Patient

Evaluation
Tarek Anis
Prof. of Andrology
Kasr El-Eini
Wednesday, December 30, 2009
 Initial Evaluation
History
–Medical
–Sexual
–Psychosocial
Physical Examination
Diagnostic Tests
Patient Education
Treatment ⇔ Specialist consultation

Wednesday, December 30, 2009

 History

Wednesday, December 30, 2009

 History

The goal of the medical history is to

Differentiate between psychogenic
and organic ED
Identify risk factors for organic ED
 Cardiovascular risk assessment

Wednesday, December 30, 2009

 Risk Factors of CVD
ED

Traditional Underlying Emerging

Age > 45 y Obesity insulin resistance/
High LDL cholesterol Sedentary lifestyle metabolic syndrome
Low HDL cholesterol Atherogenic diet
Hypertension
Diabetes
Smoking
1 2 3

Wednesday, December 30, 2009

 Risk-factors For Organic ED
 Ageing  Depression

 Hypertension  Neurological illness

 Atherosclerosis  Endocrinopathy

 Diabetes mellitus  Prescriptionand

 Smoking
recreational drugs ?

 Pelvic/perineal/penile
trauma or surgery

Wednesday, December 30, 2009

 Sexual History
Nature of the problem
Chronology of the problem
Severity of the problem
Definition of patient’s needs and
expectations

Wednesday, December 30, 2009

 Sexual History
Chronology
 Could you describe your sexual problem ?
 When was the last time you had a satisfactory erection ?
 How was your sexual function prior to this time?
 Was the onset of your dysfunction gradual or sudden ?
 When was the last time you had satisfactory penetration ?
 What portion of sexual attempts is satisfactory to you?
 Is your partner satisfied with your sexual function ?
 If we can restore your erections what would be your average
frequency of sex each month?

Wednesday, December 30, 2009

 Sexual History
Severity
 Do you have morning or night time erections ?
 How strong are the erections you get with masturbation?
 On a scale of 1 to 4 how would you rate the stiffness of those
erections ?
 With sexual stimulation can you initiate an erection?
 With sexual stimulation can you maintain an erection ?
 Do you lose erection before penetration, or before climax ?
 Do you have to concentrate to maintain an erection ?
 Do you lose the erection if you don’t have continuous direct
stimulation to the penis?
 Is there a significant bend in your penis? Do you have pain with
erection ?

Wednesday, December 30, 2009

 The Sexual Health Inventory for Men
SHIM Score
Over the past 6 months:
How do you rate your confidence that you could get an erection?
1
1 Very Low 2 Low 3 Moderate 4 High 5 Very High

When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
2
0 No sexual activity 1 Almost never or never 2 A few times 3 Sometimes 4 Most times 5 Almost always or
always

During sexual intercourse, how often were you able to maintain your erection after you had penetrated
3 (entered) your partner?

0 Did not attempt 1 Almost never or never 2 A few times 3 Sometimes 4 Most times 5 Almost always or
always

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
4
0 Did not attempt 1 Extremely difficult 2 Very difficult 3 Difficult 4 Slightly difficult 5 Not difficult

5 When you attempted sexual intercourse, how often was it satisfactory to you?

0 Did not attempt 1 Almost never or never 2 A few times 3 Sometimes 4 Most times 5 Almost always or
always

Wednesday, December 30, 2009

 Erection Hardness Score (EHS)

Severe ED Moderate ED Mild ED No ED

IIEF-EF 6 - 10 11 - 21 22 - 25 26 - 30

Penis is larger Penis is hard Penis is hard Penis is

but not hard but not hard enough for completely
enough for penetration hard and
penetration but not fully rigid
completely
hard

Sources: Goldstein I et al. N Engl J Med. 1998;338:1397-1404; Mulhall JP et al. J Sex Med. 2007;4:1626-1634.

Wednesday, December 30, 2009

 Sexual History
The Impact on the Patient / Partner
 How strong is your desire for sex, now and in the past?
 Is your erectile problem partner or situational specific ?
 Is your partner able to become aroused when you have sex
together?
 What has been your partner’s reaction to your sexual difficulties?
 Do you have difficulty reaching orgasm?
 Do you have problems with ejaculating too soon or not at all?

