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Erectile Dysfunction Overview

Diagnosing Erectile Dysfunction

The workup of a patient with ED does not have to be elaborate or expensive. The basic evaluation consists of many components that should be part of a routine physical. Furthermore, a goal-oriented approach (that is, an approach concentrating on what can be done or what is available) must be kept in mind. The two key questions that should be answered are: 1) Is there any significant medical problem? and 2) What can be done?

Taking a Medical History

Diagnosis begins with a complete medical history, which every man should have periodically regardless of whether he has erectile dysfunction. Giving an accurate and detailed medical history is essential, because it can disclose diseases that can lead to ED. Risk factors for circulatory problems, which are a major cause of ED, include hypertension, diabetes, smoking, heart disease, peripheral vascular disorders, pelvic trauma or surgery, and blood lipid abnormalities. A history of diabetes or alcoholism may be the cause of neurologic problems. Other neurologic causes, such as multiple sclerosis, spinal injury, or head injuries, will also be covered during the medical history. Your history will also reveal other important causes of ED, such as radical pelvic surgery, radiation therapy, Peyronie disease, penile or pelvic injury, prostatitis, prostate cancer, priapism (abnormally persistent erections that make penetration impossible and may cause permanent damage to the penis), or urinary problems. Your physician will also want to know about any information from previous impotence evaluations or treatments.

Treating erectile dysfunction, and any medical condition, should start by taking a detailed medical history with your doctor.
©2006 Publications International, Ltd.
Treating erectile dysfunction, and any medical condition,
 should start by taking a detailed medical history with your doctor.

You should also be prepared to list the medications (this includes illegal drugs) that you are currently taking or have taken in the past. Since one-fourth of all cases of ED are attributable to medications prescribed for other conditions, this is an extremely important part of the history. If medications are the root of your problem, cutting back on or substituting certain medications may be all that's necessary to conquer it.

Common questions that will be asked as part of the medical history include:
  • Do you have any chest pain?

  • Do you have any shortness of breath?

  • Do you experience pain in the legs with exercise or walking?

  • Do you have a history of hypertension?

  • Does your family have a history of heart disease, diabetes, or prostate cancer?

  • Do you have any swelling in the legs?

  • Do you have any numbness or a loss of sensation in the legs or penis?

  • Do you have curvature of the penis with an erection?

  • Have you experienced any dizziness or fainting?
Your physician will also ask you for a detailed and honest sexual history. This sexual history is necessary to accurately assess your specific complaints. A simple recounting of sexual activity might distinguish between problems with erection, ejaculation, orgasm, or sexual desire. Flagging sexual desire, for instance, could indicate a hormonal imbalance. The doctor will ask when the problem started and how often it occurs. And you will be asked about the quality and duration of erections, whether you experience nocturnal (nighttime) or morning erections, and whether you are able to have satisfying sex.

Other questions may cover details of sexual technique, patient and partner expectations, and the patient's specific motivation for treatment. The doctor will look at relationship and emotional factors to see if they have any bearing on your difficulties. Are you experiencing performance anxiety? Are there family problems or problems with your partner? Ideally, your partner should be part of this process and should be encouraged to come along. This will give her the opportunity to support you and to contribute to the discussion. And it will be helpful for her to hear firsthand about the causes and treatments for ED. If she does attend, she will also be interviewed, although not necessarily at the same time that you are. A written questionnaire may be helpful, but it shouldn't substitute for the interview. Finally, the physician will want to know what you hope to get out of treatment.

Psychological Screening

A good medical history includes a psychological assessment. Various psychological tests and sexual questionnaires may be used, if indicated. If the initial evaluation indicates that the erectile problem is primarily psychological or that a major relationship problem exists, your doctor will refer you to a qualified mental health professional, such as a psychiatrist, psychologist, or social worker. The same is true if you have a history of any psychiatric disorders.

