1. IN THE NAME OF GOD
2/16/2019

2. Erectile Dysfunction Diagnostic Evaluation
Dr Reza Sarhangnejad
Fellowship of Endourology
2/16/2019

3. Loss of libido Androgen deficiency Primary hypogonadism
(increased LH/FSH, Low T)
Secondary hypogonadism
(Low T, low-normal FSH/LH)
Combined hypogonadism
Aging (loss of leydig cells)
Chemotherapy/irradiation
Cryptorchidism
Chromosome abnormalities (Klinefelter Syndrome)
HIV/AIDS
Myotonic Dystrophy
Orchitis (mumps)
Testicular loss from trauma, tumor
Aging
COPD
Diabetes
Hemochromotosis
Hypogonadotropic hypogonadism
Kallman syndrome
Medication ( anti-estrogen for treatment of prostate cancer)
Obesity
Pituitary mass lesions
Prolactinoma
Psychological stress
Uremia / CKD
Cirrhosis
Sickle cell disease
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4. Loss of libido
Measurement of serum testosterone that, if abnormal, should be further evaluated by measurement of serum gonadotropins and prolactin
If semen volume is normal, it is unlikely that endocrine factors are responsible for loss of libido
Decrease in libido may also result from depression and a variety of medical illnesses that affect general health and well-being.
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5. Erectile dysfunction Definition:
NIH Consensus Statement did not specify a parameter for the duration of symptoms
Apply a 3-month interval as a minimal requirement diagnostically, except for cases of trauma or surgically induced ED
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6. Sexual History Onset Duration
Conditions: Reviewing circumstances that facilitate (stimuli used during sexual encounters, erections on awakening, and the role of self-stimulation) or hinder (anxiety, inability to perform with a designated partner, and motivational factors affecting lovemaking ) erectile function
Severity: Mild (minimally decreased ability to attain and/or maintain an erection with intermittent satisfactory sexual performance ) , Moderate (minimally decreased ability to attain and/or maintain an erection with infrequent satisfactory sexual performance ) , Severe (substantially decreased ability to attain and/or maintain an erection with rare or absent satisfactory performance )
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7. Sexual History
Etiology
psychogenic, organic, or mixed
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8. Medical History
Age
Disease states: type 2 diabetes mellitus, cardiovascular disease, hypertension, dyslipidemia, neurologic disease, hypogonadism, thyroid disorders
Consequences of trauma involving aspects of the body, pelvis, or genitalia (e.g., spinal cord injury, pelvic surgery or radiation, sexual injury)
Medications
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9. Major Erectile Dysfunction Risk Factors
Medical History
Major Erectile Dysfunction Risk Factors
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10. Drugs Associated with Erectile Dysfunction
Medical History
Drugs Associated with Erectile Dysfunction
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11. Psychosocial History Both intrapersonal and interpersonal contexts
Past and present
Occupational status, financial security, family life, and social support
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12. Physical Examination
Basic anthropometrics (i.e., height, weight, waist circumference)
Body habitus (Kallman or Klinefelter syndrome )
Cardiovascular disease (obesity, elevated blood pressure, or abnormal femoral or pedal pulses )
Neuropathy (abnormal genital and perineal sensation or bulbocavernosus reflex )
Focus on the external genitalia (penile deformity, such as micropenis, congenital chordee, or Peyronie , testes )
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13. Questionnaires and Sexual Function Symptom Scores
IIEF, which contains 15 items that address and quantify five domains: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction
Severe (5 to 7), moderate (8 to 11), mild to moderate (12 to 16), mild (17 to 21), and no ED (22 to 25).
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14. IIEF Questionnaire
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15. Cardiovascular Risk Assessment Tools
Framingham Risk Score or an alternate global risk score
High risk would be those with unstable or refractory angina, a recent history of myocardial infarction, certain arrhythmias, or uncontrolled hypertension
Even patients at low risk for cardiovascular events should receive the minimum recommendations of cardiovascular disease management
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16. Laboratory Tests
Recommended laboratory tests for men with sexual problems typically include serum chemistries, fasting glucose, complete blood count, lipid profile, and serum total testosterone
Total testosterone if abnormally low, serum-free (orbioavailable) testosterone and luteinizing hormone (LH) should be measured
Prolactin measurement may also be done
Thyroid function tests may be performed
prostate-specific antigen (PSA) testing isperformed as needed if there is a suspicion of prostate pathology that might be promoted by exogenously administered testosterone
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17. Indications for specialized evaluations :
Failure of initial treatment, referred to a urologist
Younger patients with a history of pelvic or perineal trauma, referred to a urologist
Patients with significant penile deformity (e.g., Peyronie disease, congenital chordee), referred to a urologist
Complicated endocrinopathies (e.g., secondary hypogonadism, pituitary adenoma), referred to an endocrinologist
Complicated psychiatric or psychosexual disorders (e.g., refractory depression, hypoactive sexual desire), referred to a psychiatrist
Presentations requiring vascular or neurosurgical intervention (e.g., aortic aneurysm, lumbosacral disk disease), referred to a vascular surgeon or neurosurgeon
Medicolegal reasons (e.g., workman’s compensation claims), referred to a urologist
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18. ED After Radical Prostatectomy
Case 2
ED After Radical Prostatectomy
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19. Sexual history before surgery (ED , Libido)
The source of penile blood is usually the internal pudendal artery, a branch of the internal iliac artery .In many instances, however, accessory arteries exist, arising from the external iliac, obturator, and vesical and femoral arteries, and they may constitute the dominant or only arterial supply to the corpus cavernosum in some men
Nerve sparing surgery
PSA and Testosterone
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20. 2/16/2019

