Erectile Dysfunction: Extended Evaluation

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In the ED: Initial Evaluation algorithm the patient had a thorough history, physical examination, and laboratory testing performed. At this stage the patient is ready to be treated (see ED Treatment algorithm). The purpose of the extended evaluation is twofold: (1) to define if the patient has underlying pathology that will impact upon the clinician’s management and (2) to attempt to give the patient a prognosis for his ED (i.e., to determine if the patient is curable or not.) The classic example of the former is a patient diagnosed with venous leak who has used PDE5i without much success. In this scenario, we would move this patient directly to penile injections and not reeducate him about PDE5i use or attempt any other PDE5i. Another example of this concept, based on the recent finding that ED is a harbinger of occult or future coronary artery disease, is the middle-aged healthy man who presents without overt vascular risk factors but has underlying arteriogenic ED revealed on testing. We would suggest to this patient that he seek cardiologic consultation. There is evidence that such men are at greater risk for having an abnormal cardiac stress test. From a prognostic standpoint, the classic example is someone who the clinician believes may have psychogenic ED, as all of such patients are potentially curable. From a causation standpoint, the vast majority of patients with ED have primarily organic ED and this is usually vasculogenic in nature. It is estimated that about 70 % of all men with primarily organic ED have underlying vascular risk factors such as diabetes, hypertension, dyslipidemia, cigarette smoking, or the metabolic syndrome. Such patients sometimes, although not always, have a prior history of vascular disease (myocardial infraction, peripheral vascular disease, or stroke). Other major causes of organic ED include (with approximate estimates) medications (10 %), pelvic surgery (10 %), endocrine problems (3 %), neurological problems (2 %), and other conditions (5 %, lower urinary tract symptoms related to BPH, sleep apnea syndrome, collagen vascular diseases). Thus, a good history and physical examination, combined with judicious use of laboratory testing, will help make most of the nonvascular diagnoses.