Wednesday, December 30, 2009

 Psychosocial History
Predisposing factors Maintaining factors
 Restrictive upbringing  Performance anxiety
 Disturbed family relationship
 Traumatic early sexual experiences  Guilt
 Inadequate sexual information  Poor communication
 Insecurity in the psychosexual role  loss of attraction between partners
Precipitating factors  Impaired self-image.
 Unreasonable expectations  Affective disorders or character
 Random failure pathology can lead to both precipitation
 Discord in the relationship and maintenance of sexual problems.
 Dysfunction in the partner
 Infidelity
 Reaction to organic disease
 Depression or anxiety

Wednesday, December 30, 2009

 Psychosocial History
 Aging
 Lifestylefactors
 Current psychological state
 Symptoms of depression
 Altered self esteem
 Past and present partner relationships
 Sexual practices
 Job and social position satisfaction
 History of sexual trauma / abuse
 Educational attainment

Wednesday, December 30, 2009

 Psychogenic or Organic ED ?
Characteristic Organic Psychogenic
Onset Gradual Acute
Circumstances Global Situational
Course Persistent and progressive Episodic or transient

Non-Coital Erection Absent or reduced in Initially present and full,

frequency and intensity lost in long-standing ED

Psychosexual problem Secondary Long history

Partner problem Secondary At onset
Ejaculation Normal Premature or intermittent
loss
Erection Poor from the start Unable to maintain

Wednesday, December 30, 2009

 Examination

Wednesday, December 30, 2009

 PHYSICAL EXAMINATION
General Examination
 Signs chronic diseases (hepatic, renal,
cardiovascular, granulomatous, neoplastic) and
state of disease control.
 Endocrine illnesses : diabetes, thyroid, adrenal
disease, and any degree of complications.
 Hypogonadism : Evidence of muscle
development, size and structure of the penis, size
and consistency of the testes and prostate,
gynaecomastia, body hair, fat distribution, body
proportions

Wednesday, December 30, 2009

 Obesity
Weight
Body mass index =
Hight in meters 2

Waist Circumference
Male < 40 > ۲۰ ۲٥ - ۲۰ ۲۹ - ۲٦ > ۳۰
Female < 35
Slim Ideal Over Obese Very
weight obese
18
Wednesday, December 30, 2009
 Metabolic syndrome and hypogonadism

Adopted from Jones T. 2007 : Testosterone Associations with Erectile Dysfunction, Diabetes, and the Metabolic
Syndrome. European Urology Supplements. Volume 6, Issue 16, 847-857
Wednesday, December 30, 2009
 The pathogenesis of ED in
Metabolic Syndrome
Gene
Food intake ↑ Activity ↓

Visceral obesity

↓ Androgen Insulin resistance

↑Sympathetic Sodium
activity retention

Oxidative
Stress

Aging Atherosclerosis
Suetomi et al. Negative impact of metabolic syndrome on the responsiveness to sildenafil in Japanese men. J Sex Med 2008;5:1443–1450
Wednesday, December 30, 2009
 Physical Examination
Vascular Assessment
 Pulse palpation of ankle, femoral, and dorsal penile arteries.
 Blood pressure monitoring
 Penile systolic blood pressure
– Using a 3-cm blood pressure cuff placed around the base of the penis and a
Doppler stethoscope positioned over each cavernosal artery
 Penile brachial index (PBI)‫‏‬
– Values > 0.7 are considered normal.
– PBI is diagnostic in patients with no other risk factors such as diabetes or
current intake of medications with potential adverse effects on the erectile
function.

