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ED exam

by Janet Casperson, BS, MSN, ANP-C

An ED exam and diagnosis of other sexual problems begin with a careful detailed history and physical examination.

Prior to our understanding of cardiovascular disease and its association with erectile dysfunction, a good sexual history merely consisted of inquiring about the quality of the erection, rigidity and the ability to maintain your erection until ejaculation.

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The typical urologist never focused on cardiovascular risk factors such as the family history, history of diabetes, smoking, and certain medications that can dramatically affect erections. With our new knowledge of erectile dysfunction, we know that the diagnostic paradigm for erections should begin with a complete, careful detailed patient history.

Patient History as Part of a Workup for Erectile Dysfunction

In any patient history, the patient's age is important. Age is one of the greatest risk factors for loss of erection and other sexual dysfunctions. We then inquire about cardiovascular history. This includes an exercise activity level and tolerance level, whether the patient is active or inactive and if active how much exercise is done per week. We generally like to see 30 minutes of cardiovascular exercise most days of the week with weight training three days of the week. However, at a minimum we like to see three episodes of exercise per week of at least 20 minutes duration.

Both the family and personal history of diabetes are important. Diagnostic approaches focus on differentiating between type I and type II diabetes, which we prefer to define as the "need for insulin" versus the "over production of insulin" along with the state of insulin resistance.

A thorough and very careful discussion of other cardiovascular risk factors including life style risk factors such as tobacco use, exercise, diet, family and personal history of cardiovascular disorders is needed. Determining the type of tobacco used as well as the number of years that the patient has smoked is very important. Sometimes men who smoke marijuana will have as much exposure to smoking-related risks as if they smoked other types of tobacco as well because of the way that marijuana is inhaled.

The patient's diet is important as well. The atherogenic diet which is rich in saturated and trans fats, carbohydrates and processed foods enables the inflammation process and is an important diagnostic clue in the presence or absence of erectile dysfunction. Personal and family history of dyslipidemia is important as well.

Erections and Testosterone Levels

When discussing specific targets with regards to erectile dysfunction, we inquire about frequency of erections and intercourse. Focus is placed on morning erections and the quality, duration and timing. A morning erection is a good rough measurement of the patient's overall erectile health. When the testosterone level begins to drop, there is a direct correlation to the presence of morning erections and testosterone levels. As testosterone levels diminish, there is a loss of morning erections.

Additionally, we want to know about the ability to achieve the erection with or without appropriate sexual stimulation as well as the ability to maintain the erection throughout intercourse. The length of intercourse is not as significant, because the average length of time from penetration to ejaculation has been thought to be around 2 ½ minutes. However, being able to maintain an erection in relationship to the ability to ejaculate is important. Many conditions can either prevent the ejaculation from happening or can lead to a condition known as retrograde ejaculation as discussed elsewhere.

Medications and Erections

We then discuss medication profiles. It's important to document all prescription and non-prescription medications as well as any herbal therapies or over-the-counter medications that the patient is taking. Many herbal therapies can contain significant medications that can affect erectile function. It is not uncommon for a patient to have been given a sample of Viagra®, Levitra®, or Cialis® by another physician or friend prior to seeking help with us. It is important that this information be shared.

The most damaging medications that can affect the erection are the thiazide diuretics often used to treat high blood pressure and the beta blockers used in the treatment of both high blood pressure and in men who've had a recent heart attack. These medications can cause or make existing erectile dysfunction more severe.

Other medications that can affect the erection can include a class of drugs used for depression and a host of other related conditions known as the selective serotonin reuptake inhibitors (SSRIs). These drugs are widely used and can inhibit the ability to ejaculate or make an ejaculation of decreased quality. Incidentally, these medications are used in an off-label fashion for men who ejaculate quickly because they can often times dramatically increase the "latency time", or the time from the time of penetration of the vagina to the time of ejaculation.

Documenting the use of herbal remedies is important as well. Many of the herbs that are used by men for sexual dysfunction contain adulterated quantities of sildenafil, which is the generic form of Viagra®. Over-the-counter medications can actually be genitourinary irritants which can have deleterious effects. Many of the medications used for weight loss contain a compound called ephedra. This medication can adversely affect the quality of the erection. It's well-known that men with chronic sinusitis, chronic sinus drainage or allergies who regularly take these over the counter decongestants can have a poor erectile quality. Other important findings in the history include the presence or absence and the history of priapism. Priapism is a painful erection of over four hour's duration. Priapism is either idiopathic with no discernable etiology or is related to medications or, most commonly, is a consequence of penile injections.

Physical Examination for Erectile Dysfunction

After the careful patient history examination is finished, we begin our physical exam. The physical examination focuses on the presence or absence of testes and the size of the testes. Testicular size correlates fairly directly with the amount of testosterone that is produced. Testicles that are damaged as a consequence of mumps when a man was a young man can be small or atrophic. This can have a dramatic adverse effect on testosterone production.

We also focus on the quality of scrotal sac as well as whether there is the absence or presence of a varicocele. A varicocele is a proliferation of veins on the left side that can also adversely affect the size of the testicles. We focus on palpation of the penis (the phallus). One common condition is Peyronie's disease, named after the physician to the court of Louis XIV. Peyronie's disease is scarring of the corporeal bodies or the cylinders in the penis that become erect. The scarring can cause the penis to become soft after the scarring and be bent in a variety of positions. These bends in the penis can be profound and may prevent adequate intercourse or make it very painful for the sexual partner.

