Clinical Opal - Investigating Erectile Dysfunction
Patrick is a 62 year old university lecturer who presents to you with erectile dysfunction. He states that for the past 12 months his erections have become weaker and at times he is unable to have satisfying sex with his wife.
On further questioning, Patrick is otherwise asymptomatic and denies feeling anxious or depressed. He recalls no clear precipitant to the onset of his ED. He has a very close and supportive relationship with his wife and states that his libido is normal.
Patrick has a background of hypertension, well controlled on irbesartan 150mg daily, and osteoarthritis of the knees. He denies any significant other past medical history and takes no other medication apart from the odd Panadol.
What investigations would you order to investigate Patrick’s erectile dysfunction?
ED is a persistent or recurrent inability to attain and/or maintain a penile erection sufficient for satisfactory sexual activity and intercourse.1 It is a common condition affecting 1 in 5 men over the age of 40 years and is closely associated with cardiovascular disease and diabetes.
Clinical guidelines on the assessment and management of erectile dysfunction were published in the MJA in 2022.(2)
These stated that laboratory testing should include fasting glucose and lipid profile in all cases.
They recommended that case finding for hypogonadism by ordering a total testosterone level should only occur in selected cases of men with ED, including when associated with:
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Low libido
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Incomplete response to oral phosphodiesterase type 5 inhibitor (PDE5i) treatment, and/or
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Type 2 diabetes.
They also stated that other tests such as FBC, EUC, urinalysis, TSH, FSH/LH, SHBG and prolactin should only be added if dictated by the clinical context.
Vascular imaging and neurophysiological testing are not required unless specifically indicated e.g. for young age, known history of pelvic trauma, and/or in the setting of abnormal examination findings.
References
1. Health Male clinical summary guide: Erectile dysfunction
2. Chung E, Lowy M, Gillman M, Love C, Katz D, Neilsen G. Urological Society of Australia and New Zealand (USANZ) and Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) clinical guidelines on the management of erectile dysfunction. Med J Aust. 2022 Sep 19;217(6):318-324.
Simon is a GP based in Newcastle, NSW, and a senior medical educator with Medcast. He also has medical education roles with the RACGP and GPSA.
Over the past three decades, Simon has worked in clinical and educational roles in NSW and the NT, as well as in the Republic of Ireland. He has published over 75 peer reviewed journal articles, and in 2018 received the RACGP Corliss award for his contribution to medical education.
Simon is passionate about high quality education and training. He has particular interests in GP supervisor professional development and the rational use of tests and medicines. He is a proud member of Doctors for the Environment. He spends his spare time drinking craft beer and pretending that he is a musician in the Euthymics, an all-GP band.
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