By L. Rufus. Wabash College.

The partner may provide insight into sexual difficulties order vardenafil 10 mg with visa, relationship problems vardenafil 20mg free shipping, and underlying health con- cerns that the patient may be uneasy about discussing. This may also identify the partner’s approach to and value of intimacy and sexual function in the relationship (24). The goal of this approach was to iden- tify a specific etiology such that more invasive, costly, uncomfortable treatment modalities could be applied based on the patient’s treatment goals. A full sexual history is critical with special attention to risk factors and medications (20). This should be followed by a thorough physical examination, laboratory studies, and appropriate clinical diagnostic studies. A history should include a careful sexual history to elicit these possible causes (25). Patients should be queried regarding morning erections, nocturnal erections, erectile quality, and erections during masturbation, and ejaculatory function. Patients who complain of loss of libido or sexual desire may be con- sidered as at risk for hypogonadism. Low libido, however, may be caused by medications, hypochondriasis, stress, anxiety, or depression (14). Low libido clearly requires evaluation to identify those patients with androgen deficiency of the aging male or other causes of hypo- gonadism. Those patients with chronic renal failure, especially on chronic dialysis, may have low libido caused by low testosterone and high prolactin levels (19). These abnormalities can be treated medically to decrease prolactin and increase testosterone levels. A history of ejaculatory dysfunction must also be elicited to identify those patients with premature ejaculation or delayed ejaculation. Younger men more often complain of premature ejaculation whereas those in the older age group more often have difficulties with retarded ejaculation or even absent ejaculation. This may be caused by natural aging, lack of androgen, neurologic abnormalities, medications, or pelvic surgery. Patients with retrograde ejaculation must be suspected Chapter 2 / Erectile Dysfunction: The Scope of the Problem 31 Table 2 Modifiable Risk Factors for Erectile Dysfunction Diabetes mellitus Cardiovascular disease Spinal cord injury Cigarette smoking Depression Atherosclerosis Hypertension Pelvic surgery/trauma Medications Arthritis Peripheral vascular disease Renal failure Substance abuse Endocrine abnormalities Peptic ulcer disease of having diabetes mellitus, may be using α-blocking medication, or may have had previous urologic or neurologic surgery (20). Additional history should include history of penile trauma, priapism, curvature of the penis from Peyronie’s disease, or congenital corporal disproportion. Depression and anxiety can often be identified in this initial phase of the examination. Testicular size and consistency, as well as penile anatomy, should be examined carefully. Patients with small or soft testes should be suspected of hypogonadism, and lesions of the shaft of the penis can be identified in those patients with Peyronie’s disease. A brief neu- rologic examination should be performed with an evaluation of sensa- tion of lower extremities, deep tendon reflexes, and perineal sensation. A bulbocavernosus or cremasteric reflex as well as sphincter tone on rectal examination can be quantified. Digital rectal examination to identify prostate size, consistency, nodularity, pain, or prostatitis should be conducted. If questions arise regarding penile sensation, biothe- siometry of the glans penis and penile shaft can be performed in the office with this vibratory sensation device (26). Results should be com- pared with an age-adjusted normogram to identify those patients with decreased glans penis sensation. Once a careful physical examination is completed, laboratory investigation should be tailored to the individual patient and goals of therapy. In patients who have not had recent health evaluation, fasting Chapter 2 / Erectile Dysfunction: The Scope of the Problem 33 blood glucose should be measured to identify patients at risk for diabetes mellitus. This is especially important in those patients with a family history of diabetes or those patients with personal histories of polyuria or polydipsia. In known diabetics, an Hb A1c can evalu- ate control and medical compliance with diabetic therapy. Similarly, laboratory studies can include a lipid profile to identify those patients with hypercholesterolemia. In those patients with suggestive history, a thyroid profile can be obtained as well. An initial screening of morning total testos- terone should be performed to identify testosterone level. It is impor- tant to perform this as a morning evaluation because testosterone concentration peak occurs between 8 and 10 a. Repeat testosterone levels with a free testosterone, luteinizing hormone, and prolactin level should be performed if testosterone is suspicious. It is well known that normal men have significant erectile function during rapid eye move- ment sleep. False/negative studies may be found in those patients with depression, sleep disorders, sleep apnea, sleep-altering medications, smoking, and caffeine use. The overall accu- racy of nocturnal penile tumescence monitoring is approximately 80% (29). Vascular studies to identify functional abnormalities of the arterial and venous systems can be used with accurate determination of vascular function and anatomy. Older studies using hand-held Doppler with penile brachial index identification appear to be inaccurate and poorly reproducible. However, the use of duplex ultrasound color Doppler flow studies with intracavernous injection of vasoactive agents can carefully evaluate both the arterial and venous systems that produce erections in a functional fashion.

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