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We also focus on the presence or absence of secondary sexual characteristics, which underlie the presence or absence of adequate hormonal status. After this examination is complete, we always check the prostate by inserting a gloved finger into the rectum. This examination causes some momentary discomfort but should be painless. We focus on the presence or absence of anal tone, the presence or absence of prostate enlargement or nodules that may be associated with prostate carcinoma. We also focus on any other lesions that are present in the rectum that may be signs and symptoms of colon cancer.

Arterial causes such as a decreased inflow of blood into the penis, called a venous leak, can lead to erectile dysfunction. Initially in a physical examination, we always palpate the arterial pulses in the groin as a rough diagnostic measurement of blood flow to the lower extremities. Pedal pulses, or pulses in the foot, can be easily palpated. Absence of pedal pulses, decreased hair on the lower extremities, or coolness in the lower extremity are indicators of poor blood flow. In Leriche syndrome, a syndrome caused by obstruction of the terminal aorta, these symptoms are combined with impotence.

One of the neurogenic causes of erectile dysfunction is diabetic neuropathy. The earliest signs and symptom of diabetic neuropathy is the loss of vibratory sensation of the feet. The penis and the feet share a similar neurologic etiology or neurologic area. Alcoholic neuropathy can affect erections and examination reveals very small testicles. Other neurologic conditions that are easily seen in physical examination and have a dramatic effect on erectile function include multiple sclerosis, strokes, Parkinson's disease and paraplegia. In paraplegia, the level of the damage to the spinal cord can affect the type of erection obtained with medication and determine which medication is most effective. Endocrinologic causes of erectile dysfunction include hypogonadism, pituitary tumors or rare congenital conditions such as Klinefelter syndrome (XXY males), a chromosomal abnormality of an extra sex hormone. Males with Klinefelter syndrome have an XXY chromosome instead of the usual XY male chromosome.

The presence of Peyronie's disease or a penis affected by prior priapism is usually a thickened, woody and scarred penis that is obvious on examination. Penile implant surgery is possible but the surgery is difficult because of the amount of penile scarring; choosing an experienced surgeon is crucial.

Chronic kidney deficiency places a man at higher risk for erectile dysfunction secondary to blood flow conditions and low testosterone. These may be a consequence of the conditions that are associated with renal failure including anemias, protein deficiency, high blood pressure, and anti-hypertensive medications. Measuring the patient's creatinine and kidney function is important when treating a man with erectile dysfunction who is on dialysis or has chronic renal deficiencies. The measurements are used to determine the correct dosage of either PDE-5 inhibitors or injection therapy and prevent an overdose which can lead to priapism or metabolic effects.

Questionnaires Used to Diagnose Erectile Dysfunction

Another extremely important diagnostic tool for the diagnosis of erectile dysfunction is the International Index of Erectile Dysfunction (IIEF)or its shortened version the Sexual Health Inventory in Men (SHIM). Both the IIEF and the SHIM questionnaires are available in this Center. These simple questionnaires take only about 10 minutes to complete and offer a great deal of important information for us in evaluation of erectile dysfunction. Other screening questionnaires are available, but the IIEF and the SHIM yield the most useful information for our clinical practice.

Other Tests to Help Diagnose the Cause of Erectile Dysfunction

The next level of testing includes nocturnal penile tumescence testing with a Rigi-Scan. Loops of stretchy material are placed over the penis to record the quality and duration of nocturnal erections overnight. This is a great technique to measure the baseline of erectile function. This technique is typically used in experimental laboratories and not widely applicable to general practice. Probably the most significant test we use is the color flow penile Doppler ultrasound examination of the penis. This real time imaging study uses an injection of vasoactive medication to produce an erection; the erect penis is then examined with the Doppler color flow ultrasound. This gives a large amount of information on the arterial dilation, the ability of the penis to maintain blood, the presence or absence of Peyronie's plaques and the overall blood flow as well as the presence or absence of venous leaks. We use an ultrasound in most men prior to any type of corrective surgery.

Next Steps

When our evaluation shows an abnormality in the heart history such as a multitude of risk factors, severely abnormal cholesterol or lipid profiles, we recommend that the patient have a treadmill examination as the next step. The treadmill is a very defined test which is the next level of testing for cardiovascular functioning. This exam actively monitors cardiac activity during exercise. The exam is typically done by an experienced physician such as a cardiologist or a primary care physician who is experienced with treadmill testing. Men who have other significant risk factors that have not been previously diagnosed or who have abnormalities are seen on the color flow Doppler examination are referred for a more detailed cardiovascular workup. This patient's story shows the importance of the workup for cardiovascular health:

Bob F. is a 43 year old male who was referred to our office because of failure of his first trial of medication for his erection problems. He had a several year history of the decreasing ability to achieve and maintain his erections. He had been given a sample pack of Viagra® but had not received much instruction with it. He took one of pills but didn't think it helped. He took the second pill and thought he only got a slight improvement. Overall, he was not happy with the therapy and he was referred for further evaluation.

A careful patient history found that Bob was a fairly heavy smoker and he had multiple risk factors including a positive family history of diabetes. His urinalysis was positive for the presence of glucose with his fasting sugar measured at 150. There was also a positive dipstick for microalbuminuria which is an indicator of endothelial dysfunction. His Doppler examination produced a very poor peak flow, approximately 15cc per second of blood and he had a significant venous leak as well. Because of the Bob's numerous risk factors and the fact that he happened to mention that he was having atypical chest pain at work, he was referred immediately to a cardiologist. Bob had an arteriogram that afternoon which led to the placement of two cardiac stents.

References: See Bibliography

August 2006
Posted August 2008
Last Updated December 2011

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