Wednesday, December 30, 2009

 Physical Examination
Neural assessment
 Motor deficits, changes in deep tendon reflexes, loss of
sphincter tone, decrease in light touch or pinprick sensations,
penile temperature sensation.
 Anal reflex should be elicited by squeezing the glans penis and
assessing the evoked contractions of external anal sphincter or
bulbocavernosus muscles.
 Penile vibration perception threshold is the most predictive
sensation testing procedure

Penile Examination
 Masses or plaque formation, angulation, unprovoked persistent
erection, or tight unretractable foreskin

Wednesday, December 30, 2009

 Investigations

Wednesday, December 30, 2009

 Diagnostic Tests
Recommended Diagnostic Tests
 Fasting glucose or glycosylated hemoglobin (HbA1C)
 Fasting Lipid profile
 A morning testosterone assay to assess the
hypothalamic-pituitary-gonadal axis. (total, free or
bioavailable)
Optional Diagnostic Tests
 Prolactin, LH
 CBC
 PSA

Wednesday, December 30, 2009

 Specialist Referral
 Patient’s request
 Treatment failure
 Peyronie’s disease
 Primary ED
 History of pelvic/perineal trauma
 Cases requiring vascular or neurosurgical
intervention
 Complicated endocrinopathy
 Complicated psychiatric or psychosexual disorder
 Complex relationship problems

Wednesday, December 30, 2009

 Specialized Evaluation
Endocrine evaluation
Vascular evaluation
Psycho-physiological tests
Nocturnal Penile Tumescence/rigidity
Testing
Neuro-physiologic evaluation

Wednesday, December 30, 2009

 Endocrine Evaluation
Total Testosterone
 Diurnal pattern with a peak level in the early morning and a nadir in
the evening.
 98% of testosterone is bound to plasma proteins; majority of the
binding is to albumin 40% and globulin 57%. Only 2% of total
testosterone are free.
 Bioavailable testosterone consists of both free and albumin-bound
testosterone.
 Total testosterone level decreases with age.
 SHBG is decreased in hypothyroidism, obesity and acromegaly, and
increased in aging, hyperthyroidism and estrogen therapy. it is
necessary to measure the free biologically active testosterone in these
conditions, when total testosterone can be misleading.

Wednesday, December 30, 2009

 Endocrine Evaluation
Free TESTOSTERONE
 Consists of only 2% of total. Biologically active. Exert effects in target cell where it
is converted to more potent dehydrotestosterone by 5 α-reductase.
 Level affected by
– estrogens, thyroid hormone and cirrhosis (decrease free testosterone)‫‏‬
– androgen, growth hormone, glucocorticoids and obesity (increase free testosterone
level).
 More expensive to measure free testosterone than total testosterone.
 Testosterone replacement improved sexual functions only in men with low free
fraction but NOT in subjects with a normal free fraction.
 Free testosterone level lowers significantly with aging.
 Prevalence of partial androgen deficiency in aging males (PADAM) may be as
high as 50% if free testosterone level is used. Adult Onset Hypogonadism

Wednesday, December 30, 2009

 Calculated Free T

29

Wednesday, December 30, 2009

 Androgens maintain penile tissue architecture
and Function
 Androgens maintain vascular endothelial
structure and function
 Androgens maintain tunica albuginea structural
integrity and connective tissue matrix fibro-
elastic properties
 Androgens maintain penile trabecular smooth
muscle structure and function
 Androgens regulate differentiation of pluripotent
precursor cells into trabecular smooth muscle
 Androgens maintain penile cavernosal and
dorsal nerves structure and function

Wednesday, December 30, 2009

 Endocrine Evaluation
PROLACTIN (PRL)
 Serum prolactin increases during sleep, peak in the early morning and
decline immediately after awakening.
 Determination is indicated for patients with history of decreased libido,
gynecomastia or testicular atrophy.
 A blood sample should be taken between 8 - 10 am. If the prolactin level
is raised, a repeat test should be done with the patient completely rested.
Secondary causes of hyperprolactinemia should be looked for.
 Persistent, unexplained hyperprolactinemia should warrant a CT- or a
gadolinium enhanced MRI-scan of the head to exclude a pituitary tumor.

Wednesday, December 30, 2009

 What is the metabolic
syndrome
The metabolic syndrome refers to a clustering of
various medical conditions, with a number of
pathological components, that contribute to the
development of cardiovascular diseases and
diabetes.
These pathological components include glucose
abnormality, obesity, elevated blood pressure,
and dyslipidemia.