21. Total T <200 ng/dl (7 nmol/L) <300 ng/dl (10 nmol/L)
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22. 2/16/2019

23. Rhoden and Morgentaler (2004)
BPH:
Several studies failed to show an acceleration of voiding symptoms after androgen replacement therapy
Rhoden and Morgentaler (2004)
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24. Low frequency of prostate cancer in men treated for hypogonadism
No data to support the claim that treatment with exogenous testosteron increases the risk for prostate cancer
Rhoden and Morgentaler (2004)
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25. Eur Urol Collaborative Review
Multiple reports of testosterone therapy in men after treatment for localized PCa have shown low or absent recurrence rates
Some men with untreated PCa have received testosterone therapy without evidence for PCa progression
Kheraa et al A New Era of Testosterone and Prostate Cancer: From Physiology to Clinical Implications Eropean Urology, volume 65 Issue 1, january 2014, Pages
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26. The long-held belief that PCa risk is related to high serum androgen concentrations can no longer be supported
Reasonable to consider T therapy in selected men with PCa and symptomatic hypogonadism
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27. Premature Ejaculation
Case 3
Premature Ejaculation
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28. Classification Type A & B Primary & Secondary Lifelong & Acquired
Four PE subtypes (duration of the IELT, frequency of reports, and course in life)
1. Lifelong
2. Acquired
3. Variable (occasionally experience)
4. Subjective (normal or even extended ejaculation time)
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29. Definition
None of these definitions was supported by evidence-based clinical research
ISSM ( 2013 ):
Ejaculation that always or nearly always occurs before or within approximately 1 minute of vaginal penetration (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to approximately 3 minutes or less (acquired PE)
The inability to delay ejaculation on all or nearly all vaginal penetrations
Negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy
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30. Definition
DSM-5:
A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it. This symptom must have been present for at least 6 months and must be experienced on almost all or all (approximately 75%-100%) occasions of sexual activity. It causes clinically significant distress in the individual.
Mild PE (ejaculation occurring within ~30 seconds to 1 minute of vaginal penetration)
Moderate PE (ejaculation occurring within ~15 to 30 seconds of vaginal penetration)
Severe PE (ejaculation occurring before sexual activity, at the start of sexual activity, or within ~15 seconds of vaginal penetration).
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31. Full medical and sexual history
Evaluation
Full medical and sexual history
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32. Evaluation
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33. Evaluation Lifelong Premature Ejaculation:
Hyposensitivity of the 5-HT2C
Hypersensitivity of the 5-HT1A receptor
Genetic variations
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34. Evaluation Acquired Premature Ejaculation:
Anxiety (sympathetic nervous system)
Psychological (Hypoactive sexual desire, Diminished sexual desire)
Relationship problems (Female sexual dysfunctions)
Erectile Dysfunction: as many as half of subjects with ED also experience PE
Prostatitis: PE as the main sexual disorder symptom in men with chronic prostatitis or CPPS
Hyperthyroidism: TSH screening is not necessary unless clinically indicated
Drugs (withdrawal, recreational)
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35. Physical Examination
Diagnosis of lifelong PE is based purely on the medical history because there are no predictive physical findings or confirmatory investigations
Acquired PE, a physical examination is mandatory in an effort to identify the cause of the PE
A digital prostate examination, routine in an andrologic setting for all men over 40, is useful in identifying possible evidence of prostatic inflammation or infection
Laboratory or imaging investigations are occasionally required based on the patient’s medical history.
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36. THANKS FOR YOUR ATTENTION
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