Episode 115: Erectile Dysfunction Diagnosis.  

Discussion about the diagnosis of erectile dysfunction with Andrew, Adriana, and Dr. Arreaza. Causes, labs, and physical exam is briefly discussed. Written by Andrew Kim, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments by Adriana Rodriguez, MS3, Ross University School of Medicine; and Hector Arreaza, MD.

September 22, 2022.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

In episode 39 o erectile dysfunction, Dr. Ihejirika gave us an overview, but today we will be more detailed about the diagnosis of ED. 

Definition.

The American Urological Association (AUA) published an erectile dysfunction guideline in May 2018, which is available online at no cost. Based on that guideline, erectile dysfunction can be defined as “the consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual satisfaction, including satisfactory sexual performance.” Comment: This guideline provides 25 principles for diagnosing and treating ED. 

Diagnosis.

Getting a good history is important when diagnosing erectile dysfunction. The patient should be asked about the onset of symptoms, severity, how much it hinders his sexual performance, whether the patient can get and maintain an erection, psychological factors, social factors, and presence of morning erections. 

One can use different questionnaires: the five-question International Index of Erectile Function (IIEF-5) or a single-question self-assessment. 

Single-question self-assessment:

Impotence means not being able to get and keep an erection that is rigid enough for satisfactory sexual activity. How would you describe yourself?

1. Not impotent: always able to get and keep an erection good enough for sexual intercourse.
2. Minimally impotent: usually able to get and keep an erection good enough for sexual intercourse.
3. Moderately impotent: sometimes able to get and keep an erection good enough for sexual intercourse.
4. Completely impotent: never able to get and keep an erection good enough for sexual intercourse.

Comment: Basically, the single-question self-assessment is a self-diagnosis of erectile dysfunction; the patient is giving you the severity of his condition. This questionnaire seems to be very subjective. 

International Index of Erectile Function (IIEF-5):

IIEF-5 asks five questions, and the patient answers on a scale of 1 to 5 (1 is the worst, 5 is the best)

1. How do you rate your confidence that you could get and keep an erection?
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
5. When you attempted sexual intercourse, how often was it satisfactory for you?

Diagnosis can be made based on the total score. 1 to 7: severe ED, 8 to 11: moderate ED, 12 to 16: mild-moderate ED, 17 to 21: mild ED, and 22 to 25: no ED.

This is a self-reported questionnaire, and the score should be interpreted in a clinical context. Answers will likely be biased if, for example, the questionnaire is asked by a female medical assistant.

Causes of ED:

It is important to assess for medical conditions, psychological conditions, and medications because ED can be caused by vascular, neurological, psychological, and hormonal problems. 

• Cardiovascular: Some common conditions related to ED are cardiovascular disease (PAD, CAD) and HTN.
• Endocrine: DM, HLD, obesity, testosterone deficiency (hypogonadism), hyperprolactinemia, thyroid disorder, metabolic syndrome.
• Neurologic: Neurologic conditions (multiple sclerosis, stroke, spine injury), trauma, and venous leakage.
• Lifestyle causes: sedentary lifestyle, tobacco use.
• Psychological: Performance anxiety, relationship issues, anxiety, depression, and stress are common psychological causes.
• Medications and substances: Alcohol, illicit drugs, and nicotine are important causes of ED, but some medications also cause or worsen ED: opiates, diuretics (spironolactone), antifungals (azoles), anticonvulsants, antidepressants (SSRIs), antihistamines, H2 blocker (cimetidine) antihypertensives, nasal decongestants, and antipsychotics. Remember to ask about over-the-counter medications and supplements.

Physical exam: Measure blood pressure, BMI, and a complete exam, especially a genital exam. 

A comprehensive genitourinary exam should include the inspection of the testicles (atrophy, varicocele, signs of hypogonadism). The penis should be inspected and palpated (look for scar tissue and Peyronie’s plaques) and assessment of penile stretch/flaccid length (it is done by stretching the penis. An elastic penis is a healthy penis). Dr. Winter’s expert opinion: consider a prostate exam in older patients presenting with ED.

Labs: Following physical examination, some lab tests can be ordered to further evaluate possible causes of ED. 

