Erectile Dysfunction Diagnostic Evaluation

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Diagnosis and Treatment of Erectile Dysfunction

An erectile dysfunction diagnosis is generally made by the patient without any examination or testing. This is unlike a diagnosis of high blood pressure which is made by a test to measure the blood pressure or a diagnosis of diabetes which is made by checking the blood sugar. There is no erectile dysfunction test to make the diagnosis. When a man has a problem achieving or maintaining an erection, he has erectile dysfunction and should not avoid seeing a doctor.

The evaluation of a patient with erectile dysfunction (ED) includes a complete history and physical exam to identify any medical conditions that may be contributing factors. In some cases, hormone testing is indicated.

There are many tests that can be performed to help determine the specific cause of the erectile function. When considering the “differential diagnosis of erectile dysfunction”, the objective is to find out the specific underlying problem. ED can be neurogenic (caused by a nerve problem) or more often vasculogenic (caused by a vascular problem). The erectile dysfunction diagnosis of vascular ED can be then further sub-divided into a problem with inadequate blood entering the penis (arterial insufficiency) or the blood not being stored and escaping (venous leak). The following are erectile dysfunction evaluation tests:

Penile Duplex with Pharmacological Erection

Of all of the erectile dysfunction diagnostic testing options, the penile duplex is the one test we most commonly perform (when indicated). For this test, a penile ultrasound (called a penile duplex) is performed, and this provides anatomical information. It also provides some information about the blood vessels (arteries and veins) that supply the penis. The most useful information is obtained after an erection is induced by the injection of a small amount of medication into the base of the penis with a very small needle that causes an erection. When the penis is erect, the blood flow through certain arteries (eg. dorsal arteries) can be measured (velocity) to assess for arterial insufficiency, and this test also can be used to assess for venous leak.

We find that this test is most useful in men with pelvic fracture trauma associated erectile dysfunction who may have specific artery injuries and men with Peyronie’s Disease (a disorder of penile curvature) seeking graft surgery to straighten the penis to see if there is any venous leak as this finding would be a contraindication for a graft.

Risks of a penile duplex include a painful prolonged erection that requires urgent treatment.

Direct Infusion Cavernosometry and Cavernosography

This is a very sophisticated test that involves the injection of vasoactive medication into the penis and the use of needles placed on both sides of the penis. Saline is infused at a certain rate as monitors to measure penile pressure. This may be followed by the injection of contrast for radiographic imaging. This test was more commonly performed in the 1990s and has fallen out of favor.

Pudendal Angiogram

This is an invasive vascular test performed by an Interventional Radiologist in an Imaging Center. In some ways it is similar to a coronary arteriogram-angiogram where instead of getting images of the arteries providing blood supply to the heart, the pudendal arteriogram provides information related to the blood supply to the penis. The reason it is called “pudendal” angiogram is because the pudendal artery branches into the different blood vessels that enter the penis. This is a test we use only in very selected cases when planning penile revascularization surgery, which is only indicated in very select cases, such as when there is a specific artery injury in a young man from pelvic fracture trauma.

Erectile Dysfunction Evaluation: When to do tests and when not to do tests

When tests are performed, this is beneficial to the doctor as there is generally financial compensation. When a test is done, information is obtained, and the patient may benefit by feeling like he is getting quality care when a number of tests are being performed to try to “get to the bottom” of the cause of the erectile dysfunction. What we consider most important when deciding if we should do a test or not do a test is if and how it benefits the patient.

Many of these erectile dysfunction tests are invasive, and can be uncomfortable, and are not without risks. Therefore, our approach to testing is to recommend testing only when the information obtained influences decision making. If the test shows “A” we do this, and if it shows “B”, we do that.

In most patients who seek treatment of their erectile dysfunction, none of these tests are indicated, as these tests often do not influence management. For most patients, the appropriate management of erectile dysfunction is to identify the least invasive treatment that works. In general, the first treatment option that should be recommended is oral medication such as Viagra, and if an invasive test would not change that recommendation, regardless of the test result, we would not consider that test to be indicated.