Erectile dysfunction (ED) (also called impotence) describes the ‘consistent or recurrent inability to attain and/or maintain a penile erection sufficient for sexual intercourse’.
In men aged 40–70y, mild ED is found in 17%, moderate ED in 25%, and complete ED in 10%. Incidence increases with age, with complete ED affecting approximately 15% of men in their 70’s and 30–40% in their 80’s.
ED is generally divided into psychogenic and organic causes. It is often multifactorial.
Sexual: onset of ED (sudden or gradual); duration of problem; presence of erections (nocturnal, early morning, spontaneous); ability to maintain erections (early collapse, not fully rigid); loss of libido; relationship issues (frequency of intercourse and sexual desire).
Sexual function symptom questionnaires: International Index of Erectile Function; Brief Male Sexual Function Inventory (BMSFI); quality of life questionnaire (QoL-MED).
Medical and surgical: enquire about risk factors, including diabetes mellitus (ED affects 50% overall and 30% of treated diabetics); cardiovascular disease; hypertension; peripheral vascular disease; endocrine or neurological disorders; pelvic and penile surgery, radiotherapy, or trauma (which damage innervation and blood supply to the pelvis and penis). Intermediate or high risk cardiovascular disease requires further specialist assessment and treatment prior to ED treatment.
Psychosocial: assess for social stresses, anxiety, depression, coping problems, patient expectations, and relationship details.
Drugs: enquire about current medications and ED treatments already tried and their outcome.
Social: smoking, alcohol consumption. An organic causeis more likely with gradual onset (unless associated with an obvious cause such as surgery where onset is acute); loss of spontaneous erections; intact libido and ejaculatory function; existing medical risk factors and older age groups.
Full physical examination (cardiovascular, abdomen, neurological); BP; DRE to assess the prostate; assess secondary sexual characteristics; external genitalia assessment to document foreskin phimosis, penile deformities and lesions (Peyronie’s plaques); confirm presence, size, and location of testicles. The bulbocavernosus reflex can be performed to test integrity of spinal segments S2–4 (squeezing the glans causes anal sphincter and bulbocavernosal muscle contraction).
Tests For ED
Blood tests: Fasting glucose; serum (free) testosterone (taken 8.00–11.00 a.m.); fasting lipid profile are basic work-up tests. SHBG; U&E; LH/FSH; prolactin; PSA; thyroid function test should be selected according to patient’s history and risk factor profile.
Nocturnal penile tumescence and rigidity testing: The Rigiscan device contains two rings that are placed around the base and distal penile shaft to measure tumescence and number, duration, and rigidity of nocturnal erections. Useful for diagnosing psychogenic ED and for illustrating this diagnosis to patients.
MRI: Useful for assessing penile fibrosis and severe cases of Peyronie’s disease.