EUROPEAN UROLOGY SUPPLEMENTS 12 (2013) 712

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Diagnostic Evaluation of a Man Presenting with Erectile

Dysfunction

Andrea Salonia *
Department of Urology, University Vita-Salute San Raffaele, Via Olgettina 60, 20132 Milan, Italy

Article info Abstract

Keywords: Context: Erectile dysfunction (ED) has progressively emerged as an important

Erectile dysfunction sentinel marker of cardiovascular and overall health among men. A timely and
Diagnosis accurate diagnosis of ED may thus represent a significant opportunity both to
Cardiovascular disorders diagnose the dysfunction per se and to identify comorbid and potentially life-
Sexual history threatening conditions.
LUTS Objective: To summarise the diagnostic evaluation of the man presenting with ED.
Testosterone Evidence acquisition: The most recently developed European Association of Urol-
Colour duplex Doppler ogy guidelines, International Society for Sexual Medicine recommendations, and
ultrasound standard operating procedures were analysed.
Evidence summary: The basic work-up for a man seeking help for ED should begin
by considering that ED may share several modiable and nonmodiable common
risk factors with cardiovascular disorders and other potentially life-threatening
conditions. In this context, a comprehensive medical history should be taken for
each patient including the assessment of current medications. A thorough sexual
history should also be noted including information about age, sexual orientation,
marital status, and sexual experience to gain a better understanding of the mans
sexual ecology. Physical examination and laboratory tests for patients with ED are
highly recommended but not always necessary. Recommended laboratory tests for
men with ED typically include a fasting glucose and lipids prole if not assessed in
the previous 12 mo. Hormonal tests must include a morning sample of total
testosterone. Some patients may need specic diagnostic tests including the
Rigiscan assessment of nocturnal penile tumescence and rigidity, a dynamic duplex
ultrasound penile blood ow evaluation, a dynamic infusion cavernosometry or
cavernosography, or an internal pudendal arteriography.
Conclusions: Most patients with ED can be adequately managed with a basic
diagnostic work-up that includes a comprehensive medical and sexual history,
along with a physical examination and some laboratory tests. Some selected
patients may also need specic diagnostic tests.
# 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Tel. +39 02 2643 7286; Fax: +39 02 2643 7298.

E-mail address: salonia.andrea@hsr.it.

