Dr. Anmar Nassir, FRCS(C)

Canadian board in General UrologyFellowship in Andrology (U of Ottawa)Fellowship in EndoUrology and Laparoscopy (McMaster Univ)

Assisstent Prof Umm Al-QuraConsultant Urology King Faisal Specialist Hospital

   Diagnostic TestsDiagnostic Tests Main TreatmentsMain Treatments

Before 1970Before 1970 Psychosexual historyPsychosexual history Psychosexual therapyPsychosexual therapy

1970s1970s Medical and psychosexual Medical and psychosexual history, sleep labhistory, sleep lab

Penile prosthesis and Penile prosthesis and psychosexual therapypsychosexual therapy

1980s1980s History, physical examination, History, physical examination, testosterone , duplex testosterone , duplex ultrasound, DICC (goal-ultrasound, DICC (goal-directed approach)directed approach)

Yohimbine, intracavernous or Yohimbine, intracavernous or transurethral therapy, transurethral therapy, vacuum devicevacuum device

1990s-Present1990s-Present Process-of-care modelProcess-of-care model Oral phosphodiesterase-5 Oral phosphodiesterase-5 inhibitorsinhibitors

   1st ICUD algorithm1st ICUD algorithm   

   2nd ICUD algorithm (patient-2nd ICUD algorithm (patient-centered approach)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) 1999.

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

disease disease

CharacteristicCharacteristic OrganicOrganic PsychogenicPsychogenic

OnsetOnset GradualGradual AcuteAcute

CircumstancesCircumstances GlobalGlobal SituationalSituational

CourseCourse ConstantConstant VaryingVarying

Noncoital erectionNoncoital erection PoorPoor RigidRigid

Psychosexual Psychosexual problemproblem

SecondarySecondary Long historyLong history

Partner problemPartner problem SecondarySecondary At onsetAt onset

Anxiety and fearAnxiety and fear SecondarySecondary PrimaryPrimary

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:Vascular:

Dynamic infusion cavernosometry and cavernosography Dynamic infusion cavernosometry and cavernosography (DICC) (DICC)

Intracavernous injection pharmacotesting (ICI)Intracavernous injection pharmacotesting (ICI) ICI and color duplex ultrasoundICI and color duplex ultrasound

ArteriographyArteriography

MRI MRI Infrared spectrophotometry Infrared spectrophotometry CT angiography CT angiography Radioisotope penographyRadioisotope penography

NeurophysiologicNeurophysiologic

Nocturnal penile tumescence and rigidity (NPTR)Nocturnal penile tumescence and rigidity (NPTR) Bulbocavernosus reflex latencyBulbocavernosus reflex latency

Biothesiometry (vibratory thresholds) Biothesiometry (vibratory thresholds) Dorsal nerve conduction velocityDorsal nerve conduction velocity Corpus cavernosum electromyography (CC-EMG)Corpus cavernosum electromyography (CC-EMG)

MRI or PET scanning of brain (during AVSS)MRI or PET scanning of brain (during AVSS) Plethysmography/electrobioimpedancePlethysmography/electrobioimpedance Erectiometer/rigidometerErectiometer/rigidometer