Evaluation Of Male Erectile Dysfunction  INTRODUCTION              

 In recent years, the importance of physical factors in the entero pathogenesis of male erectile dysfunction has become incontrovertibly established. It is now know that erectile dysfunction can occur as a result of psychological factors, physical factors or both.

 HISTORY-TAKING Too often, history taking is performed very cursorily; this can lead to great blunders. Because of the intimate admixture of psychological and physical issues in erectile function, a detailedpsychosexual, marital and social history is mandatory. Such a history not only improves the diagnostic yield but also goes a long way in planning proper treatment. 

Importantly, it can help avert many a post- operative disaster should the candidate require surgery. A detailedsexual history is invaluable. Direct questions should be asked about the rigidity and duration of erection during sleep, masturbation and sexualintercourse. History-Taking should also include a systematic check list for contributory organic factors 

One  often; a good history alone can lead the clinician to a working diagnosis of the relative preponderance of psychological or physical factors in any given patient. 

PHYSICAL EXAMINATION  Although physical examination often contributes very little to the eventual diagnosis and treatment plan, the importance of its thoroughness cannot be over- emphasized.A thorough general and local examination must be performed. A complete neurogenic impotence is still made mainly by elimination of other causes coupled with a high index of clinical suspicion. 

INVESTIGATIONS) General Systemic Investigations contribute little to the diagnosis and management of impotence per se. However, these must be performed in the interest of the general health of the patient and to identify contributory underlying causes. Monitoring of diabetes, for example, does little to alter the continuing impact of the diabetic process on the erectile apparatus. The same is perhaps true for other systemic diseases associated with erectile dysfunction. It must be noted that even endocrine disorders usually affect the libido rather than the erection itself. Hormonal measurements, therefore, do not obviate the need for more specific tests. 

b) Specific The armamentarium of diagnostic gizmos and devices flooding the impotence market is quite confusing to the newcomer dabbling in impotence. While some of these are indubitably useful, many are mere research tools that contribute little to an objective diagnosis. Besides, the international literature on the subject is very contradictory and clear standards have not been enunciated for many of thesetests.It is still possible, however, with the modalities available today to make a fairly accurate diagnosis of the predominant causal factor/s in any patient. It is not necessary to perform all tests on all patients. The work-up should be tailored according to the individual needs of the patient.Apart from the patient’s economic capacities, time is an important consideration especially in case of the patients coming from faraway places.The psychological make-up and the attitude of the patient are also important.An invasive test should be eschewed in favor of non-invasive ones in especially anxious. The ultimate goal of the investigative work-up is to determine whether the cause of the impotence is psychological, arterial, venous, neurological or endocrinological.  It is important to remember that often many factors may co-exist in the same patient.

 1) The Injection Test If performed correctly, this test alone can enable a working diagnosis within one day. Drug used are prostaglandin or papaverine hydrochloride. Prostaglandin is preferable when the patient has to travel within a few hours because of the much lesser risk of priapism. Many other vasoactive substances and their combinations (most notably papaverine –phentolamine have been described. However, these are not indispensable and their non –availability should not be a deterrent to an accurate diagnosis. Papaverine hydrochloride alone is adequate for most purposes. It is cheap and freely available throughout India. Prolonged erections and priapism, should they occur, are very easy to treat. The biggest enemy of papaverine is the anxious patient. For these reasons, it is very important that the patient’s anxiety should be allayed. If necessary, the test should be repeated on more than on occasion. If there is no suspicion of neurological disease, it is safe to start with a dose of 45-60mg. A 26-30gauge needle is used to inject the drug directly into the corpora cavernosa atthe mid-shaft level. The patient should always be given the privacy of a quiet,relaxed room. This test should never be performed in a busy out- patientsetting with people walking in and out. This is certain to affect the out comeof the test. The patient should beseated upright during the injection. Pressure on the puncture site should bevery gentle or it can have a retrograde milking effect on the penis. This canlead to false-negative results even after appropriate dosage and can cause drug-related systemic side effects as well. After injection, the penisshould be gently stroked in order to distribute the drug and facilitate the lubricating jelly help. Visual Sexual Stimulation (VSS) using eroticliterature, computer software or video films may be used but doesn’t always help. Unlike in the west, erotica does not have the same effect on the Indian male. This is probably because of socio-cultural and attitudinal differences.  Lastly, it must be remembered that erotic literature and films are prohibited by law in India. For these reasons, VSS can be safely omitted without notable compromise india gnostic yield. Likewise, it may or maynot be very helpful to keep the patient in his sexual partner’s company during the conduct of this test. Many men are embarrassed in their partner’s presence and this might affect the outcome of the test.  The patient remains seated throughout the test, it is best to seat the patient on a large bed with his back propped against a back- rest or a wall. The legs should be stretched out on the bed. These simple precautions will prevent accidental injuries which could arise from the systemic effects of papaverine hydrochloride.  If the patient is relaxed and a suitable does has been injected, a good erection will occur within 10minutes. Erectile dysfunction secondary to arterial disease may take several minutes longer to produce an erection.  Patients with neurogenic importance may develop priapism with very low doses of papaverine but this should not be a deterrent to using adequate dosages. If the erection is unequivocally rigid and the penis cannot be buckled, vasculogenic impotence can be virtually eliminated and no further investigations are necessary.  If the erection is not rigid enough, a second does may be employed at the same setting. This is quite safe and systemic side effects are uncommon.  However, it must be emphasized that this should be performed in a hospital setting with full infrastructural back-up rather than in an office environment. Any curvature of the penis can be studied at the same time. If the erection is still not rigid enough, vascular disease must be eliminated using more sophisticated tests. A Doppler study can be easily combined with the injection test. If an objective measurement of the erection is desired either for academic,medico-legal or psychotherapeutic purpose, a real- time Rigiscan monitoring maybe performed at the same session.

