Erectile Dysfunction: Extended Evaluation

  • John P. Mulhall
  • Peter J. Stahl
  • Doron S. Stember


In the ED: Initial Evaluation algorithm the patient had a thorough history, physical examination, and laboratory testing performed. At this stage the patient is ready to be treated (see ED Treatment algorithm). The purpose of the extended evaluation is twofold: (1) to define if the patient has underlying pathology that will impact upon the clinician’s management and (2) to attempt to give the patient a prognosis for his ED (i.e., to determine if the patient is curable or not.) The classic example of the former is a patient diagnosed with venous leak who has used PDE5i without much success. In this scenario, we would move this patient directly to penile injections and not reeducate him about PDE5i use or attempt any other PDE5i. Another example of this concept, based on the recent finding that ED is a harbinger of occult or future coronary artery disease, is the middle-aged healthy man who presents without overt vascular risk factors but has underlying arteriogenic ED revealed on testing. We would suggest to this patient that he seek cardiologic consultation. There is evidence that such men are at greater risk for having an abnormal cardiac stress test. From a prognostic standpoint, the classic example is someone who the clinician believes may have psychogenic ED, as all of such patients are potentially curable. From a causation standpoint, the vast majority of patients with ED have primarily organic ED and this is usually vasculogenic in nature. It is estimated that about 70 % of all men with primarily organic ED have underlying vascular risk factors such as diabetes, hypertension, dyslipidemia, cigarette smoking, or the metabolic syndrome. Such patients sometimes, although not always, have a prior history of vascular disease (myocardial infraction, peripheral vascular disease, or stroke). Other major causes of organic ED include (with approximate estimates) medications (10 %), pelvic surgery (10 %), endocrine problems (3 %), neurological problems (2 %), and other conditions (5 %, lower urinary tract symptoms related to BPH, sleep apnea syndrome, collagen vascular diseases). Thus, a good history and physical examination, combined with judicious use of laboratory testing, will help make most of the nonvascular diagnoses.


Lower Urinary Tract Symptom Peak Systolic Velocity Venous Leak Intracavernosal Injection Cavernosal Smooth Muscle 
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Suggested Reading

  1. Althof SE. What’s new in sex therapy (CME). J Sex Med. 2010;7(1 Pt 1):5–13.PubMedCrossRefGoogle Scholar
  2. Bookstein JJ, Valji K, Parsons L, Kessler W. Pharmacoarteriography in the evaluation of impotence. J Urol. 1987;137(2):333–7.PubMedGoogle Scholar
  3. LeRoy TJ, Broderick GA. Doppler blood flow analysis of erectile function: who, when, and how. Urol Clin North Am. 2011;38(2):147–54.PubMedCrossRefGoogle Scholar
  4. Levine LA, Lenting EL. Use of nocturnal penile tumescence and rigidity in the evaluation of male erectile dysfunction. Urol Clin North Am. 1995;22(4):775–88.PubMedGoogle Scholar
  5. McCabe M, Althof SE, Assalian P, Chevret-Measson M, Leiblum SR, Simonelli C, et al. Psychological and interpersonal dimensions of sexual function and dysfunction. J Sex Med. 2010;7(1 Pt 2):327–36.PubMedCrossRefGoogle Scholar
  6. Mulhall JP. Cavernosometry: is it a dinosaur? J Sex Med. 2008;5(4):760–4.PubMedCrossRefGoogle Scholar
  7. Mulhall JP, Anderson M, Parker M. Congruence between venocclusive parameters during dynamic infusion cavernosometry: assessing the need for cavernosography. Int J Impot Res. 2004;16(2):146–9.PubMedCrossRefGoogle Scholar
  8. Mulhall JP, Teloken P, Barnas J. Vasculogenic erectile dysfunction is a predictor of abnormal stress echocardiography. J Sex Med. 2009;6(3):820–5.PubMedCrossRefGoogle Scholar
  9. Rosen RC, Althof SE, Giuliano F. Research instruments for the diagnosis and treatment of patients with erectile dysfunction. Urology. 2006;68(3 Suppl):6–16.PubMedCrossRefGoogle Scholar
  10. Shabsigh R, Fishman IJ, Shotland Y, Karacan I, Dunn JK. Comparison of penile duplex ultrasonography with nocturnal penile tumescence monitoring for the evaluation of erectile impotence. J Urol. 1990;143(5):924–7.PubMedGoogle Scholar
  11. Teloken PE, Park K, Parker M, Guhring P, Narus J, Mulhall JP. The false diagnosis of venous leak: prevalence and predictors. J Sex Med. 2011;8(8):2314–9.CrossRefGoogle Scholar
  12. Whang SY, Sung DJ, Lee SA, Park BJ, Kim MJ, Cho SB, et al. Preoperative detection and localization of accessory pudendal artery with contrast-enhanced MR angiography. Radiology. 2012;262(3):903–11.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • John P. Mulhall
    • 1
  • Peter J. Stahl
    • 2
  • Doron S. Stember
    • 3
  1. 1.Sexual and Reprodictive Medicine Program Department of Surgery Division of Urology, Department of SurgeryMemorial Sloan-Kettering Cancer CenterNew YorkUSA
  2. 2.Department of UrologyColumbia University College of Physicians & SurgeonsNew YorkUSA
  3. 3.Department of UrologyBeth Israel Medical Center Albert Einstein College of Medicine of Yeshiva UniversityNew YorkUSA

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