Specialized diagnostic tests ED

Nocturnal penile tumescence and rigidity (NPTR)

The nocturnal penile tumescence and rigidity (NPTR) assessment should take place for at least two nights. 
The presence of an erectile event of at least 60% rigidity recorded on the tip of the penis, which lasts for 
10 minutes or more, should be considered as indicative of a functional erectile mechanism (24).

Intracavernous injection test

The intracavernous injection test offers limited information regarding vascular status. A positive test is defined
as a rigid erectile response (unable to bend the penis) that appears within 10 minutes after the intracavernous
injection and lasts for 30 minutes (25). Such a response may indicate a functional but not necessarily normal
erection, since an erection may coexist with arterial insufficiency or veno-occlusive dysfunction (26). Its clinical
implication is that the patients will respond to the intracavernous injection programme. In all other cases, the
test is inconclusive, and a duplex ultrasound of the penile arteries should be requested.

Duplex ultrasound of penile arteries

A peak systolic blood flow higher than 30 cm/sec and a resistance index higher than 0.8 are generally conside-
red to be normal (25). There is no need to continue vascular investigation when the duplex examination is normal.

Arteriography and dynamic infusion cavernosometry or cavernosography (DICC)

When it is abnormal, arteriography and dynamic infusion cavernosometry or cavernosography should be
performed only for patients who are considered potential candidates for vascular reconstructive surgery.

Psychiatric assessment

Patients with psychiatric disorders must be referred to a psychiatrist particularly interested in ED. For younger
patients (<40>

Penile abnormalities

Patients with ED due to penile abnormalities, such as hypospadias, congenital curvature, or Peyronie’s disease
with preserved rigidity, may require surgical correction with high success rates.

Pathophysiology of erectile dysfunction

Pathophysiology of erectile dysfunction

Vasculogenic
-
Cardiovascular disease
-
Hypertension
-
Diabetes mellitus
-
Hyperlipidaemia 
-
Smoking 
-
Major surgery or radiotherapy (pelvis or retroperitoneum)
•
Neurogenic
-
Central causes 
-
Multiple sclerosis
-
Multiple atrophy
-
Parkinson’s disease
-
Tumours
-
Stroke
-
Disk disease
-
Spinal cord disorders
-
Peripheral causes 
-
Diabetes mellitus
-
Alcoholism
-
Uraemia 
-
Polyneuropathy 
-
Surgery (pelvis or retroperitoneum)
•
Anatomical/structural
-
Peyronie’s disease
-
Penile fracture
-
Congenital curvature of the penis
-
Micropenis
-
Hypospadias, epispadias
•
Hormonal
-
Hypogonadism
-
Hyperprolactinemia
-
Hyper- and hypothyroidism
-
Cushing’s disease
•
Drug-induced
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Antihypertensives (of all classes, most common by diuretics and beta-blockers)
-
Antidepressants 
-
Antipsychotics
-
Antiandrogens
-
Antihistamines
-
Recreational drugs (heroin, cocaine, methadone)
•
Psychogenic
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Generalized type (e.g. lack of arousability and disorders of sexual intimacy)
-
Situational type (e.g. partner-related, performance-related issues or due to distress)

Sexual history
The sexual history may include information about previous and current sexual relationships, current emotional
status, onset and duration of the erectile problem, as well as possible previous consultations and treatments.
Detailed descriptions of the quality of both erotic and morning erections, in terms of rigidity and duration, as
well as arousal, ejaculation and orgasmic problems, should be discussed. The use of validated questionnaires,
such as the International Index for Erectile Function (IIEF), may be helpful in order to assess all sexual function
domains (erectile function, orgasmic function, sexual desire, ejaculation, intercourse and overall satisfaction),
but also the impact of a specific treatment modality .

Physical examination
A focused physical examination must be performed on every patient, with particular emphasis on the
genitourinary, endocrine, vascular and neurological systems (16). The physical examination may reveal
unsuspected findings, such as Peyronie’s disease, prostatic enlargement or cancer, as well as the signs and
symptoms indicative of hypogonadism (small testes, alterations in secondary sexual characteristics, diminished
sexual desire, and changes in mood) (17). A rectal examination should be performed in every patient older than
50 years. Blood pressure and heart rate should be measured if they have not been assessed in the previous 
3-6 months. Particular attention must be given to patients with cardiovascular disease.
Laboratory testing
Laboratory testing must be tailored to the patient complaints and risk factors. All patients must undergo a
fasting glucose and lipid profile if not assessed in the previous 12 months. Hormonal tests must include a

Managing ED: implications for the every-day clinical practice

Managing ED: implications for the every-day clinical practice

The advances in basic and clinical research in ED made during the last 15 years has led to the development of
several new treatment options for ED, including new pharmacological agents for intracavernous, intraurethral,
and, more recently, oral use (11-13). Reconstructive vascular surgery is associated with poor outcomes in long-
term follow-up (14,15). As a result, treatment strategies have been significantly modified.
The current availability of effective and safe oral drugs for ED, together with the tremendous media
interest in this condition, has resulted in an increasing number of men seeking help for ED. Many physicians
without background knowledge and clinical experience of the diagnosis and treatment of ED are involved in
decision-making concerning the evaluation and treatment of these men. Therefore, some men with ED may
undergo little or no evaluation before treatment is initiated, or men without ED may seek treatment in order to
enhance their sexual performance. In such circumstances, the underlying disease causing the symptom (ED)
may remain untreated. Such observations have made the development of guidelines for the diagnosis and
treatment of ED, a necessity.

