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Further testing is based on the patient s goals Patients who will accept only noninvasive forms of therapy may be offered medical therapy or a vacuum constriction device, as described below Most patients undergo further evaluation with direct injection of vasoactive substances into the penis Such substances (prostaglandin E1, papaverine, or a combination of drugs) will induce erections in men with intact vascular systems Patients who respond with a rigid erection require no further vascular evaluation However, organic and psychogenic impotence can be differentiated by use of nocturnal penile tumescence testing, where the frequency as well as the rigidity of erections are recorded by a simple device attached to the penis before sleep Patients with psychogenic impotence will have nocturnal erections of adequate frequency and rigidity Additional vascular testing is indicated in patients who fail to achieve an erection with injection of vasoactive substances on serial attempts using increasing doses or combination of drugs and who would consider vascular reconstructive sur-
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drug is contraindicated in patients taking nitroglycerin All patients being evaluated for acute chest pain should be asked if they are taking sildenafil before administering nitroglycerin Fixed atherosclerotic disease in the aortoiliac system is associated with diminished efficacy Newer PDE-5 inhibitors, including vardenafil (Levitra) and tadalafil (Cialis), have a longer half-life and are similarly effective Some patients who do not respond to one PDE-5 inhibitor may respond to one of the other agents Apomorphine SL is a dopamine D1 and D2 agonist and is approved for use in Europe
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the history and physical examination (see Figure 23 1) Oligospermia is the presence of less than 20 million sperm/mL in the ejaculate; azoospermia is the absence of sperm As spermatogenesis takes approximately 74 days, it is thus important to review events from the past 3 months
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A Symptoms and Signs
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The history should include prior testicular insults (torsion, cryptorchidism, trauma), infections (mumps orchitis, epididymitis), environmental factors (excessive heat, radiation, chemotherapy), medications (anabolic steroids, cimetidine, and spironolactone may affect spermatogenesis; phenytoin may lower FSH; sulfasalazine and nitrofurantoin affect sperm motility), and drugs (alcohol, marijuana) Sexual habits, frequency and timing of intercourse, use of lubricants, and each partner s previous fertility experiences are important Loss of libido and headaches or visual disturbances may indicate a pituitary tumor The past medical or surgical history may reveal thyroid or liver disease (abnormalities of spermatogenesis), diabetic neuropathy (retrograde ejaculation), radical pelvic or retroperitoneal surgery (absent seminal emission secondary to sympathetic nerve injury), or hernia repair (damage to the vas deferens or testicular blood supply) Physical examination should pay particular attention to features of hypogonadism: underdeveloped secondary sexual characteristics, diminished male pattern hair distribution (axillary, body, facial, pubic), eunuchoid skeletal proportions (arm span 2 inches > height; upper to lower body ratio < 10), and gynecomastia The scrotal contents should be carefully evaluated Testicular size should be noted (normal size approximately 45 25 cm, volume 18 mL) Varicoceles should be looked for in the standing position and on occasion may be appreciated only with the Valsalva maneuver The vas deferens, epididymis, and prostate should be palpated
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D Penile Prostheses
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Prosthetic devices may be implanted directly into the paired corporal bodies Such prostheses may be rigid, malleable, hinged, or inflatable Each is manufactured in a variety of sizes and diameters Inflatable models may result in a more cosmetic appearance but may be associated with a greater likelihood of mechanical failure
E Vascular Reconstruction
Patients with disorders of the arterial system are candidates for various forms of arterial reconstruction, including endarterectomy and balloon dilation for proximal arterial occlusion and arterial bypass procedures utilizing arterial (epigastric) or venous (deep dorsal vein) segments for distal occlusion Patients with venous disorders may be managed with ligation of certain veins (deep dorsal or emissary veins) or the crura of the corpora cavernosa Experience with vascular reconstructive procedures is still limited, and many patients so treated still fail to achieve a rigid erection
Basson R et al Sexual sequelae of general medical disorders Lancet 2007 Feb 3;369(9559):409 24 [PMID: 17276781] Carson CC et al; Patient Response with Vardenafil in Sildenafil Non-Responders (PROVEN) Study Group Erectile response with vardenafil in sildenafil nonresponders: a multicentre, double-blind, 12-week, flexible-dose, placebo-controlled erectile dysfunction clinical trial BJU Int 2004 Dec;94(9):1301 9 [PMID: 15610110] Lue TF Erectile dysfunction N Engl J Med 2000 Jun 15;342 (24):1802 13 [PMID: 10853004] Lue TF et al Summary of recommendations on sexual dysfunctions in men J Sex Med 2004 Jul;1(1):6 23 [PMID: 16422979] Nehra A et al Vardenafil improved patient satisfaction with erectile hardness, orgasmic function and sexual experience in men with erectile dysfunction following nerve sparing radical prostatectomy J Urol 2005 Jun;173(6):2067 71 [PMID: 15879836] Seftel AD Erectile dysfunction in the elderly: epidemiology, etiology and approaches to treatment J Urol 2003 Jun;169 (6):1999 2007 [PMID: 12771705]
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