Wednesday, December 30, 2009

 Diagnostic Criteria for Metabolic
Syndrome in Men
WHO 1999 NCEP–ATP III IDF 2005
World Health Organization 2001 The International Diabetes
Federation
The National Cholesterol
Education Program
FBS ≥ 110 mg/dL FBS > 110 mg/dL FBS > 100 mg/dL
Glucose
↑ insulin or IR Type 2 DM Type 2 DM
abnormality
T2 DM
Waist/Hip ratio > 0.90 WC ≥ 102 cm Central obesity (ethnic
Obesity WC ≥ 94 cm specific values)
BMI ≥ 30 kg/m2
≥ 150 mg/dL ≥ 150 mg/dL ≥ 150 mg/dL or on
Triglyceride
(combined with HDL). specific treatment
HDL Cholesterol < 35 mg/dL < 40 mg/dL < 35 mg/dL
BP ≥ 140/90 mmHg BP ≥ 130/85 mmHg Systolic BP ≥ 130 mmHg
Blood Pressure or HTN on Rx or HTN on Rx Diastolic BP ≥ 85 mmHg
or HTN on Rx

Traish, A. M., Guay, A. T., Feeley, R., & Saad, F. (2008). The Dark Side of Testosterone Deficiency:I. Metabolic
Syndrome & Erectile Dysfunction. J Androl, doi:10.2164/jandrol.108.005215
Wednesday, December 30, 2009
 Endocrine Evaluation
Secondary Hyperprolactinemia
 Coitus Drugs
 Hypothyroidism Protirelin, fenfluramine,
 Stress thyrotropin - releasing
hormone, estrogens,
 Chronic renal failure
antipsychotic agents,
 Exercise methyldopa, opiates,
 Severe liver disease opioids,
metoclopramide,
 Sleep reserpine and
amoxapine

Wednesday, December 30, 2009

 Indications For Vascular Testing
 To select patients for penile vascular surgery or to determine the proper
dose for intracavernous injection therapy.
 The candidates for revascularization are younger men with isolated lesions
in the pudendal or the common penile arteries, due to pelvic or perineal
trauma.
 The candidates for venorestrictive surgery are men with anatomic
abnormalities such as ectopic veins exiting the cavernous corpora or
abnormal communications between the cavernosum and glans or
spongiosum. These men may have a history of 1ry ED, urethral surgery, or
blunt trauma to the erect penis
 Pharmacotest in the office allows the patient to experience the maximal
degree of rigidity he may get after maximal pharmacological stimulation.

Wednesday, December 30, 2009

 Specialized Vascular Testing

 In office penile injection pharmacotest

 Penile Pharmaco Doppler Ultrasound
 Dynamic Infusion Cavernosometry and
Cavernosography
 Penile arteriography
 CT - and MR-Imageing

Wednesday, December 30, 2009

 In Office Penile Injection Pharmacotesting

 I.C.I of a vasoactive medication and rating of the subsequent

erection quality by inspection and palpation.
 The simplest Scale of rating erectile rigidity
1) Increase in size (no rigidity)
2) Rigidity inadequate for penetration
2) Rigidity adequate for penetration
3) unbending rigidity of at least 20 minutes duration.
 A positive response implies the patient does not have
significant vascular pathology. i.e. normal venoocclusion but
may occur with borderline arterial function
 10 µg of PGE1, combined with genital stimulation and/or visual
erotic stimulation, is the best possible initial challenge
 Re-dosing
 Inadequate erectile response may be due to anxiety

Wednesday, December 30, 2009

 Penile Pharmaco Duplex Ultrasound (PPDU)

Wednesday, December 30, 2009

 Penile Pharmaco Duplex Ultrasound (PPDU)‫‏‬

 PSV
 EDV PSV

Velocity
 Acceleration Time
 Acceleration TIME
= Δt / PSV
EDV
 RI
= PSV - EDV / PSV
Δt TIME

