Diagnosis of ED: First Level

Current guidelines for management of ED, sometimes differing in details, agree on the great importance of the anamnesis as basis of a correct diagnosis of ED. History taking has been shown more precise if partners are involved in clinical interview, facing the erectile problem within the couple. When it is correctly taken, the anamnesis allows to minimize any further diagnostic test for a complete evaluation of erectile dysfunction.

A good anamnesis consists of three aspects, medical, sexual and psychosocial.

Medical history should identify the presence of concomitant pathologies and reveal risk factors for ED onset (for example drugs or alcohol abuse, uncompensated diabetes mellitus, previous radiotherapy for cancer, etc.). Only correcting these factors, patients often can benefit. Most chronic pathologies usually are able to cause loss of erection because of both specific organic modification and psychological correlates following ED. Sexual history has the purpose of investigating in detail on which is the real dimension of patient’s ED. Sexual history has the purpose of investigating in detail on which is the real dimension of patient’s ED. Sexual history should be able to assess if patient presents loss of libido, if ED is prevalent in obtaining or maintaining erection, if erectile dysfunction is associated with other sexual disorders (i.e., ejaculation or arousal disorders), how often this dysfunction happens and should investigate on quality and duration of morning erection. All these information, usually allow the physician to obtain very important elements leading to a correct etiogical diagnosis. Psychosocial history can identify psychological and relational dynamics affecting somehow ED. These conditions could be classified as pre-disposing (inadequate sexual education, uncertain psychosexual role, etc.), precipitating (infidelity, psychiatric diseases, etc.) and maintaining (loss of attraction as regards one’s partner, performance anxiety, etc.), based on time when take part in ED genesis.

In evaluation of a patient with ED, the physician can make use of specific validated questionnaires filled in by the patients himself, giving a correct measurement of ED severity. These questionnaires include the International Index of Erectile Function (IIEF), the sexual health inventory for men, the brief male sexual function inventory, the erectile dysfunction inventory for treatment satisfaction and the sexual encounter profile. The IIEF is certainly the most famous and used questionnaire in clinical practice and it showed a high diagnostic specificity and sensibility. It also allows to classify erectile dysfunction into three severity degrees: mild, moderate or severe, based on total score. Validated questionnaires result particularly useful for men who have difficulty in expressing their problems. Nevertheless, in these patients questionnaires should not replace the anamnesis, which remain the most important tool for a correct diagnosis of erectile dysfunction. Moreover the scales for ED assessment represent very effective instruments for long-term evaluation of pharmacological therapy.

An extensive physical examination is not usually request in management of ED. It should confirm results coming out from anamnesis with particular attention at cardiovascular and genito-urinary system.

Laboratory tests can be useful to complete diagnostic evaluation. Each patient suffering ED should perform routine haemato-chemical tests to evaluate general health status (i.e., lipidic profile, glycaemia, haemachrome, transaminase, serum creatinine) and hormonal tests. Hormonal assessment appears indispensable in case of ED matched to loss of libido. Other hormonal assays (DHT, FSH, LH, PRL and E 2 ) should be performed when low testosterone serum levels are found. Therefore hormonal tests allow identification of endocrine alterations that can be promptly corrected setting up an hormone replacement therapy. This substitutive treatment can resolve erectile problems in most of patients.

When first level diagnostic tests are performed in a right way, urologist can make accurate diagnosis and can prescribe adequate treatment in a large number of patients with ED.

After all that we asserted, invasive specialistic diagnostic test could be reserved only for primary erectile disorder (not caused by organic disease or psychogenic disorder), for young patients who have always had difficulty, for men with a history of genital trauma who could benefit from potentially curative vascular surgery, for men with abnormality at physical examination, for patient’s or his partner’s request, for medico-legal reasons or when the initial screening tests have indicated a significant abnormality.

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Mirone Vincenzo
Via Pansini 5, Napoli, Italy

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Mirone Vincenzo
Via Pansini 5, Napoli
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