Dr. Anmar Nassir, FRCS(C) Canadian board in General Urology Fellowship in Andrology (U of Ottawa) Fellowship in EndoUrology and Laparoscopy (McMaster Univ) Assisstent Prof Umm Al-Qura Consultant Urology King Faisal Specialist Hospital

Diagnostic Tests Main Treatments Before 1970 Psychosexual history Psychosexual therapy 1970s Medical and psychosexual history, sleep lab Penile prosthesis and psychosexual therapy 1980s History, physical examination, testosterone, duplex ultrasound, DICC (goal- directed approach) Yohimbine, intracavernous or transurethral therapy, vacuum device 1990s-Present Process-of-care model Oral phosphodiesterase-5 inhibitors 1st ICUD algorithm 2nd ICUD algorithm (patient- centered approach)

 Tests 10 yrs back:  Duplex ultrasonography  Pharmacologic cavernosometry and cavernosography for penile vascular function.  The RigiScan ▪ a computerized device for monitoring penile tumescence and rigidity,  The widespread use and abuse of these tests led to the introduction of a goal-directed approach, devised to conserve health care dollars and minimize patient morbidity from excessive testing

 Recent approach to the management of ED is built on a  patient-centered and  evidence-based principle Rosen et al, 2004

 To make a diagnostic and treatment decisions it emphasized the role of  patient education and dialogue  the need to consider the patient's goals and motivation.  Ideal evaluation based on  medical and psychosexual history  focused physical examination  laboratory testing

 the International Index of Erectile Function (IIEF) (1997),  the Brief Male Sexual Function Inventory (BMSFI) (1995),  the Dysfunction Inventory for Treatment Satisfaction (EDITS)  the Derogatis Sexual Function Inventory (245 items) 1979  the Center for Marital and Sexual Health Questionnaire (18 items) 1997  the recently added Male Sexual Function Scale (Rosen R, personal communication).

 The most widely used.  Statistically validated in many languages.  Its 15 items address and quantify five domains:  erectile function,  orgasmic function,  sexual desire,  intercourse satisfaction  overall satisfaction

 Questionnaires:  helpful in the recognition and initial evaluation  should not substitute for a detailed sexual history.  The physician should always be attentive to both the intrapersonal and interpersonal aspects of sexual dysfunction.  Careful attention should be paid to both the style and the content of the initial evaluation.

 A comprehensive sexual history is essential to  confirm the diagnosis,  evaluate the patient's overall sexual function.  Sexual history-taking should be aimed at ascertaining the severity, onset, and duration of the problem, as well as the presence of concomitant medical or psychosocial factors.  It is necessary to determine whether the presenting complaint (e.g., ED, premature ejaculation) is the primary sexual problem or if some other aspects of the sexual response cycle (desire, ejaculation, orgasm) are involved.

The goals of medical history-taking are 1. to evaluate the potential role of underlying 1. medical conditions (e.g., atherosclerosis, diabetes) 2. Co-morbidities (e.g., depression) 2. to differentiate between potential organic and psychogenic causes; 3. to assess the potential role of medication  some may cause or contribute to the patient's sexual difficulties  some, such as nitrates, may be contraindications for specific treatments, such as phosphodiesterase inhibitors.

 Age  Male gender  Hypertension  Diabetes mellitus  Cigarette smoking  Dyslipidemia  Sedentary lifestyle  Family history of premature coronary artery disease

CharacteristicOrganicPsychogenicOnsetGradualAcute CircumstancesGlobalSituational CourseConstantVarying Noncoital erection PoorRigid Psychosexual problem Secondary Long history Partner problem Secondary At onset Anxiety and fear SecondaryPrimary

 The physical examination is an essential, although in most cases it may not identify the specific cause.  It should include:  general screening for medical risk factors or comorbidities, ▪ body habitus (secondary sexual characteristics), ▪ assessment of the cardiovascular, neurologic, ▪ genital systems, with particular focus on the genitalia and secondary sex characteristics.

1. Fasting glucose, 2. Lipids, 3. Hormonal profiles. These tests are performed primarily to:  confirm specific causes  (e.g., hypogonadism)  assess comorbidities  (e.g., diabetes, hyperlipidemia).

 pharmacologic penile arteriography

 Pharmacologic cavernosography

 RigiScan

 Indications for specialized TESTS are:  failure of initial treatment,  Peyronie's disease,  primary ED,  history of pelvic/perineal trauma,  cases requiring vascular or neurosurgical intervention,  complicated endocrinopathy,  complicated psychiatric disorder,  complex relationship problems,  medicolegal concerns.

Vascular:  Dynamic infusion cavernosometry and cavernosography (DICC)  Intracavernous injection pharmacotesting (ICI)  ICI and color duplex ultrasound  Arteriography  MRI  Infrared spectrophotometry  CT angiography  Radioisotope penography

Neurophysiologic  Nocturnal penile tumescence and rigidity (NPTR)  Bulbocavernosus reflex latency  Biothesiometry (vibratory thresholds)  Dorsal nerve conduction velocity  Corpus cavernosum electromyography (CC-EMG)  MRI or PET scanning of brain (during AVSS)  Plethysmography/electrobioimpedance  Erectiometer/rigidometer