Wednesday, December 30, 2009

 PPDU Assessment Of Penile Inflow Tract

 Parameters: Peak Systolic blood flow Velocity

(PSV) and Acceleration Time (Δ t).
 A PSV < 25 cm/s and/or an Δ t >122 ms are
indicative for severe penile arterial insufficiency.
 PSV > 25 cm/sec but < 30 cm/s suggests mild
arterial insufficiency
 Blood flow velocities should be measured
between 1 and 10 minutes following pharmaco-
stimulation
 Change in artery diameter after pharmaco-
stimulation
Wednesday, December 30, 2009
 PPDU for Veno-Occlusive Mechanism

The diagnosis “venoocclusive

dysfunction” should be considered
when
PSV > 30 cm/s
EDV > 3 - 5 cm/sec
 RI < 0.9 ( = PSV - EDV / PSV )
Erectile rigidity rated as inadequate

Wednesday, December 30, 2009

 Normal PPDU
Excellent
erectile
response in 72-
y old man
associated with
PSV 57 cm/s
and reversal of
diastolic flow

Wednesday, December 30, 2009

 Venous Occlusive Disease PPDU
Cavernous
venous
occlusive
disease with
PSV exceeding
35 cm/s, and
diastolic flow 8
cm/s, RI < 0.9
⇓⇓⇓⇓
⇓⇓⇓⇓

Wednesday, December 30, 2009

 Mixed Vascular PPDU
Mixed Vascular
insufficiency
with PSV 27
cm/s and RI
0.83

Wednesday, December 30, 2009

 PPDU In Staging OF Peyronie's Disease

Wednesday, December 30, 2009

 PPDU In Staging OF Peyronie's Disease

 Indications include patients with a severe angulation in

whom corrective surgery is considered or men with
complete loss of erection and request placement of a
penile prosthesis.
 The preoperative staging includes demonstration of
collaterals from the dorsal vascular bundle. Operative
mobilisation of the neurovascular bundle for plaque
excision would of necessity sacrifice the dorsal
contribution to cavernous inflow.
 For medicolegal reasons it also may be important to
measure penile length and diameter during PPDU, as
every operation on the penile shaft is associated with
some risk of shortening.

Wednesday, December 30, 2009

 Dynamic Infusion Cavernosometry and
Cavernosography (DICC)

In patients who are suspected to have a site-

specific leak and in whom vascular surgery
is considered a treatment option
Congenital
Peyronie's disease with poor rigidity
History of penile fracture
Perineal / pelvic trauma

Wednesday, December 30, 2009

 DICC
 Injection of vasoactive agent is made and equilibrium pressure
measured at 10 minutes. An intracavernous pressure of 80-90
mm Hg + rigidity is a normal response.
 Infusion of heparinized saline; the flows to maintain the
intracavernosal pressures at 30, 60, 90,120,and 150 mm Hg are
measured. Complete smooth muscle relaxation is Mandatory for
the validity of the test.
 Maintenance flow rate (MFR) is the flow to maintain the
intracavernous pressure at 150 mm Hg. Normal MFR ≤ 3 ml/min.
 Cavernous artery systolic occlusion pressure (CASOP) is
obtained by monitoring cavernous arterial pulsatile flow with
Doppler. Normal CASOP < 35 mm Hg below brachial artery
systolic pressure.
 At 150 mm Hg, flow of saline is stopped and intracavernosal
pressure fall over 30 second is recorded. Normal < 45 mm Hg.

Wednesday, December 30, 2009

 Cavernosography
 Normal
 Full erection
during DICC
 Corpora
outlined with no
draining veins

Wednesday, December 30, 2009

 Cavernosography
 Both corpora
are outlined
 Plethora of
veins draining
the corpora are
seen

Wednesday, December 30, 2009

 Cavernosography
 Leak through
the left femoral
vein

⇓⇓
⇓
Wednesday, December 30, 2009
 Cavernosography
 Opacification of
the corpus
spongiosum

⇓⇓
⇓
and dorsal vein

Wednesday, December 30, 2009

 Cavernosography

Cavernosography of
patients with

⇓⇓
⇓
Peyronie’s disease.
Distal circumferential
plaque with site
specific leak

Wednesday, December 30, 2009

 Penile Arteriography
 Accurate penile arteriography requires
pharmacologically stimulated erection since the
vessels of the flaccid shaft are contracted and
tortuous and consequently hard to visualize.
 Provides the best anatomic information about the
origin of the common penile arteries, but as a
screening test it is too invasive and nonspecific.
 It is reserved for young men with a history of
pelvic / perineal trauma who may be candidates for
operative revascularization.