Erectile Dysfunction Treatment

Erectile Dysfunction Treatment

There are many types of treatments for erectile dysfunction, everything from medications, 

simple mechanical devices to psychological counseling & therapy. The only way to manage 
and solve erectile dysfunction problems is to get to the root of the cause. By understanding the 
cause factors and severity of the condition could help in determining the best treatment or 
combination of treatments.
Here is a rundown of some treatment to erectile dysfunction.
Medical Treatment
Erectile dysfunction (ED) is now easily treated with oral medication such as Sildenafil 
Citrate or its popular name - Viagra. Viagra is an example of the category of drugs called 
PDE5 inhibitors, and it treats ED by relaxing the smooth muscles of the penis during arousal, 
leading to a successful and sustained erection. Viagra can produce this effect for 4 hours from 
the time of ingestion. This small blue pill has a proven safety record and has been beneficial 
for men with ED who have had wide ranging health issues.
The huge success of Viagra led to further research and soon other drugs like Cialis, which is 
Viagra's greatest competitor, were introduced. Cialis is one of the most successful anti-ED drugs that can help men with erectile dysfunction (ED) get and keep an erection satisfactory 
for sexual activity. Cialis should be taken an hour before sexual intercourse, it sometimes 
starts working within 16 minutes and its effects lasts for 24 to 36 hours, several times longer 
than other anti-ED drugs such as, Viagra. Because of its extended period of effectiveness, you 
do not have the pressure to perform within a few hours. You and your partner can relax and 
choose the suitable moment that is right for both of you.
However, Viagra and Cialis is only beneficial to some men.
Although these medications can help many people, not all men can or should take them to 
treat erectile dysfunction. If you are under other medications, these drugs are not at all 
advisable. This is because these drugs, on combining with the medications that are taken 
everyday may cause blood pressure problems and heart attacks. Don't take Viagra or Cialis 
with nitrate medications, such as the heart drugs nitroglycerin (Nitro-Bid, others), isosorbide 
mononitrate (Imdur) and isosorbide dinitrate (Isordil). The combination of these medications, 
which work to widen (dilate) blood vessels, can cause side effects such as dizziness, low 
blood pressure and heart problems.
Though, there is another alternative like Zenerx can undo the side-effects. Zenerx works to 
increase blood flow to the penis (similar to Viagra and Cialis), but it provides you with even 
more. The herbal ingredients in Zenerx’s unique formulation is 100% natural which is what 
sets it apart from products like Viagra, Cialis, Levitra and others. Zenerx is 100% herbal and 
chemical free which means, all the benefits of better health is the key areas that most improve 
and impact sexual ability and performance - only without any unpleasant side effects. Zenerx 
has more advantages on treating erectile dysfunction than other well known brand in the 
market. You can find more information on Zenerx at Zenerx.com
Others such as vacuum devices, injections, penile implants and blood vessel repair are 
also options to treat Erectile Dysfunction (ED). Remember, all medical conditions can be 
treated.
Therapy & Counseling
In cases where the sexual function has been inhibited by psychological reasons, therapy and 
counseling can help address the feelings of anxiety and guilt. An open dialogue with your 
doctor can help you overcome such anxieties and over time, release you from such inhibitions.
Some people think that it might be embarrassing to talk about sexual health to doctor. Just 
remember that erectile dysfunction is a common problem, and your doctor won’t be surprised 
when you mention the topic. Discussing it with your doctor before a problem occurs can help 
you prevent or delay erectile dysfunction. Being open with your doctor can also help determine 
the best treatment for you.
Communication
Men who suffer from poor sexual health such as erectile dysfunction may find themselves 
distancing from their partners; physically and emotionally. This can give the mistaken 
impression that they've lost interest or no longer find their partner attractive. If you find yourself 
relating to such a scenario, learn to communicate with your partner. As in all relationships, 
communication is the key, so address the issue with your partner. It takes two for a healthy 
sexual relation and that means being open and frank about your needs and concerns.
Communication is an important part of sexuality and close relationships. It involves talking 
clearly, listening carefully and fully understanding each other. Bridge the gap between you and 
your partner and you will discover that not only will she be the support that you need; you will most likely be more open to explore new ways to enjoy an even more healthy and stimulating 
sex life.
Lifestyle Modifications
Lifestyle modifications such as reducing the intake of alcohol, avoid smoking tobacco, 
ensuring a proper diet, control your blood sugar, managing work stress and spending 
quality time with your family will likely to decrease chances of erectile dysfunction. Learn to 
prevent erectile dysfunction before it happen to you.
Re-Examine Your Attitude
As you grow older, two of the things that brought you the greatest joy - your children and your 
career are no longer prevalent in your every day life. This means that your personal 
relationship takes an increased importance. This is the time for you to re-examine your 
attitude towards sex. Sensual closeness and sexual intimacy is a way to affirm the love of 
life. It is an expression of the satisfaction gained from the present. It expresses the closeness 
of your relationship and is an important measure of the quality of life. Ageing just signals a 
change in sexual life - not the end of it.