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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
Pelvic/perineal/penile
trauma or surgery
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
Sources: Goldstein I et al. N Engl J Med. 1998;338:1397-1404; Mulhall JP et al. J Sex Med. 2007;4:1626-1634.
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
↑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.
Penile Examination
Masses or plaque formation, angulation, unprovoked persistent
erection, or tight unretractable foreskin
29
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
PSV
EDV PSV
Velocity
Acceleration Time
Acceleration TIME
= Δt / PSV
EDV
RI
= PSV - EDV / PSV
Δt TIME
⇓⇓
⇓
Wednesday, December 30, 2009
Cavernosography
Opacification of
the corpus
spongiosum
⇓⇓
⇓
and dorsal vein
Cavernosography of
patients with
⇓⇓
⇓
Peyronie’s disease.
Distal circumferential
plaque with site
specific leak
Selective Internal
pudendal
pharmaco penile
angiography with
digital
subtraction
Selective internal
pudendal
arteriogram
showing proximal
occlusion of the
cavernosal artery
and normal dorsal
artery
58
Motor Autonomic
Bulbocavernosus EMG Cardiovascular reflex tests
Reflex latency testing EMG
Sensory
Nerve conduction velocity
Evoked potentials
Biothesiometry
Reflex latency testing
CVDs
2-3 years
ED
DeBusk, Erectile Dysfunction Therapy in Special Populations and Applications: Coronary Artery Disease. Am J
Cardiol 2005;96: 62M–66M
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
75
76
Clinical Cardiovascular
Sexual Indeterminate assessment and
Evaluation
Inquiry
Risk re-stratification
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
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