The Physical Examination

A physical examination is the second step in the diagnostic process. The exam can give clues to systemic problems. For example, if the penis does not respond as expected to certain touching, a problem in the nervous system may be responsible for the dysfunction. If examination reveals abnormal secondary sex characteristics, such as hair distribution, hormonal problems involving the endocrine system might be the cause. The exam will also include pulse rates in the arteries of the legs and lower extremities. Circulatory problems might be indicated by the pulse rates or perhaps by discovery of an aneurysm in the abdomen.

The physician will also examine the genitals, evaluating testes size and consistency. Unusual characteristics of the penis might explain the cause of the dysfunction. For example, severe angulation of the shaft during erection could be the result of Peyronie disease. The physician will also perform a digital rectal exam to evaluate prostate size and anal sphincter tone.

Laboratory Tests

Simple blood tests can also be an effective tool in diagnosing erectile dysfunction.
©2006 Publications International, Ltd.
Simple blood tests can also be an
effective tool in diagnosing
 erectile dysfunction.

Several simple laboratory tests can also help indicate the causes of ED. Typically, the tests for systemic diseases will include complete blood counts, urinalysis, lipid profile, measurement of creatinine and liver enzymes, and fasting blood sugar. Hormonal evaluation includes thyroid examinations. Laboratory evaluation will also include a morning serum testosterone test. ED caused solely by low testosterone levels is unusual, but lowered sexual desire as a result of low testosterone may be a contributing cause. If a low testosterone level is reported, you will be retested.

Additional Tests for Erectile Dysfunction

Healthy men have involuntary erections during sleep, so if you don't have nocturnal erections, it is likely that there is a physical, rather than a psychological, cause for your ED experiences. When a patient reports no erections whatsoever or when a psychological cause is suspected, a nocturnal penile tumescence test can be helpful. This test monitors erections that occur during sleep, either by using a Velcro band or another, more sophisticated tool. You should be aware, however, that the nocturnal penile tumescence tests are not completely reliable and are rarely indicated. Scientists have not standardized such tests, and doctors have not determined when they should be used to obtain the best results.

When diagnostic tests are inconclusive, further studies, including invasive tests, may be necessary. Further testing is also necessary for patients who are considered candidates for vascular surgery. Additional testing might include intracavernous pharmacologic injection -- an injection of a drug such as papaverine, phentolamine, or prostaglandin into the corpora cavernosa. If the injection produces a fast and sustained erection, the test can eliminate any significant arterial or venous insufficiency. The injection test also indicates good candidates for injection therapy.

Patients who are candidates for vascular surgery or who want more accurate assessment of their arterial functions may undergo other tests including ultrasonography, cavernosometry/cavernosonography, and pharmacologic pelvic or penile angiography. However, the effectiveness of these procedures is limited by appropriate patient selection, the skill of the professional doing the testing, the variable interpretation of results, and the poor predictability of success of arterial and venous surgery. Further research is necessary to develop standards for methodology and interpretation of results.

The medical and sexual histories, the physical exam, and the laboratory tests will all help your physician determine whether your problem with ED is primarily physical, psychological, or a combination of the two. Once the diagnosis is made, your doctor will help you determine how to proceed. Depending on the cause, you may be referred elsewhere for help. If you have a hormonal imbalance, for instance, you may be referred to an endocrinologist for further evaluation. Or perhaps the initial results suggest that you'd benefit from a complete neurologic evaluation. If psychological causes are suspected, you will be urged to seek further psychological evaluation and therapy. No matter what the diagnosis, treatment is available. In the next section, we help you get that treatment for erectile dysfunction. From when to see a doctor to who you should take with you, we'll cover all the bases.

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This information is solely for informational purposes. IT IS NOT INTENDED TO PROVIDE MEDICAL ADVICE. Neither the Editors of Consumer Guide (R), Publications International, Ltd., the author nor publisher take responsibility for any possible consequences from any treatment, procedure, exercise, dietary modification, action or application of medication which results from reading or following the information contained in this information. The publication of this information does not constitute the practice of medicine, and this information does not replace the advice of your physician or other health care provider. Before undertaking any course of treatment, the reader must seek the advice of their physician or other health care provider.