  2) The Rigiscan Test  The Rigiscan is the gold standard for NPTR (Nocturnal Penile Tumescence and Rigidity) measurement. It is the test of choice for non-invasive diagnosis.It is especially suitable for anxious patients since it can be performed in the privacy of their own bedrooms. Its ability to objectively quantify erectile rigidity and establish physical normalcy makes it an important, reassurance providing device to the patient with purely functional problems. It is also useful in medico-legal cases. Time and cost are two relative deterrents.A Rigiscan tracing showing a good number of erectile episodes  with rigidity levels of 80% or more and a duration of 20 minutes or more in a single episode almost effectively rules out serious vascular disease.  Arterial insufficiency and venous leaks can also be suspected on the basis of the Rigiscan graphs.Patients with purely arterial disease generally have low levels of maximum rigidity but of adequate duration.  Patients with predominant venous leakage will have varying rigidity levels depending on the severity of the leakage but the duration is almost always shortened. These patients must be evaluated using other means. The erectile response to vasoactive injection can be objectively studied by the concomitant application of the Rigiscan monitor.This is called a Real time study. 1 Abnormal NPTR Showing few ill sustained episodes with inadequate rigidity. All in all, the Rigiscan Is an extremely useful device. In an era where many doctors as well as patients continue to believe that most impotence is predominantly due to psychological factors, it is important to eliminate psychological causes first even though such a policy grossly violates conventional medical teaching according to which organic disease must always be eliminated first.  2) Penile Ultrasound A Doppler evaluation of the penile arteries is indicated if the erectile response to the injection testis inadequate or if the patient’s Rigiscan study is suggestive of arterial insufficiency. Pure arterial disease or trauma.Ultrasonographic evaluation of the cavernosal arteries can be performed with varying degrees of sophistication once cavernosal smooth muscle has been effectively relaxed by vasoactive injection. A simple acoustic Doppler probe, which is inexpensive portable, emits auditory signals which can effectively eliminate  gross cavernosal arterial disease. Duplex Doppler and Colour Doppler studies can help visualization of the cavernosal arteries and measurement of flow. They can also hint at the presence of venous disease. But while these are useful for quantifying penile arterial flow and help diagnose abnormalities in the main cavernosal arteries,they cannot altogether eliminate arterial insufficiency because of their inability to image the microvasculature. Thus, a normal arterial study does not eliminate arterial disease. This is important to bear in mind.  3) DICC (Dynamic Infusion Cavernosometry & Canvernosography) 

The DICC is an useful hemodynamic test for the diagnosis of CVOD (Corporal Veno-Occlusive Dysfunction). In its simplest form, two cannula are inserted into the corpora cavernosa after smooth muscle relaxation has been achieved with a vasoactive injection. One cannula connected to a pressure transducer; the other conducts saline or radiopaque contrast solution at controlled flow rates through an adjustable flow pump. Pressures are measured after injection and 30 seconds after a pressure of 150 mm Hg has been induced. Flow rates are measured in order to induce erection and attain 150 mm Hg, to maintain erection at 150 mm Hg; the study is then repeated at a pressure setting of 90 mm Hg. 

The Cavernosal Artery Systolic Occlusion Pressure (CASOP) is also measured at the same time using a Doppler device. These are also the only universally accepted standards for DICC evaluation. There are some centers that perform an 8 or 9 track multi-phasic DICC. Radiologic visualization of leaking penile veins (cavernosography)is performed at the same sitting in many centres. Such radiologic studies are useful only if site-specific, selective ligation is planned as a surgical option.  4) Neurologic Evaluation  Many tests have been used for the evacuation of neurogenic impotence. These include nerve conduction studies, biothesiometry and corpus cavernous electromyography (CCEMG), among others. None of these is 100% reliable. The diagnosis of neurogenic impotence continues to be based on elimination of vasculogenic causes, a high index of clinical suspicion and a thorough neurological examination. In any case, tests for neurogenic impotence, whatever their results, will not alter treatment options.