1. Introduction of the corporeal veno-occlusive mechanism [1]. Erectile

dysfunction (ED), defined as the persistent inability to attain
Erection is a complex neurovascular phenomenon under and maintain an erection sufficient to permit satisfactory
hormonal and psychological control. It includes arterial sexual performance [2], may relate to multifaceted complex
dilation, trabecular smooth muscle relaxation, and activation mechanisms. Among those are disruptions in neural,
1569-9056/$ see front matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.eursup.2013.03.001
8 EUROPEAN UROLOGY SUPPLEMENTS 12 (2013) 712
vascular, and hormonal signalling [1]. ED is highly prevalent
in men of increasing age, with moderate to severe ED rates
ranging between 5% and 20% according to different sources
[3].
ED has progressively emerged as an important sentinel
marker of cardiovascular health and a proxy of overall
health among men [49]. Data suggest that ED may be
significantly linked to an increased risk of cardiovascular
disease (CVD), coronary artery disease, stroke, and all-cause
mortality [6], and the increase is probably even indepen-
dent of conventional cardiovascular risk factors [6,8,10].
A timely and accurate diagnosis of ED represents a
significant opportunity not only to diagnose the dysfunc-
tion per se and the associated etiologic factors but also to
identify comorbid and potentially life-threatening condi-
tions [3,10]. While maintaining the standards of simplicity
and reproducibility, the diagnosis of ED has to be as detailed
as possible. This means taking a thoughtful medical and
sexual history including validated psychometric question-
naires to evaluate subjective complaints. Physical exami-
nation, laboratory testing, and instrumental assessment
must be tailored both to patient complaints and individual
risk factors.
2. Basic diagnostic assessment of erectile
dysfunction
2.1. Medical history
The basic work-up for ED diagnosis should begin by
recognising that ED shares several common risk factors
with CVD [11]. A comprehensive medical history for
each patient must include both modifiable risk factors
[1214] (eg, limited or no physical exercise, obesity [15],
dyslipidaemia, smoking and use of recreational drugs [3],
and excessive alcohol intake [3,12]) and nonmodifiable risk
factors [12].
Among the large number of potential comorbid
conditions, the signs and symptoms of diabetes mellitus
[12,16,17], controlled and uncontrolled hypertension
[11,18], sleep disturbances (eg, obstructive sleep apnoea
[19]), metabolic syndrome [20,21], and late-onset
hypogonadism/testosterone deficiency syndrome [22,23]
or other hormonal causes of male sexual dysfunctions [24]
should be considered.
The work-up should also consider symptoms and signs of
depression (which may be primary to the disorder or even
acquired after ED onset) [25] or anxiety disorders [12,26,27]
because they may have an impact on the long-term
treatment compliance of men with ED, and they may also
cause poor adherence to any medication/treatment ap-
proach [28]. Impairment of erectile functioning is also
frequently comorbid with neurologic disorders or with the
functional outcomes of neurologic diseases. For instance,
the prevalence and severity of multiple sclerosis,
Parkinsons disease, and the outcomes of stroke cerebri
must always fall within the anamnestic medical evaluation
of a patient seeking medical help for ED [29]. Any known or
newly diagnosed psychiatric disorder will require a formal
psychiatric approach [3]. The medical history will then
consider all major pelvic and retroperitoneal surgeries that
may have had an impact on male sexuality [1,3,30].
From an epidemiologic standpoint, it is of major
importance that ED is strongly related with ageing, with
a steep incline in prevalence rates in men >40 yr of age and
reaching a rate of 77.5% in men 75 yr [12,31]. The
prevalence of ED is also closely linked to a progressive
increase in the occurrence of lower urinary tract symptoms
(LUTS) [32,33], the presence and severity of which must be
carefully investigated in the patient experiencing im-
pairment of erectile function. Certainly less prevalent but
of great importance, especially in symptomatic younger
men, is the presence of pelvic pain syndromes (eg, chronic
pelvic pain syndrome, chronic abacterial prostatitis), also
possibly associated with voiding disorders and ED [34]. The
medical history should also take these factors into account.
A thorough evaluation of a patients current treatment
for any reason should include a complete medical history.
Detailed knowledge of concurrent therapy (eg, antidepres-
sants, antipsychotics, antihypertensives [ie, thiazides, b-
blockers] [35], nitrates and nitrate donors, antiandrogens)
not only has a role in helping the physician gain a better
understanding of the possible pathophysiologic pathways
of ED but also may potentially play a protective role. Some
medications for ED (eg, phosphodiesterase type 5 inhibitors
[PDE5-Is]) may be dangerous if taken concurrently with
other compounds, for whatever medical reason [3]. Due to
the high prevalence of coexisting ED and LUTS, a complete
medical history should include collecting information
regarding the potential use of any a-blockers and 5a-
reductase inhibitors [36].
2.2. Sexual history
Taking a sexual history is mandatory for all patients
complaining of any sexual dysfunction/disorder [3,37].
Age, sexual orientation, marital status, and sexual experi-
ence should always be considered to better understand the
individuals sexual ecology. After having inquired whether
or not the patient is sexually active and has sought medical
help previously, the basic and minimal work-up in men
