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The European Association of Urology issued updated guidelines on erectile dysfunction in 2006. These can be found in European Urology, 49, pages 806 to 815. The previously published guidelines for the clinical consideration and treatment therapies for erectile dysfunction were updated because of the scientific information accumulated since the original guidelines were issued and the updated clinical practice such as the administration of Viagra. Such an update is particularly relevant in view of the fact that a study of epidemiological reports suggest that between 5 and 20% of men complain of moderate or severe erectile dysfunction. In some ways, the risk factors for erectile dysfunction are fairly well recognized. Smoking, hypertension, atherosclerosis, and other conditions such as hyperlipidemia and pelvic surgery are known to increase the chance of erectile dysfunction. We also have clear evidence about lifestyle factors and their impact on erectile issues. For example, in the Massachusetts Male Aging Study, men who started physical activity in their 40s and beyond showed a 70% reduction in risk for erectile dysfunction compared to men who remained sedentary. In addition, regular exercising showed that erectile dysfunction could be significantly reduced in a longitudinal study over a period of eight years. Again, there is plenty of evidence to suggest that reduction in body mass index and increase in physical activity score correlated with lower levels of erectile dysfunction. As far as the management of erectile dysfunction is concerned, there are several implications in everyday clinical practice. For one thing, the number of men who are seeking help with these issues has increased due to the publicity around the availability of effective and safe oral medications. Nonetheless, certain aspects of medical treatment remain the same: initially, a detailed medical history should be taken, including specific attention to the presence or absence of hypertension, myocardial disease, lipid levels, kidney function, hypogonadism, and any neurological or emotional disorders. As has been observed on several occasions in the literature, the atmosphere in which the initial consultation is conducted has major impact in creating a relaxed atmosphere which in turn facilitates communication between the doctor, the man with ED, and his partner. Only in such an environment would it be possible to obtain detailed descriptions of such things as the number and hardness of morning erections, whether erections develop in response to masturbation, sexual arousal and ejaculation and the presence of any other sexual dysfunctions. Apparently, urinary tract symptoms and ED occur in about half of men aged 50 years or over: fortunately, at this stage the presence of ED is not necessarily an indication of diabetes and the other comorbidities such as hypertension, cardiac disease and hyperlipidemia. One of the problems here is that men over the age of 50 are often required to undergo prostate surgery, and such surgery is a well-established cause of ED. Other factors known to be associated with ED are chronic use of drugs, both legal and illegal, hypogonadism, cardiovascular disease, and diabetes, among others. An investigation of the patient's condition, using the international index for erectile function (IIEF), can be used to assess all aspects of sexual function from development of erection, through sexual desire, arousal, ejaculation, intercourse, and overall sexual and orgasmic satisfaction. This document can also be helpful in determining a specific treatment methodology and studying its impact. If you are a man who is going for an investigation of ED, you may expect that your doctor will give you a complete physical examination with emphasis on the genitourinary, endocrinological, and vascular systems. Any condition that you are aware of such as Peyronie's disease, prostatic enlargement, reduced sexual desire, or any change in your health which may suggest that you're going through andropausal symptoms, should be reported to the doctor. The cardiovascular system and sexual activity As has been reported elsewhere on this website, there is a high level of cardiovascular disease amongst men who have sexual dysfunction and are seeking treatment for it. In general, we know that sexual problems appear long before the potential cardiac risks, so erectile dysfunction can be a useful indicator of forthcoming heart disease. What is of special interest to doctors seeking to identify the correct treatment for ED are intermediate-risk and high-risk men, two categories of patients that include (1) men whose cardiac condition is uncertain or whose risk profile suggests that further testing and evaluation should be undertaken, and (2) men whose cardiac condition is either severe or unstable, to the extent sexual activity may constitute a significant risk to health. Indications for specific diagnostic tests are as follows:
The revised guidelines for the treatment of ED suggest that the majority of men with ED can be managed within a sexual care clinic, but the above situations suggest that specific diagnostic testing may be required and this may take place outside the environment of the clinic. For example, nocturnal penile tumescence and rigidity testing may be needed. This is a test to record any erection that a man experiences during the night; any complete or partial erection of at least 60% rigidity for a time equal to or greater than 10 minutes is considered to be an indication that the man's erectile mechanism is functional. Alternatively, an intracavernosal injection that produces a rigid erection within 10 minutes, and which lasts for at least 30 minutes, also indicates a functional erectile mechanism, although in this case there is less certainty that the man's erectile capacity is normal, because such an erection can coexist with arterial insufficiency or a problem in the mechanism of venal occlusion that prevents blood flowing out of the penis. In cases where there is doubt about the results of the test or the diagnosis, ultrasound examination of the penile arteries can be conducted. Men with conditions such as Peyronie's, congenital curvature of the penis, or hypospadias, may require surgery before treatment for erectile dysfunction. Treatment options for erectile dysfunctionThe new guidelines suggest that the primary goal of any treatment strategy for a man with ED is to cure all the man's symptoms with a holistic approach. In other words, treatment specifically for erection problems should be associated with lifestyle or other changes to target modifiable or reversible factors. Although treatment with drugs such as Viagra can be successful, it does not necessarily cure the underlying problem, except possibly in cases where a (young) man is experiencing psychogenic erectile dysfunction or hormonally induced erectile dysfunction that can be cured with specific treatments. In other cases, testosterone deficiency may be a cause of ED, or a contributory factor. Such a deficiency may be the result of primary testicular failure or secondary testicular failure due to pituitary or hypothalamus problems. An excessive level of prolactin can be caused by a pituitary tumor. In such cases, the advice of an endocrinologist is absolutely essential. For example, testosterone supplementation can be very effective, but in some ways it is a last resort, and used only when other possible endocrinological causes have been excluded. Men who receive testosterone supplementation should also have a digital rectal examination and a PSA test. The revised guidelines suggest there is no reason to avoid testosterone therapy if men have coronary artery disease and/or a diagnosis of hypogonadism or erectile dysfunction. The only aspect of the treatment that may be problematic is an increase in hematocrit. Unfortunately however, testosterone supplementation, despite its obvious benefits may not always cure erectile dysfunction. For men who have significant psychological issues, an appropriate form of psychosexual therapy and/or another therapeutic approach such as Viagra may be necessary.
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Other pages on this website about the causes of erectile dysfunction and impotence
Other sections on erectile dysfunction
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