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DIAGNOSIS

During the first visit, the essential step in the management of ED is the taking of a comprehensive medical and psychological history of the patient and his partner when possible (7,8). A detailed medical history is critical as many common disorders are associated with ED, including hypertension, diabetes mellitus, myocardial disease, lipidaemia, hypercholesterolaemia, renal insufficiency, hypogonadism, neurological and psychiatric disorders, and indeed any chronic illness. Genitourinary and rectal surgery, as well as many drugs, particularly antihypertensive and psychotropic drugs may cause ED. Other drug groups and substance abuses are well-documented causes of ED. The chronic use of alcohol, marijuana, codeine, meperidine, methadone and heroin is associated with a high incidence of ED (9). The influence of radiation therapy on ED is well known. Evaluation has revealed vasculogenic alteration to be the most consistent organic erectile abnormality in radiotherapy (10).

The initial enquiry about medical history allows a more relaxing atmosphere to be established and permits questions about erectile function and other aspects of sexual history to be asked more easily, even when men do not volunteer to describe their problem. The sexual history may include information about previous and current sexual relationships, current emotional status, onset and duration of the erectile problem and possible previous consultations and treatments. Detailed descriptions of the quality of both erotic and morning erections, in terms of rigidity and duration, as well as arousal, ejaculation and orgasmic problems should be discussed. The use of validated questionnaires, such as the International Index for Erectile Function, may be helpful in order to assess objectively not only the present status but also the impact of a specific treatment (11).

A focused physical examination must be performed on every patient, with particular emphasis on the genito-urinary, endocrine, vascular and neurological systems (7). The physical examination may reveal unsuspected findings, such as Peyronie's disease, small testes and prostatic cancer. A rectal examination should be performed in every patient older than 50 years.

Laboratory testing (blood glucose and testosterone) should be carried out in the majority of the patients and selectively in other patients when lipid profile, prolactin and prostate-specific antigen (PSA) assessment should be considered (12-14).

It is important that the physician facilitates communication with the patient and his partner, and explains

the strategy behind the diagnostic and therapeutic approach. It may not often be possible to involve the partner on the first visit, but an effort should be made to involve the partner during the second visit. On that occasion the physician examines the results of the blood tests. If any abnormality is observed, further investigation by referral to another specialist may be necessary.

The discussion considers patient's expectations and needs, and should involve the physician, the patient and their partner. It should cover the understanding of the disorder, interpretation of the diagnostic tests and rational selection of treatment options. Patient and partner education are essential components in the management of ED (15).

While the majority of patients with ED can be managed within the sexual care setting, some circumstances may dictate the need for specific diagnostic testing:

• The patient with primary erectile disorder because, beside psychogenic causes, it is mandatory to
exclude organic disease

• Young patients with a history of pelvic or perineal trauma who could benefit from potentially curative
vascular surgery

• Specific tests may also be indicated at the request of the patient or his partner

• For medico-legal reasons.

Among the specific tests used are: assessment of nocturnal penile tumescence and rigidity using Rigiscan-NPTR; vascular studies, such as intracavernous vasoactive drug injection and duplex ultrasound completed with arteriography or cavernosometry; neurological studies, such as bulbocavernous reflex latency and nerve conduction; endochnological studies and specialized psychodiagnostic evaluation. The NPTR should take place for at least two nights. The presence of an erectile event of at least 60% rigidity recorded on the tip of the penis, lasting for 10 min or more, should be considered as indicative of a functional erectile mechanism (16).

The intracavernosal injection test offers limited information regarding vascular status. A positive test is defined as a rigid erectile response (unable to bend the penis) that appears within 10 min after the intracavernosal injection and lasts for 30 min. Such a response may be considered to be associated with normal arterial and veno-occlusive haemodynamics (16). In all other cases, the test is inconclusive, and a duplex ultrasound of the penile arteries should be requested. A peak systolic blood flow higher than 30 cm/sec, and a resistance index higher than 0.8 are generally considered as normal (16). If the result of the duplex examination is normal, the vascular investigation stops. When it is abnormal, arteriography and cavernosometry should be performed only for patients who are considered potential candidates for vascular reconstructive surgery. Patients with psychiatric disorders will be sent to a psychiatrist particularly interested in ED. Patients with penile abnormalities, such as hypospadias, congenital curvature or Peyronie's disease with preserved rigidity, may require surgical correction with very good success.

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