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Impotence: evaluation
Definition
Impotence (also called erectile dysfunction or ED) describes the persistent inability to achieve or maintain a penile erection sufficent for sexual intercourse.
Epidemiology
Moderate to severe ED is found in ~10% of men aged 40 - 70 years. Prevalence increases with age.
Aetiology
ED is generally divided into psychogenic and organic causes , although it is often multifactorial.
History
- Sexual: onset of ED (sudden or gradual); duration of problem; presence of erections (nocturnal, early morning, spontaneous); ability to maintain erections (early collapse, not fully rigid); loss of libido; relationship issues (frequency of intercourse and sexual desire, relationship problems).
- Medical and surgical: hypertension; cardiac disease; peripheral vascular disease; diabetes mellitus; endocrine or neurological disorders; pelvic surgery, radiotherapy, or trauma (damaging innervation and blood supply to the pelvis and penis).
- Drugs: enquire about current medications and ED treatments already tried (and outcome).
- Social: smoking, alcohol consumption.
An organic cause is more likely with gradual onset (unless associated with an obvious cause such as surgery, where onset is acute); loss of spontaneous erections; intact libido and ejaculatory function; existing medical risk factors; and older age groups. The International Index of Erectile Function (IIEF) or ED intensity scale can be used to quantify severity.
Examination
Full physical examination (CVS, abdomen, neurological); digital rectal examination to assess prostate; external genitalia assessment to document foreskin phimosis and penile lesions (Peyronie's plaques); confirm presence, size, and location of testicles. The bulbocavernosus reflex can be performed to test integrity of spinal segments S2 - 4 (squeezing the glans causes anal sphincter and bulbocavernosal muscle contraction).
Investigation
Blood tests fasting glucose; PSA; serum testosterone; sex hormone binding globulin; LH/FSH; prolactin; thyroid function test; fasting lipid profile.
Nocturnal penile tumescence testing Rigiscan device contains 2 rings which are placed around base and distal penile shaft to measure tumescence and number, duration, and rigidity of nocturnal erections.
Colour Doppler USS measures arterial peak systolic and end diastolic velocities,1 pre and post intracavernosal injection of PGE1.
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