The proper goal-oriented evaluation of a man proactive and complaining of erectile dysfunction requires a sympathetically elicited history, a focused physical examination and various carefully selected special investigations.

PHYSICAL EXAMINATION

Physical examination in erectile dysfunction should involve careful assessment of the external genitalia to detect the presence of cutaneous penile lesions, a Peyronie’s plaque or testicular abnormalities. Rectal examination should be performed to exclude benign prostatic hyperplasia or induration/nodularity suggestive of prostatic cancer. A focused neurological evaluation, including assessment of anal sphincter tone, should be performed and peripheral pulses palpated to detect signs of vascular disease. The distribution of body hair may provide a clue to androgen status. Blood pressure should be recorded with the patient both standing and lying down, and the presence or absence of obesity and/or gynecomastia noted. The abdomen should be palpated to exclude aortic aneurysm.

SPECIAL INVESTIGATIONS

Blood and urine testing
A key condition to exclude is undiagnosed diabetes mellitus. This is best accomplished by random measurement of blood sugar, as dipstick testing of urine to detect glycosuria does not reliably exclude the diagnosis. Because renal failure is also frequently associated with erectile dysfunction, electrolytes and creatinine should also be measured in addition to liver function tests, especially in those who admit to a high alcohol intake. Documentation of a full blood count and erythrocyte sedimentation rate is also a sensible precaution. Evaluation of the androgen status of the patient is usually indicated, as some may respond to hormone replacement therapy.
A serum testosterone (best measured as an early-morning sample) and sex hormone binding globulin (SHBG) should be requested. In addition, if the free testosterone level is low, a prolactin level should be measured, as hyperprolactinemia is associated with erectile dysfunction and may be corrected by treatment with bromocriptine. Some specialists also advocate testing of thyroid function, although this is a relatively unusual cause of erectile dysfunction, at least in younger men. If prostate cancer is a possibility, then a prostate-specific antigen (PSA) test should be requested, especially if treatment with androgen replacement therapy is being contemplated, as this may stimulate occult prostate cancer cells.

Nocturnal penile tumescence testing
Although still advocated by some, nocturnal penile tumescence testing is a rather cumbersome way to differentiate psychogenic from organic impotence. The same information (whether or not an erection develops during sleep) may be gleaned with the use of the snap gauge device or even with a strategically located ring of postage stamps. Only a few laboratories continue to employ nocturnal penile tumescence testing as a routine assessment of patients with erectile dysfunction.

Diagnostic intracorporeal injection
Injection of a vasodilator substance into one or other of the paired corpora cavernosa provides the clinician with two valuable pieces of information.

1. First, it confirms that a normal vasodilatory response is capable of developing (although a failure to respond does not necessarily indicate organic erectile dysfunction, since the response may be inhibited by excessive nervousness).
2. Second, this technique assesses the feasibility of self-injection pharmacotherapy as a treatment option. Originally, papaverine, with or without the α-blocker phentolamine, was used in this context. Nowadays, PGE1 (5–20 mg in 1 ml) is preferred, sometimes in combination with other agents such as papaverine, because of a lower incidence of prolonged erectile responses and priapism.

Color duplex Doppler ultrasound assessment of intracorporeal blood flow
More precise quantitative information concerning the erectile response to intracorporeal vasoactive agents such as PGE1 may   be obtained by imaging the cavernosal arteries with color duplex Doppler ultrasonography as the erectile response develops.   Normally, the velocity of blood flow through these vessels increases rapidly in response to PGE1 to more than 30 cm/s. As the   erection develops during systole, there is forward flow whereas, during diastole, the flow is reversed because of high   intracorporeal pressures. Thus, this test may help to distinguish between venous leakage and arterial insufficiency. Viagra Australia discount shop – myviagrainaustralia.com

Dynamic infusion cavernosometty and cavernosography
If veno-occlusive dysfunction is suggested by color Doppler ultrasonography investigation, then its presence and location may   be confirmed by dynamic infusion cavernosometry and cavernosography (DICC). This investigation involves pre-dosing with   intracavernous PGE1, followed by infusion of saline with simultaneous measurement of intracorporeal pressure and flow   required to maintain erection. Venous leak is characterized by an infusion of ≥120ml/min being necessary to maintain   erection. The source of the venous leakage may be visualized by performing cavernosography using a 50:50 solution of   radiographic contrast and saline. Leakage is usually visualized from the deep dorsal vein and/or the deep crural veins as well   as into the corpus spongiosum of the glans. Although deep dorsal venous leakage is one of the most common appearances   (Figure 52), multiple rather than single leakage sites are the rule rather than the exception.

Functional selective pharmacopudendal angiography
Pharmacopudendal angiograms may be indicated in the relatively small number of patients whose penile Doppler ultrasound   studies suggest arterial insufficiency and who are candidates for arterial reconstruction. The selective pudendal angiogram   may be performed under local anesthesia and some sedation through a single femoral percutaneous puncture. The test should   also include a non-selective pelvic angiogram with the catheter above the aortic bifurcation—the pelvic flush—and a selective   pudendal angiogram on each side. The non-selective pelvic angiogram is used to identify lesions of the common and internal   iliac arteries as well as to visualize the inferior epigastric arteries, which are the potential future donor vessels for penile   bypass surgery. Occasionally, an arteriovenous fistula is detected and its embolization may restore erectile function.

A team of scientists in Italy have recently published research that offers hope of the development of a new type of erectile dysfunction medication, but from a very unlikely source – the smell of rotten eggs. Strange as it sounds, there is a strong link between the noxious gas and a good sex life, namely that when the penis is erect, just before penetration hydrogen sulphide is released, the same gaseous compound that makes old eggs and car exhausts smell so repulsive.

The intriguing discovery was even made in a rather offbeat way, through tests done on the discarded penile tissue of male-to-female transsexuals, into which the gas was injected. The suggestion has been made that the gas helps cause the nerve cells to relax, allowing blood to flow to the penis and enable erection.

The discovery is so exciting because it has echoes of the research that lead to the development of the universally popular erectile dysfunction medication canada Viagra, one of the first treatments to be sold that helps men suffering from this very common problem. There are at the moment only three treatments that doctors agree are effective at combating the problem, Viagra, Levitra and Cialis. The drugs are available for patients with certain conditions on the NHS, though many who are not eligible decide to buy Viagra and the other medications privately. However a spokesman from the Sexual Dysfunction Association has said that there is certainly a need for an “alternative…(as Viagra) is only about….80% to 85% effective for the general population“.

The field of erectile dysfunction medication is an interesting one, as many men still feel embarrassed to visit their GP with impotence problems, preferring to buy on the internet. As a recent application to sell Viagra over the counter was recently denied, it still can only be sold with a prescription from the doctor, but there are a small number of legal online clinics who do offer this service, which has proved extremely popular.

However the continued stigma attached to the disorder has resulted in a massive boom in illegal internet pharmacies offering ‘generic’ and counterfeit medications. Viagra, have led the fightback by the drugs companies, launching an aggressive campaign highlighting the dangers of buying illegal medication.

If a new erectile dysfunction medication is subsequently developed as a result of this research, the battle between the drugs companies will intensify still further. Though Pfizer no longer has the monopoly over ED medication, Viagra is still by far the drug with the most amount of brand recognition, but Cialis is remarkable for offering a markedly different result to Levitra and Viagra, which function in very similar ways. If the new treatment is noticeably different to the three already on the market, not only will men have greater choice but increased competition may result in a drop in prices, which will perhaps go some way to combating the growing sales in illegal pills.