Erectile dysfunction: Investigating a patient
Erectile dysfunction (ED) has been defined as the persistent inability to achieve and/or to maintain an erection for a satisfactory sexual intercourse. This event can occur occasionally without inducing psychological or managerial problems, but frequent ED can lead to emotional and relational disorders which can often reduce self-esteem, reinforcing dysfunctional processes. ED represents a very important public health problem and can strongly compromise both the patient and the couple’s quality of life because of a combined presence of organic and psychological aspects and frequent correlation with clinical comorbidities.
Epidemiological data on ED are often altered by the patient’s resistance to consult a specialist. However, ED reaches very remarkable proportions worldwide. The Massachusetts Male Ageing Study (MMAS - 1994), the first epidemiological study on a large scale performed on men between 40 and 70 years old, showed an incidence of erectile dysfunction in 52% of men; among these, 10% of the patients suffered severe ED.
Prevalence of ED varied from 30-40% in men 40 years old to 70% in men 70 years old. A direct relationship between age and severity of erectile deficit has been demonstrated.. The National Health and Social Life Survey (1999) reported the presence of ED in 18% of men 50 and 59 years old. Lately, Mirone et al (2004), having based his study on a wide Italian population, described an ED incidence variability from 4.6% in men under 25 years old to 37.6% in men over 74 years old, with an overall prevalence of 12.8%.
These data seems to be applicable worldwide, although not dependent on ethnic or racial differences. Even if developing countries have heavy sexual taboos, prevalence of this problem is sometimes strongly underestimated.
Generally, aetiology of ED can be classified as organic or psychogenic. However, this classification doesn’t seem to be very clear, with a prevalence of mixed forms, being the organic and psychological factors often interrelated and overlapped.
Organic and psychogenic ED have different for presenting symptoms, severity and association with environmental variables. Psychogenic dysfunction usually appears suddenly with an immediate loss of erection. On the other hand organic dysfunction shows a gradual onset with worsening of underlying pathologies.
Therefore, this classification can be very helpful for the management of a patient with ED. In the presence of organic ED, the treatment of underlying pathology should be the first step of therapeutic regimen, while a patient with a psychogenic ED should be addressed to adequate counselling representing the principal care for this kind of dysfunction.
ED must be considered a public health problem. Its prevalence in the male population worldwide seems to be very high, leading to the important worsening of life quality among patient and his partner. In the majority of patients, an organic, psychogenic or more frequently, mixed organic/pshycogenic aetiology can be recognized for erectile deficit. A good anamnesis and a good relationship between patient and physician, based on mutual confidence, are needed for correct management of men suffering erectile problems. Finding out, underlying ED conditions is an essential factor for an adequate olistic approach to patient care, even if this may not seem to modify the initial therapeutic choices. Oral PDE5-inhibitors currently represent therapeutic cornerstone for most patients suffering erectile dysfunction, showing high effectiveness, very good compliance and low rate of adverse events in this subjects.
Therefore good anamnesis, correct approach to patients and his problems, issue of validated questionnaire, routine laboratory tests and hormonal profile seem to be enough in most cases to make an aetiological diagnosis of erectile dysfunction and to identify and remove ED risk factors (smoking, hypertension, drugs or alcohol abuse, hypercholesterolemia, hypertriglyceridemia, hormonal alterations, psychiatric diseases, etc.).
So second level diagnostic test can be limited to patients in whom the first level diagnostic assessment had not given clear results, to young patients with persistent ED when the exclusion of the presence of an underlying organic pathology is necessary, to patients with suspected veno-occlusive or neurogenic ED and to all patients when a better characterization of disease is needed.
Via Pansini 5, Napoli, Italy
Via Pansini 5, Napoli
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