The first thing that is done to assess erectile dysfunction is obtaining detailed medical and psychological history of patient and his partner. Erectile dysfunction (or impotence) can have various pathophysiological reasons – vasculogenic, neurogenic, hormonal, etc.
Pathophysiology of Erectile Dysfunction
Vasculogenic Erectile Dysfunction
- cardiovascular pathology;
- extensive surgical intervention (radical prostatectomy) or radiotherapy (pelvic and retroperitoneal areas).
Neurogenic Erectile Dysfunction
- multiple sclerosis;
- multiple atrophy;
- Parkinson’s disease;
- blood stroke;
- pathology of intervertebral discs;
- diseases of spinal cord.
- alcohol addiction;
- surgical intervention in pelvic or retroperitoneal area, radical prostatectomy.
Anatomical or Structural Erectile Dysfunction
- Peyronie’s disease;
- fracture of penis;
- congenital penis deformities;
- hypospadias, epispadias.
Hormonal Erectile Dysfunction
- hyper- and hypothyroidism;
- Cushing’s disease.
Erectile Dysfunction Caused by Drug Therapy
- antihypertensive drugs (the most common causes – diuretics and beta-blockers);
- neuroleptic drugs;
- antiandrogenic drugs;
- narcotic drugs (heroin, cocaine, methadone).
Psychogenic Erectile Dysfunction
- lack of sexual excitement;
- difficulties with intimacy, etc.
- situation associated with partner, environment that makes it difficult to perform sexual intercourse;
- stress, etc.
Studies that Identify Causes of Erectile Dysfunction
1. Study of Blood Flow in Penis
Vasoactive medicament is pre-prepared in a syringe. Penis is fixed in such a position that cavernous body on the right or left is well defined. Preparation is injected into cavernous body with a very thin needle. During injection, patient does not experience pain. This study allows to objectively assess quality of erection.
2. Ultrasound Examination of Penile Vessels
Immediately before test, injection of vasoactive drug is performed in order to record dynamic blood flow studies in penis. Ultrasound dopplerography (USDG) of penile vessels is the most reliable and least invasive method for diagnosing erectile dysfunction. USDG allows to determine structure of cavernous bodies, reveal main vessels of penis, assess direction and velocity of blood flow in each phase of erection. One of the main indicators is determination of peak systolic velocity at rest and at stimulated erection in different phases. Normally, peak systolic velocity is 35 cm/s. During stimulated erection with peak systolic velocity less than 25 cm/s arterial insufficiency is not excluded.
3. Сavernosometry and Cavernosography
Typically, it is performed in patients with long history of dysfunction or if there is a history of perineal trauma. With the help of two needles, saline solution is injected into cavernous bodies, and intrapericletic pressure is measured after injection of vasodilator preparations. Inability to maintain intracavernous pressure at the level of average systolic blood pressure indicates presence of vaso-occlusive dysfunction. Normally to maintain intracavernous pressure of more than 100 mm Hg, rate of outflow through veins does not exceed 3 – 5ml/min, and within 30 seconds pressure should not decrease from 150 mm Hg more than by 45 mm Hg. After cavernosometry, cavernosography is performed, which allows to establish precisely location of pathological outflow.
4. Angiography of Penis
It is often performed in young patients after traumatic damage of penile arteries or with penile compression in anamnesis (prolonged wearing of extender). Through femoral artery, inner genital artery is catheterized and X-ray contrast preparation is administered together with vasoactive drug. Then, with the help of digital X-ray machine, various phases of expansion of penile vessels are visualized during erection increase. During study, pathological narrowing of arteries of penis is determined.