Wednesday, December 30, 2009

 Penile Arteriography

Selective Internal
pudendal
pharmaco penile
angiography with
digital
subtraction

Wednesday, December 30, 2009

 Penile Arteriography

Selective internal
pudendal
arteriogram
showing proximal
occlusion of the
cavernosal artery
and normal dorsal
artery

Wednesday, December 30, 2009

 CT- And MR Imaging
 CT and MRI are
sophisticated techniques,
which visualize pelvic and
genital anatomy
 They may be used in
specialized settings of
pelvic, perineal or penile
trauma or Peyronie's
disease

Gadolinium- enhanced MR angiogram in pelvic fracture patient

Intact Left pudendal, perineal, and common penile arteries
Rt pudendal disrupted by trauma

Wednesday, December 30, 2009

 Assessing Endothelial Function
 Serum markers
– Endothelin-1 : a proinflammatory peptide secreted from endothelial cells
– Asymmetrical dimethylarginine (ADMA) : a competitive inhibitor of NOS
– Inflammatory markers : interleukin-6,Tumor necrosis factor-alpha, C-reactive
protein
– Markers of cellular adhesion : E-selectin, intercellular adhesion molecule-1
and vascular cell adhesion molecule-1
 Cellular markers
– Circulating endothelial progenitor cells : using flow cytometry.
 Imaging
– Intima-media thickness (IMT) of the common carotid artery by
ultrasonography.

58

Wednesday, December 30, 2009

 Assessing Endothelial Function
 Physiological measurements
– Brachial Artery Post Occlusion Vasodilatation
• Forearm ischemia is induced by interrupting
arterial blood supply with a cuff inflated to
suprasystolic pressure.
• Release of the tourniquet induces reactive
hyperemia caused by dilation of the distal
microvasculature.
• The magnitude of the change in vessel diameter
from the baseline period to the peak observed
during reactive hyperemia is indicative of the
degree of endothelial function
– Venous Occlusion Plethysmography
• Measuring volume changes in an arm or finger by
mercury strain gauges during hyperemia.
59

Wednesday, December 30, 2009

 Nocturnal Penile Tumescence / Rigidity Testing

 NPT or sleep related erection is a recurring cycle

of erections associated with rapid eye movement
during sleep
 Registration is useful for separating
psychological and organic cases
– Sleep erections are androgen-dependent and thus
usually impaired in hypogonadal men
– Anxiety and depression may influence the content of the
dream state, negatively affecting NPT
– Sleep disturbances such as apnea or motor agitation can
also induce erroneous recordings

Wednesday, December 30, 2009

 Nocturnal Penile Tumescence

Wednesday, December 30, 2009

 Nocturnal Penile Tumescence
 Dysfunction at the level of the cortex and spine
may still permit nocturnal tumescence while
causing an ED in the awake state.
 Normal NPT may also occur in patients with a mild
vascular problem who often loose an erection
during pelvic thrusts.
 NPT evaluation has proved to be age-dependent
and quite costly, as it is ideally done in a specially
equipped sleep center
 NPT is tested over at least 2 nights, to eliminate
the 'first night effect'

Wednesday, December 30, 2009

 Nocturnal Penile Tumescence
 Rigiscan® measures radial rigidity (compressibility)
in stead of axial rigidity (buckling force)
 When Rigiscan® base and tip radial rigidity exceeds
60% of maximum, correlation with axial rigidity is
poor. In this range, the Rigiscan® fails to discriminate
axial rigidities between 450 and 900 g of buckling
force. As an axial rigidity of more than 550 g is
necessary for vaginal penetration, the Rigiscan® may
not be able to detect subtle abnormalities in erectile
function
 NPT with at least 1 erectile episode of tip penile
rigidity greater than 60% and 10 minutes in duration
might be associated with potency

