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 |