man may signify a serious but treatable medical condition. Easy Internet access to oral erectogenic agents may not be in such a man's best interest. A quick and cost-effective medical evaluation is most appropriate in such circumstances.
All ED patients need to undergo a detailed sexual and medical history, a focused physical examination, and related laboratory testing, including testosterone levels, serum glucose, and lipid profile. The presence of risk factors for vascular disease, such as diabetes mellitus, high blood pressure, serum lipid abnormalities, smoking, and history of ischemic heart disease, should be documented. Furthermore, history of penile trauma, chronic renal failure, previous pelvic or genital surgery, and Peyronie's disease can be obtained by questionnaire.
The introduction of validated sexual-function questionnaires over the past few years complement the initial evaluation. The International Index of Erectile Function (IIEF) and the Sexual Health Inventory for Men (SHIM) are 2 of the better known instruments used. A well-organized, brief sexual history can be an effective diagnostic instrument. Questions should review the phases of male sexual response and focus on problems of desire, arousal/erection, orgasm/ejaculation, and pain.
If there are no contraindications (eg, nitrate use), a trial of oral PDE-5 inhibitors is a reasonable diagnostic (and potentially therapeutic) approach for a middle-aged man with ED. If oral agents don't work or are not medically permitted, an office intracavernosal injection with a vasoactive agent (eg, PGE1) can be an important step to differentiate organic from psychogenic ED. In some clinics, the intracavernosal injection can be combined with penile duplex Doppler sonography to evaluate the vascular system of the penis. Abnormalities in the vascular system usually involve referral to a urologist with special interest in the surgical management of impotence. Normal vascular studies may suggest referral to healthcare professionals proficient in the psychogenic aspects of sexual medicine.
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