-A1C and glucose levels can be ordered to look for diabetes. 

-Lipid panel for hyperlipidemia.

-TSH should be checked for thyroid function and to rule out hypothyroidism. 

-Testosterone deficiency can be assessed by measuring morning serum total testosterone level, which is defined as total testosterone < 300 with signs and symptoms. 

-Prolactin (perform pituitary MRI in any degree of hyperprolactinemia. In patients taking medications that cause hyperprolactinemia, get MRI if prolactin is above 100) 

Why is it important to diagnose ED?

ED can be linked to organic causes.

- Glucose: ED is linked to increased fasting serum glucose levels (diabetes). People with PMH of DM are 3 times more likely to develop ED. The longer the patient had diabetes, the stronger association with ED. Fasting glucose levels are associated with the highest risk of ED. The probability of having undiagnosed DM is 1/50 in the age group 40 to 59 without ED but increases to 1/10 for those with ED.

- Testosterone and obesity: Low serum testosterone levels can contribute to the link between metabolic syndrome and ED. In men with obesity, the adipose tissue enzyme aromatase is more prevalent and can convert testosterone into estradiol to cause hypogonadism. Furthermore, adipocytes can cause inflammation and recruit inflammatory cytokines, leading to impaired endothelial function and ED. 

- Cardiovascular disease: ED and CVD have some common risk factors: older age, HTN, dyslipidemia, smoking, obesity, and DM. ED is related to an increased risk of CVD, CAD, and stroke. Usually, it is thought that ED arises two to five years prior to CAD. If a patient develops signs and symptoms of ED before CAD, the patient can be counseled and educated to make lifestyle modifications to prevent CAD.

Furthermore, men with ED are more likely to experience angina, MI, stroke, TIA, CHF, and cardiac arrhythmias when compared to their counterparts without ED. A study from 2003 suggested that patients with ED have a 75% increased risk of developing peripheral vascular disease. Studies suggest ED can predict silent CAD, and one study concluded that the incidence of CAD in men below 40 years of age with ED was seven times higher than that of the control population without ED. It is important to diagnose ED because it can be used as a marker for assessing cardiovascular risk.

ED can be linked to many causes, and we as clinicians should be able to identify those causes to prescribe a more specific treatment. Not all ED will respond to “the blue pill”. We will talk about treatment in another episode. 

Conclusion: Now we conclude episode number 115, “Erectile Dysfunction Diagnosis.” Male sexual health sometimes can be taboo, and patients may not fully disclose personal issues like erectile dysfunction. Andrew and Adrianna explained that an open discussion about erectile dysfunction can help you diagnose underlying conditions, including cardiovascular disease. Dr. Arreaza reminded us that the diagnosis of erectile dysfunction should prompt a deeper investigation in most cases before you attribute it to psychological factors. 

This week we thank Hector Arreaza, Andrew Kim, Adriana Rodriguez, and Fiona Axelsson. Audio edition by Adrianne Silva. 

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! 

___________________________________________________

References:

1. Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. Journal of Urology. 2018;200(3):633-641. doi:10.1016/j.juro.2018.05.004. https://www.auajournals.org/doi/epdf/10.1016/j.juro.2018.05.004.
2. Rew KT, Heidelbaugh JJ. Erectile Dysfunction. American Family Physician. 2016;94(10):820-827. Accessed September 19, 2022. https://www.aafp.org/pubs/afp/issues/2016/1115/p820.html.
3. Khera M. Evaluation of male sexual dysfunction. UpToDate. www.uptodate.com. Last updated: April 28, 2020. Accessed September 19, 2022. https://www.uptodate.com/contents/evaluation-of-male-sexual-dysfunction.
4. Abrams H, Winter A, Williams PN, Watto MF. “#317 Erectile Dysfunction”. The Curbsiders Internal Medicine Podcast. https://thecurbsiders.com/episode-list. January 24, 2022.
5. Royalty-free music used for this episode: Gushito, Burn Flow. by Videvo, downloaded on May 06, 2022, from https://www.videvo.net/royalty-free-music-track/good-vibes-alt-mix/1017292/