What is the appropriate workup for erectile dysfunction?

Appropriate Workup for Erectile Dysfunction

The appropriate workup for erectile dysfunction requires a comprehensive medical history, targeted physical examination, essential laboratory tests including serum total testosterone, fasting glucose/HbA1c, and lipid profile, and cardiovascular risk assessment to identify underlying causes and guide treatment. 1

Medical History Components

• Sexual history:

  • Nature and duration of erectile problems
  • Distinguish from other sexual difficulties (e.g., penile curvature, premature ejaculation)
  • Frequency and severity of symptoms
  • Use validated questionnaires like International Index of Erectile Function (IIEF) 2, 1

• Medical history:

  • Comorbidities: diabetes, hypertension, cardiovascular disease, neurological conditions, endocrine disorders
  • Surgical history, especially pelvic or prostate procedures
  • Current medications (particularly antihypertensives, antidepressants, tranquilizers) 2
  • Lifestyle factors: smoking, alcohol consumption, exercise habits, obesity
  • Psychological factors: depression, anxiety, stress

Physical Examination

• Vital signs (blood pressure, heart rate)
• Genital examination
• Secondary sexual characteristics assessment
• Cardiovascular assessment
• Neurological examination when indicated 1

Laboratory Testing

1. Essential tests:

   • Serum total testosterone (or bioavailable/free testosterone if available)
   • Fasting glucose/HbA1c
   • Lipid profile
   • Consider PSA if testosterone therapy might be considered 1

2. Additional tests (for non-responders to initial therapy):

   • Nocturnal penile tumescence
   • Penile Doppler ultrasound
   • Bulbo-cavernosus reflex
   • Dorsal sensory nerve conduction
   • Pudendal nerve SSEP
   • Assessment of PGE1 effect on erection 2

Cardiovascular Risk Assessment

• Determine if patient can perform exercise equivalent to walking 1 mile in 20 minutes or climbing 2 flights of stairs in 20 seconds 1
• Categorize patients into cardiovascular risk groups (low, intermediate, high) according to Princeton Consensus guidelines 2
• Consider cardiology referral for high-risk patients before initiating ED treatment

Common Pitfalls to Avoid

1. Assuming ED in young men (<40) is purely psychogenic without proper evaluation
2. Failing to measure testosterone levels
3. Not addressing psychological aspects of ED
4. Overlooking ED as a potential marker for underlying cardiovascular disease
5. Not discussing potential side effects of treatments before prescribing 1

Treatment Algorithm

1. First-line therapy: PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil)

   • Effective in 60-65% of men with ED regardless of comorbidities
   • Contraindicated in patients taking nitrates or with unstable cardiovascular disease 1, 3

2. Second-line options (for PDE5 inhibitor non-responders):

   • Vacuum erection devices
   • Intracavernosal injection therapy (alprostadil, papaverine)

3. Third-line options:

   • Penile prosthesis implantation (high satisfaction rates) 4

4. Adjunctive measures:

   • Lifestyle modifications (weight loss, exercise, smoking cessation)
   • Psychosexual therapy (50-80% success rates for psychogenic ED)
   • Testosterone therapy (only if deficiency confirmed <300 ng/dL with symptoms) 1

Remember that ED can be an early marker of cardiovascular disease, and proper evaluation may uncover previously undiagnosed conditions such as diabetes, hypertension, or atherosclerosis 5. A thorough workup not only addresses the erectile dysfunction but may also identify and allow treatment of these underlying conditions, potentially improving overall health outcomes.