with ED should consider the onset and duration of the
erectile problem, along with a detailed investigation about
the rigidity and duration of nocturnal/morning erections,
erogenous erections, and erections achieved by masturba-
tion [3,37]. Althof et al. [37] recently stated that sexual
history taking should always be conducted in a culturally
sensitive manner, considering the individuals background
and lifestyle, status of a partner relationship, and the
clinicians comfort level and experience with the topic. This
would also eventually take into consideration the ability to
gather information about potential problems with sexual
desire, nongenital arousal, ejaculation, and orgasm.
Diagnosis of congenital or acquired penile curvature (eg,
secondary due to Peyronies disease) is mainly based on
medical and sexual histories [38]. Sexual history taking
must detail the potential symptomatology associated with
the appearance of plaques on the penis, the presence or
 EUROPEAN UROLOGY SUPPLEMENTS 12 (2013) 712
absence of pain in a state of penile flaccidity or erection, and
the impact of the geometric modification of the erect penis
in terms of sexual ecology [37,38].
To provide an objective frame of reference for interpret-
ing ED severity, validated questionnaires, such as the
International Index of Erectile Function [39] or the
Male Sexual Health Questionnaire [40], may help assess
all sexual function domains, as well as the impact of a
specific treatment modality. However, the use of these
psychometric tools in everyday clinical practice is certainly
not required.
2.3. Physical examination
Physical examination in patients with ED usually does not
reveal the diagnosis. According to the recommendations of
the International Consultation in Sexual Medicine (ICSM)
for the clinical evaluation of men and women with sexual
dysfunction [41], physical examination is highly recom-
mended but not always necessary (grade C) [41]. Therefore,
the aim of physical examination in men with ED is to assess
genitourinary anatomy as well as endocrine, vascular, and
neurologic systems [3,42]. Of major clinical importance is
the role of the physical examination in assessing potential
signs and symptoms of comorbidities including neurologic,
cardiovascular, and possibly life-threatening conditions.
Physical examination is highly recommended and may
reveal important information in patients with Peyronies
plaques or atrophic testicles. Local examination thus
includes inspection of the penile shaft for size, position of
the meatus, scars and skin abnormalities, and palpation for
fibrous plaques. Testicular size and consistency are
assessed. Digital rectal examination is certainly advisable
in patients >45 yr of age [42] (>50 yr according to the
European Association of Urology [EAU] guidelines [3]) and
in men who might be possible candidates for testosterone
replacement therapy [3,42].
A general examination ideally should include evaluation
of male secondary sex characteristics, gynaecomastia,
pulses, peripheral sensations, and scars from previous
surgeries or trauma. Blood pressure and heart rate should be
measured, especially if they have not been assessed
thoroughly in the previous 36 mo [3]. Waist circumference
measurement is helpful in counselling the patient about the
risks related to obesity and the possibility of metabolic
syndrome [15,20]. Particular attention must be paid to
patients with either known or suspected CVD [3,11,42].
2.4. Laboratory assessment
The EAU guidelines on male sexual dysfunction suggest
tailoring laboratory testing to the patients complaints and
risk factors. According to the recommendations of the ICSM
for the clinical evaluation of men and women with sexual
dysfunction, it is once again highly recommended but not
always necessary (grade C) [41]. Recommended laboratory
tests for men with ED typically include a fasting glucose
[3,16,17] and lipids profile [3,15], if not assessed in the
previous 12 mo [3]. Hormonal tests must include a morning
9
sample of total testosterone [3,22,23,42]. Additional labo-
ratory tests (eg, thyroid function, prolactin, and luteinising
hormone) may be performed at the discretion of the
physician based on the medical history and the clinicians
judgement [24,42].
According to the EAU guidelines on prostate cancer [43],
current evidence is insufficient to warrant widespread
population-based screening by prostate-specific antigen
(PSA) for prostate cancer (PCa). However, serum PSA
measurement is indicated in selected men >45 yr of age
during the work-up of patients presenting with ED,
particularly for the detection of PCa and if testosterone
replacement therapy is considered [3,42].
3. Specialised diagnostic tests
The vast majority of patients with ED can be managed
adequately without further diagnostic assessments, but
some patients may benefit from specific diagnostic tests
[3]. Among them are men with primary erectile disorders
(not associated with an acquired organic disease or a
psychogenic disorder), young patients with arteriogenic ED
coupled with a history of either pelvic or perineal trauma, and
patients with complex endocrine, psychiatric, or psychosex-
ual disorders. Specific tests should be ordered for men with
congenital or acquired penile deformities who may eventu-
ally benefit from surgical correction [42].
3.1. Rigiscan assessment of nocturnal penile tumescence and
rigidity
The Rigiscan device assesses nocturnal penile tumescence
and rigidity in a quiet setting (usually home) that respects
the privacy of the patient. At least two consecutive nights of
recording are necessary to evaluate nocturnal penile
tumescence and rigidity [44]. Nocturnal penile tumescence
and rigidity with at least one erectile episode of tip penile