Wednesday, December 30, 2009

 Nocturnal Penile Tumescence

NPT with at least 1 erectile episode

of tip penile rigidity greater than
60% and 10 minutes in duration
might be associated with potency

Wednesday, December 30, 2009

 Nocturnal Penile Tumescence

A 23-year-old, healthy, potent

volunteer
Several erectile episodes of
adequate rigidity and duration

A 46 year old male, with a 15-y

history of diabetes mellitus and 8-y
history of erectile dysfunction,
Abnormal NPT patterns
few erectile episodes, of inadequate
rigidity and duration.

Wednesday, December 30, 2009

 Neurological Testing
 Psychogenic erections, initiated in
supraspinal centers in response to
auditory, visual, olfactory, and
imaginative stimuli, are mediated by
sympathetic pathways
 Reflexogenic erections, elicited by
tactile stimulation at the genital
level, are mediated by a spinal reflex
arc consisting of afferent somatic
and efferent parasympathetic nerve
fibers

Wednesday, December 30, 2009

 Neurological Testing

Motor Autonomic
 Bulbocavernosus EMG  Cardiovascular reflex tests
 Reflex latency testing  EMG

Sensory
 Nerve conduction velocity
 Evoked potentials
 Biothesiometry
 Reflex latency testing

Wednesday, December 30, 2009

 Neurological Testing
Vibration perception threshold (biothesiometry)‫‏‬
 The test provides a biothesiometric screening method for
abnormality within the penile sensory afferent pathway. It is
performed with a portable hand-held electromagnetic
vibration device that has a fixed frequency and variable
amplitude of vibrations. The loss of, or an abnormal decrease
in, vibratory sensation suggests the presence of a peripheral
neuropathy.
Dorsal nerve conduction velocity
 A sensory deficit of the dorsal nerve may reduce the ability to
sustain erections during coitus. The decrease in sensory
transmission from the penis is also often associated with
ejaculation difficulties.

Wednesday, December 30, 2009

 Neurological Testing
Sacral Reflex Arc latency
 Determines the time interval required for a reflex arc that utilizes the dorsal
penile/ pudendal afferent pathway, the S2-S4 spinal cord segment, and the
pudendal/perineal efferent pathway. The test may be helpful in documenting
suspected lesions (S2–S4) caused by multiple sclerosis, spinal cord trauma,
spinal cord tumors, and herniated intervertebral discs.
 Parasympathetic sacral neurons are anatomically close to the central portion
of the pudendal pathways, insults to the somatic innervation at these sites
may also cause parasympathetic dysfunction.
Pudendal Nerve Somatosensory Evoked Potential
 Allows the evaluation of the peripheral and suprasacral afferent pathways by
stimulating the pudendal nerve at the penis. The evoked waveforms are
recorded at various sites within the CNS, but most typically over the conus
medullaris and parietal cortex.

Wednesday, December 30, 2009

 Neurological Testing
Perineal electromyography
 The test identifies disturbances in pudendal motor pathways,
which may be associated with metabolic or toxic disorders such
as diabetes and alcoholism
Autonomic innervation
 Cardiovascular reflex tests assess variations in heart rate and
blood pressure in response to various stimuli such as forced
breathing, standing up or tilting, Valsalva's manoeuvre,
sustained isometric handgrip.
 Heart rate variations reflect parasympathetic function, while
blood pressure variations reflect sympathetic function.

