Patients should understand that lifestyle habits that negatively affect the heart and the peripheral vascular system or the nervous system will also negatively affect the penis . |
chronic renal failure , and hepatic failure , also negatively impact on erectile function . Testosterone levels do decline slightly with age , but are only related to ED in the small minority of men (~ 3-5 %) who are truly hypogonadal and have low hormone levels . Substance abuse , such as excessive intake of alcohol or other recreational drugs is a major contributor to ED .
Smoking , a known cause of arterio-occlusive disease , is clearly a co-factor and probably an independent etiologic factor itself . Penile anatomical defects and Peyronie ’ s disease may contribute to erectile problems . Spinal cord injuries , pelvic and prostate surgery and pelvic trauma are less common causes of dysfunction . Psychogenic disorders , including depression , dysphoria , and anxiety states are associated with an increased incidence of multiple sexual dysfunctions including erectile difficulties . Latrogenic ED can result from nerve disrupting pelvic or prostate surgery ; inadequate glycemic , blood pressure , or lipid control ; and many of the medications commonly used in primary care . Antihypertensive medications , notably diuretics and central acting agents , can cause ED , as can digoxin , psychopharmacologic agents , including some of the newer antidepressants , and antitestosterone hormonal agents .
Investigation medical history
The medical history should include review for risk factors and screening for psychological problems . A medication review , including over-the-counter drugs may reveal the source of the problem since medications have been implicated in up to 25 % of cases of ED .
Some medications have adverse effects on all phases of sexual functioning , making clarification of the patient ’ s complaint a priority before
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ascribing symptoms to specific medication side-effects .
When evaluating for the presence of psychological problems , brief screening for depression may elicit responses . Other psychiatric conditions , such as anxiety , may also be responsible for ED . It is critical that the social history include assessing for stress regarding a relationship or substance abuse including alcohol and cigarettes . Specific questions regarding the presence of claudication during activity ( e . g ., walking up stairs ) or decreased thigh muscle strength or size increases suspicion for pelvic inflow vascular occlusive disease .
Finally , a review of daily activities and of cardiovascular status are important to determine the potential risk for enhancing ED in patients who may have a sedentary lifestyle and who may be at risk for an adverse cardiac event when sexual activity potential is increased .
Sexual history
A sexual history is the most important component of diagnosis . Some physicians may find it useful to use a sexual health questionnaire , and to involve the partner as this will not only confirm the problem , but also may reveal other causes of sexual dysfunction .
Focused physical examination
The physical examination should be comprehensive , with emphasis on several areas . Evaluation of blood pressure , cardiac size and heart sounds , and a complete peripheral vascular examination looking specifically for abdominal or femoral bruits , diminished femoral pulses , orthigh muscle wasting ( signs of decreased pelvic inflow ), may contribute to the diagnosis of vascular disease as an associated cause .
A neurologic examination that includes the evaluation of pelvic sensory function and anal sphincter tone is needed to
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confirm both sympathetic and parasympathetic function .
A digital rectal examination of the prostate should be conducted , and a visual and manual exam of the penis to discover any anatomical defects and help to identify Peyronie ’ s disease . Immature secondary sex characteristics , including lack of male hair distribution , poor penile and testicular development , gynecomastia , and fine wrinkling at the corners of the eyes and mouth , indicate the possibility of hypogonadism .
Laboratory evaluation
Laboratory testing to evaluate ED will confirm risk factors / entities previously identified . A urine analysis to rule out renal disease or infection ; a complete blood count to note any potential hematologic disorder ; a chemistry profile to check for fasting glucose , renal , and hepatic function ; a lipid profile to rule out hyperlipidemia ; and TSH to evaluate thyroid function .
Prostate specific antigen ( PSA ) should be considered in men over age 45 years with risk factors for prostate cancer especially if testosterone treatment is a possibility . A morning serum total testosterone and prolactin level should be measured on all patients , although the threshold level of testosterone for maintaining an erection is unknown .
Borderline or unequivocally low levels require confirmation of diagnosis by measuring calculated free or bioavailable testosterone and sex hormone binding globulin ( SHBG ) levels . SHBG binds 60 % of testosterone and often is low or low normal in obesity and many normal men and therefore results in artifactually low serum total testosterone measurements .
Unequivocally low testosterone measurements additionally require measuring luteinising hormone ( LH ) and prolactin for differential diagnosis . However , the majority
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30 | May 2017 |
The Specialist Forum | Vol . 17 No . 4 |