rigidity >60% and 10 min in duration may be associated
with normal erectile function [3,44].
3.2. Intracavernous injection test
Preliminary clinical evaluation is achieved by the intraca-
vernosal injection (ICI) of a low-dose vasoactive agent
(usually 215 mg of prostaglandin E [PGE]-1 or a bi/tri-mix
in an office setting [45]). According to the EAU guidelines on
male sexual dysfunction, the ICI test provides only limited
information about vascular status in men with ED [3,46,47].
The test is considered inconclusive as a diagnostic proce-
dure, and colour duplex Doppler ultrasound (CDDU) of the
penile arteries should be requested [2].
3.3. Dynamic duplex ultrasound penile blood flow evaluation
In-office evaluation of ED by CDDU may benefit the choice
of the most appropriate therapy [3,45]. As per the mandate
of the International Society for Sexual Medicine, established
standardised operating procedures for CDDU were recently
published [45]. CDDU is usually a dynamic test requiring
10 EUROPEAN UROLOGY SUPPLEMENTS 12 (2013) 712
intracavernosal injection of a vasoactive agent performed
by an experienced sonographer in a physicians office or by a
radiologist in a hospital setting. CDDU helps reveal some
aspects of the physiology of penile erection, evaluation,
causes of variability, and interpretation.
Because of the influence of psychological and environ-
mental factors on erectile function, CDDU needs to be
performed in a dimly lit quiet room, preferably in the
presence of only the trained operator and an assistant if
needed. A high-resolution solid-state linear array ultra-
sound transducer (with a frequency of 7.512 mHz)
specifically for examining small body parts is required.
Using a 27- to 30-gauge half-inch needle, an ICI of a single or
a combination of vasoactive agents (eg, PGE-1, phentol-
amine, and papaverine, with or without subsequent
redosing) is performed. An audiovisual setup for visual
sexual stimulation may be especially helpful when the
patient is anxious about his medical condition/situation
[45]. Using a PDE5-I, given approximately 1 h prior to
beginning the examination, is considered a valuable option,
particularly for a younger patient; however, normative
values using this form of erectogenic stimulation are not yet
available [45].
The ultrasound procedure initially involves scanning the
entire penis (longitudinal and cross-sectional views) to
observe cavernosal homogeneity, presence of plaques,
fibrosis, echogenicity, or calcification. The inner diameter
of the intracavernosal arteries (both left and right) and
occasionally the peak systolic velocities (PSVs) in both
arteries are then measured using the Doppler blood flow
mode.
PSVs are considered effective parameters to evaluate
arterial competence; a PSV 30 cm/s indicates definite
arterial flow after adequate pharmacologic stimulation,
whereas a PSV <25 cm/s is diagnostic of arterial insuffi-
ciency as the cause of ED [45,48]. Conversely, the end
diastolic velocity (EDV) and the corresponding semiquan-
titative measurement of the resistive index (RI) may be
informative about penile veno-occlusion normalcy. In
association with a normal arterial response, an EDV
>6 cm/s and RI <0.6 indicates a venous leak is present
[45,49]. Using the mean data from multiple evaluations of
PSV and EDV, RI measurements, the peak tumescence and
rigidity response, and based on the clinical history and
predictions all taken together, patients with ED may be
rigorously classified from the vasculogenic standpoint
[45].
3.4. Dynamic infusion cavernosometry or cavernosography
The standard method of diagnosing venous leakage is by
dynamic infusion cavernosometry and cavernosography
(DICC) [3,45]. Veno-occlusive dysfunction (VOD) is an
organic cause of ED that occurs when an abnormal venous
drainage prevents a rigid erection in the presence of a
normal penile arterial flow. VOD can be diagnosed by an
abnormal cavernosometry, and the site of the leakage can
be assessed through cavernosography [45]. Cavernosome-
try/cavernosography should not be used primarily to
establish an organic aetiology for ED [45]. In this context,
DICC is not routinely used; it should be performed only in
patients failing to respond to oral/local therapy and in
possible candidates for vascular reconstructive surgery [3].
3.5. Internal pudendal arteriography
Arteriography is the most invasive diagnostic test for
vasculogenic ED. It should be considered only in highly
selected cases of young men with decreased cavernosal
arterial inflow by CDDU and a history of pelvic or perineal
trauma [3,45]. In men with ED, arteriography may highlight
a discrete focus of arterial occlusion that could be corrected
with microvascular surgery; this diagnostic procedure is
not indicated when operative revascularisation is not an
option. Conversely, pudendal angiography, in conjunction
with microembolisation, is first-line therapy for high-flow/
traumatic priapism [50].
4. Conclusions
Because ED has progressively emerged as an important
sentinel marker of cardiovascular and overall health among
men, a timely and accurate diagnosis of men presenting
with erectile function impairment may represent a signifi-
cant opportunity not only to diagnose the dysfunction per
se, but also to identify comorbid and potentially life-
threatening conditions. Most patients with ED can be
adequately managed with a basic diagnostic work-up that
includes a comprehensive medical and sexual history, along
with a physical examination and some laboratory tests.
Only selected patients may also need specific diagnostic
tests.
Conflicts of interest
The author has nothing to disclose.
Funding support
None.
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