Wednesday, December 30, 2009

 Management of ED in
cardiovascular Patients

Wednesday, December 30, 2009

 Clinical spectrum of coronary
artery disease

CVDs
2-3 years

ED

DeBusk, Erectile Dysfunction Therapy in Special Populations and Applications: Coronary Artery Disease. Am J
Cardiol 2005;96: 62M–66M

Wednesday, December 30, 2009

 Cardiovascular risk assessment in ED
patients
Princeton Consensus Panel II
Asymptomatic; < 3 coronary artery
disease risk factors, excluding ≥ 3 major coronary artery disease Unstable or refractory angina
gender risk factors, excluding gender
Uncontrolled hypertension
Controlled hypertension Moderate, stable angina
Left ventricular dysfunction/
Mild, stable angina
Recent myocardial infarction (> 2 < congestive heart failure (NYHA
Has had successful coronary 6 weeks) class III or IV)
revascularization
Left ventricular dysfunction/ Recent myocardial infarction (< 2
Uncomplicated past myocardial congestive heart failure (NYHA weeks), stroke
infarction (> 6–8 weeks) class II)
High-risk arrhythmias
Mild valvular disease Non-cardiac sequelae of
atherosclerosissuch as stroke or Hypertrophic obstructive and other
Left ventricular dysfunction/ peripheral vascular disease cardiomyopathies
congestive heart failure (NYHA
Moderate or severe valvular disease
class I*)

Intermediate
Low Risk High Risk
Risk
<10% >20%
10-20%
Wednesday, December 30, 2009
 Low risk
Asymptomatic and <3 major risk factors
Controlled hypertension
Mild, stable angina pectoris
Postrevascularization and without residual ischemia
Post-myocardial infarction (MI) (>8 weeks), asymptomatic.
Mild valvular disease
Left ventricular dysfunction/congestive heart failure
(NYHA class I)

The Second Princeton Consensus on Sexual Dysfunction and Cardiac Risk: New Guidelines for Sexual Medicine
Graham Jackson, Raymond C. Rosen, Robert A. Kloner, John B. Kostis, Journal of Sexual Medicine, Volume 3 Page 28 - January 2006
74

Wednesday, December 30, 2009

 Intermediate or indeterminate
risk
Asymptomatic and ≥3 CAD risk factors (excluding
gender)
Moderate, stable angina pectoris
MI >2 weeks but <6 weeks
LVD/congestive heart failure (NYHA class II)
Noncardiac atherosclerotic sequelae (peripheral arterial
disease, history of stroke, or transient ischemic
attacks)

75

Wednesday, December 30, 2009

 High risk

Unstable or refractory angina

Uncontrolled hypertension
CHF (NYHA class III, IV)
Recent MI (<2 weeks)
High-risk arrhythmias
Obstructive hypertrophic cardiomyopathies
Moderate to severe valve disease

76

Wednesday, December 30, 2009

 Cardiovascular risk in ED patients
Princeton Consensus Panel II
High Sexual activity deferred until
stabilization of
Risk cardiac condition

Clinical Cardiovascular
Sexual Indeterminate assessment and
Evaluation
Inquiry
Risk re-stratification

Low Initiate or resume sexual activity or

Risk treatment for sexual dysfunction

Wednesday, December 30, 2009

 Every ED Patient
High
isk
Sexual activity deferred until
stabilization of should be
investigated for
cardiac condition

Vascular Risk
minate
Cardiovascular Factors
assessment and
re-stratification
FBG
BP
Low Initiate or resume sexual activity or
BMI
Risk treatment for sexual dysfunction
Lipid profile

Wednesday, December 30, 2009

 Management recommendations based on graded
cardiovascular risk assessment

Grade of Risk Management Recommendations

Low risk Primary care management

Consider all first-line therapies
10 years risk <10%
Reassess at regular intervals (6-12 m)
(60% to 70%)
High Risk Priority referral for specialized cardiovascular management
Treatment for sexual dysfunction to be deferred until cardiac condition stabilized;
10 years risk >20% dependent on specialist recommendations
(10% to 15%)

Intermediate Risk Specialized cardiovascular testing

(e.g., Exercise tolerance testing, echo cardiography)
10 years risk 10-20% Re-stratification into high risk or low risk based on the results of cardiovascular
(15% to 30%) assessment

79
Kostis JB, Jackson G, Rosen R, et al. Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference). Am J Cardiol. 2005;96:313-321

Wednesday, December 30, 2009