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Initial Evaluation

History

• HPI: onset, severity/rigidity, degree of bother, situational factors, pain, stable/worsening symptoms
• Age: prevalence 1-10% < 40yo, 15% 40-49yo, 30% 50-59yo, 40% 60-69yo, 50-100% 70-90yo
• Commonly associated risk factors: HTN (38-42%), DM (20%), HLD (42%), depression (11%), premature ejaculation (30-60%)
• PMHx: cardiovascular disease, DM, endocrine issues (hypoT), neurologic disorders, psych diagnoses (depression, anxiety, stress), liver disease, alcoholism
• PSHx: prostatectomy, cystectomy, aortoiliac vascualr surgery, aneurysm repair, proctocolectomy, pituitary surgery, penile surgery, pelvic trauma
• Meds: antiHTN, SSRIs, TCAs, antipsychotics, MAOi, antiandrogens, cimetidine, opiates, 5ARi, LHRH agonists/antagonists, prior ED therapies
• Social Hx: partner(s), substance use
• Psychosexual factors: social, cultural, religious, education

Key Questions

1. Are you able to obtain + sustain an erection satisfactory for intercourse?
2. Do you have morning and/or nocturnal erections?
3. Are you able to masturbate?

Physical

• Vitals: check for uncontrolled HTN
• Testosterone deficiency: obesity, gynecomastia, decreased body hair
• Genital exam: hypogonadism, penile curvature, testis presence and size
• DRE: not required for evaluation

Further Diagnostics

• Questionnaires: IIEF or SHIM (abridged version of IIEF)
• Labs: can check BMP, glucose, lipids, HbA1c, testosterone (draw in AM)
• Low testosterone: check bioavailable (serum-free) T (albumin + SHBG) and luteinizing hormone, consider prolactin and estrogen
• Further workup (see below): consider if young, family hx cardiac disease, pelvic trauma, failed prior therapy, likely psychogenic, Peyronie disease, lifelong ED

Invasive Texting

Adjunct testing

• Almost never required prior to offering treatment options, as only patients with arterial insufficiency benefit from specific treatment options
• Nocturnal penile tumescence/rigidity (NPTR): detects erections during REM w/ strain gauge, BP cuff, "stamp roll test," determines organic vs psychogenic ED
• ICI + stimulation: good erection after 10min rules out veno-occlusive disease but not arterial insufficiency
• Penile duplex doppler sonography: perform ICI then examine, check arterial and venous flow
• Cavernosometry: place two needles in corpora, infuse heparinized saline and inject erectogenic medication, measure intracavernosal pressure, assess "flow to maintain" (flow required to maintain pressure 150mmHg) and "intracavernosal pressure decay (pressure decline after stopping infusion)
• Cavernosography: infuse contrast during cavernosometry and obtain images
• Pudendal arteriography: gold standard for assessing arterial insufficiency, assess patency of inferior epigastrics, stenosis of penile blood supply, ability to bypass blockages
• Cavernous arterial systolic occulsion pressure (CASOP): perform ICI, then use BP cuff to determine presure when blood flow becomes detectable
• Penile brachial index: similar to CASOP but measured when flaccid, penile SBP divided by brachial SBP

Expected test findings

Test	Arterial insufficiency	Venous leak	Psychogenic ED
NPTR	Poor erection		Good erection
ICI + stimulation
Penile ultrasound	PSV < 30cm/s PSV < 60cm/s (sum of R + L) cavernous artery diameter < 0.7mm	Normal PSV, EDV < 3cm/s RI ≤ 0.8	No abnormalities
Cavernosometry	No abnormalities	Flow to maintain < 3mL/min IC pressure decay > 45mmHg in 30s
Cavernosography		Venous drainage visualized
CASOP	Brachial SBP - CASOP < 35mmHg	No abnormalities
Penile brachial index	PBI ≤ 0.7

Cardiac evaluation

Importance of evaluation

• Penis/heart relationship: the penis is the dipstick of the heart, development of ED can predate cardiac disease by 5-10 years (25% increased risk at 10yrs)
• MI risk during intercourse: sex causes < 1% MI, absolute risk < 0.01% within 2hr sex
• Assess METS: ask whether patient tolerate 20min walking on flat surface or walking 2 flights stairs in 10 seconds, if patient can tolerate 3 METs activity without chest pain then can tolerate sexual activity
• Workup: check blood pressure, T, lipids, HbA1c if not checked within past 12mo
• Cardiac meds: PDE5i contraindicated if taking nitrates, guanylate cyclase stimulators (riociguat, nicorandil), vardenafil contraindicated with QT prolonging antiarrhymthics, a-blockers + PDE5i can worsen hypotension

Princeton III criteria

• Low risk: no cardiac disease and able to exercise w/o symptoms, have undergone successful revascularization, Class I-II heart failure, controlled asymptomatic HTN, mild cardiac valve disease
• Intermediate risk: mild/moderate stable angina, MI in past 2-8 weeks, Class III heart failure, or non-cardiac vascular disease (PVD, CVA, TIA)
• High risk: unstable/refractory angina, recent MI (< 2 weeks), arrythmias, uncontrolled HTN/DM, Class IV heart failure, moderate/severe valve disease, obstructive hypertrophic cardiomyopathy
• Management: intermediate/high risk require cardiology consult/evaluation prior to starting ED therapies, low risk requires no further workup