Diagnosis of erectile dysfunction (ED). ED is a widespread condition that is not life – threatening, but affects the physical and mental health of men. ED has a significant impact on the quality of life of both the man himself and his partner and family members.
According to the World Health Organization (WHO), erectile dysfunction is observed in every tenth man over the age of 21. At the age of 40-50 years, ED is detected in 40% of men, in 50-60 years in 57%. Every third man over the age of 60 is not able to perform sexual intercourse at all.
To date, it is known that an erection is a complex psychoneurovascular reaction that occurs as a result of the close interaction of the endocrine, nervous, and cardiovascular systems. When these systems become discoordinated and men lose the ability to achieve or maintain sufficient erections to satisfy their sexual needs, a condition called ED develops.
ED is a multifactorial, polyethological disease. The occurrence of an adequate erection of the penis can be significantly influenced by three key factors: systemic diseases, poor nutrition and medication. It should be noted that with age, the frequency of somatic burden increases, which negatively affects erectile function, in particular, arterial hypertension, coronary heart disease and diabetes mellitus develop. In this regard, a comprehensive personalized approach to the diagnosis of ED is needed to determine the true cause of the development of ED and determine further treatment tactics.
Today, in addition to lifestyle modification (maintaining sufficient physical activity, quitting smoking) and limiting risk factors (normalizing lipid levels, blood pressure, and blood sugar), there are three lines of ED therapy. The first line includes the use of phosphodiesterase inhibitors of the fifth type, the second – vacuum devices for erection, shock wave therapy, intracavernous injections. Finally, the third-line method is the implantation of penile prostheses (phalloprosthesis). To determine the pathogenetic treatment of ED, its nature should be established. A personalized treatment and diagnostic approach with the use of additional research methods will allow you to get the expected better treatment results in the long term.
Diagnosis of erectile dysfunction
One of the paradigms of modern ED diagnostics currently implies a single algorithm for examining all patients. However, this position leads to ineffective treatment.
It is known that ED is not a disease, but a symptom. For example, to date, there is sufficient evidence that ED can be a potential marker of cardiovascular diseases, since it occurs due to endothelial dysfunction, damage to the coronary arteries and peripheral vessels. Thus, endothelial dysfunction can lead to a violation of the mechanisms of normal blood flow in the pelvis, as well as in the coronary circulation system. At the same time, the pathogenetic causes of endothelial dysfunction may be different.
In this regard, today more than ever, the question of optimizing the existing modern methods of diagnosing ED, aimed at assessing the state of the endothelium, as well as the androgen and psychosexual status of a man, is relevant. The main task of the survey is to form a complete objective picture of the state of health of a man and actively correct the detected deviations. In this case, the treatment of ED will be highly effective, as pathogenetically justified and safe as possible.
Currently, the examination of men suffering from ED includes a number of laboratory and instrumental diagnostic measures. In addition to assessing the history of the disease, sexual disorders, conducting questionnaires (according to the International Index of Erectile Function, the Questionnaire of Age-related symptoms of Androgen Deficiency in men, the Hospital Scale of Anxiety and Depression), laboratory tests (determining the level of glucose, total testosterone, lipid profile, etc.), special research methods deserve special attention. These include assessment of nocturnal penile tumescence and rigidity, pharmacodopplerography of penile vessels, assessment of systemic endothelial function, electrophysiological examination of the penis, and cavernosography.
Assessment of nocturnal penile tumescence and penile rigidity
The greatest difficulties in the study of erectile disorders are caused by the differential diagnosis of psychogenic and organic disorders of erectile function. The preservation of spontaneous erections in the absence of adequate ones is considered an indirect sign of psychogenic disorders. A differential diagnosis between psychogenic and organic forms of ED can be made, including the assessment of nocturnal penile tumescence.
Nocturnal penile tumescence was first described by H. M. Halverson in 1940, who observed infants, and then by P. Ohlmeyer in 1944, who observed healthy men of all ages. In healthy men, during the night in the REM sleep phase, there are three to five episodes of spontaneous erections lasting on average about 10-15 minutes (from 20% of the sleep time during puberty to two to seven minutes in older age).
Monitoring of the development of nocturnal penile tumescence is carried out using the RigiScan computerized system, developed in 1985.The system allows you to qualitatively and quantitatively evaluate nocturnal erections. To date, the study of nocturnal penile tumescence remains an important tool in the diagnosis of ED, since it makes it possible to analyze the effectiveness of adequate therapy aimed at restoring sexual disorders.
Thus, it was shown that the assessment of penile tumescence helps to predict the effect of taking phosphodiesterase inhibitors of the fifth type (viagra, cialis, levitra or their analogues). S. M. Elhanbly demonstrated a positive correlation between rigidity in the head and base of the penis and the effectiveness of sildenafil.
In men who have undergone radical nerve-sparing prostatectomy, the assessment of nocturnal penile tumescence is important for an adequate choice of pharmacotherapy for the purpose of early recovery of sexual function. According to A. Bannowsky, with a well-performed operation, episodes of spontaneous erection are observed as early as the first night after the removal of the urethral catheter. In the absence of nocturnal penile tumescence, it is assumed that the neuronal integrity of the cavernous nerve has been damaged, and then, according to the authors, it is necessary to additionally use intracavernous injections to restore erectile function.
Assessment of nocturnal penile tumescence is also important for young males with spina bifida pathology, since the level of spinal cord damage plays a key role in the rehabilitation of sexual function.
However, in patients with diabetes, the value of this test is reduced, since many of them have concomitant somatic diseases and take medications that affect the reliability of the results.
False-positive results can be observed in neurogenic ED. False negative-in old age of the patient, with his agitation, depressive states, sleep disorders and hypogonadism, as well as taking alcoholic beverages, antiandrogens, antidepressants, barbiturates, benzodiazepines, diuretics, sympatholytics, anticholinergic anticonvulsants, sedatives and narcotic drugs, nicotine.
However, the mechanism of development of spontaneous erections differs from adequate ones, and patients who have excellent nocturnal erections may have signs of ED. In this regard, the normal values according to the results of the study of nocturnal penile tumescence do not exclude organic ED. Therefore, the question of the diagnostic value of this method of investigation remains debatable to this day, and the assessment of nocturnal penile tumescence is mainly used in scientific and clinical studies.
The presented review of works published over the past decade confirms the fact that the main task of diagnosis of erectile dysfunction is to establish its true cause. It is obvious that it is advisable to use research methods with proven effectiveness, since this will ensure an effective approach to treatment. Currently, methods for diagnosis of erectile dysfunction need to be optimized. It is necessary to develop a personalized diagnostic algorithm aimed at assessing the state of the cardiovascular system, endothelium, androgen status, etc. to improve the effectiveness and safety of treatment for men suffering from various forms of ED.