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Tests and diagnosis for erectile dysfunction
Before considering a diagnosis of erectile dysfunction that requires treatment, a doctor will look for symptoms that have persisted for at least three months.3
Once a patient's history has been established, a doctor will then undertake further investigation. One simple test, known as the 'postage stamp test,' can be helpful in determining if there is a medical cause of erectile dysfunction rather than a psychological one. This test checks for the presence of nighttime erections - men usually have three to five a night - by seeing if postage stamps applied around the penis before sleep have snapped off overnight.
Men with psychogenic erectile dysfunction usually have normal erections during sleep and as they wake up in the morning, whereas an organic cause will often prevent these erections.1,5
Other tests of nocturnal erection include the Poten test and Snap-Gauge test. These methods provide limited information, but can help guide a doctor's choice of further tests.1,5,13
It is always worth talking to your doctor about problems with erection because they can be the earliest signal of atherosclerotic disease - narrowing of the arteries, which can lead to heart disease.6
A patient information page produced by the American Heart Association is poetic about the importance of getting a diagnosis:6
"Talk with your doctor about a broken sex life, and you might be able to prevent a broken heart."
What the doctor will investigate
The numerous potential causes of erectile dysfunction means that a doctor will typically ask a lot of questions and arrange for blood tests to be performed. Such tests can check for heart problems, diabetes and low testosterone, among other things. The doctor will also usually carry out a physical examination, including of the genitals.5
The questions will help to determine any potential cause in the patient's history - this might include checking for use of prescription drugs, herbal products and alcohol, pelvic surgery or trauma, and smoking.5
The patient's medical records will be checked for diabetes or high blood pressure, and the doctor will also want to rule out atherosclerosis and symptoms of vascular, hormonal, neurological, and psychological disorders.5
All patients should be checked for signs and symptoms of depression, and the consultation might explore recent emotional events, and relationship status, including asking questions about any conditions the sex partner may have.5
Treatments for erectile dysfunction
In this section we take a look at the available treatment options for erectile dysfunction, from drugs to vacuum devices, surgery treatments and dietary supplements.
Drug treatments for erectile dysfunction
The first option for the treatment of erectile dysfunction - once the condition has been established as a persistent problem, rather than a one-off or temporary one - is a group of drugs called PDE-5 (phosphodiesterase-5) inhibitors.
The best known treatments for erectile dysfunction are sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis).
All except one of these pills are taken 30 to 60 minutes before sex - the best known being the blue-colored pill sildenafil (Viagra). Other options are vardenafil (Levitra), tadalafil (taken as a once-daily pill; Cialis), and avanafil (Stendra).5
PDE-5 inhibitors must be prescribed by a doctor, who may check for heart conditions and use of other medications. For example, a cardiologist may need to advise on the best timing for the use of erectile dysfunction drugs in men who keep nitrate drugs for rare occasions of angina chest pain caused by coronary artery disease.5
Less commonly used drug options include prostaglandin E1, which is applied locally, into the penis (either injected into it or inserted down the opening into the urethra, as with the suppository alprostadil, brand named Muse). Most men prefer a pill, however, so these locally acting drugs tend to be reserved for men who cannot take oral treatment.5
Online pharmacies selling drugs for erectile dysfunction
It is possible to buy treatment over the internet for erectile dysfunction, but there are four items worth checking before trusting a website for any purchase. The US Food and Drug Administration has a consumer safety guide about this, including a recommendation to check that the online pharmacy:
- Is located in the US and licensed (check the list maintained by the National Association of Boards of Pharmacy)
- Has a licensed pharmacist to answer questions
- Requires a prescription
- Offers direct contact with a person who can discuss any problems.
The FDA also offers tips for spotting the dangers of an unsafe website, including watching out for these clues:
- There is no way to contact the website by phone
- Prices are dramatically lower than those offered by legal online pharmacies
- Prescription drugs are offered without requiring a prescription - which is illegal
- Personal information is not protected.
The FDA adds that these illegal sites may send drugs of unknown quality and origin, even sending the wrong drug or a dangerous product.
Vacuum erection devices are a mechanical way of producing an erection for men who do not want or cannot use drug treatments or find they are not working.
The penis is made rigid by the use of a vacuum pump sealed around it that draws up blood - this is prevented from then leaving the penis by the use of an accompanying band - a rubber ring is rolled to the base of the organ and sexual penetration can begin.9,12
The lack of spontaneity with the use of vacuum devices, and other potential issues, means that many men find other treatments for erectile dysfunction preferable. Some of the other issues with such mechanical devices include:5
- Bruising of the penis
- Tissue damage caused if the ring is left on for too long
- Coldness of the tip of the penis.
Penile implants are a final option reserved for men who have not had any success with drug treatments and other non-invasive options.
These prostheses are surgically placed mechanical implants, taking the form of a device inflated by fluid when needed, or one that is simply moved into the upward position but keeps the penis hard at all times while not upright.5,12
The most complex of these implants is the three-piece version that is totally concealed within the body and gives a normal appearance, both when in operation and for the flaccid penis. It is triggered by a release valve that fills the implant with fluid.14
Guidelines drawn up by specialist urology doctors have outlined the following risks to consider when planning to have implant surgery:15
- The possibility and consequences of infection and erosion ("infection is a devastating complication of any prosthetic surgery" but anti-infection measures applied to implants have improved)
- Mechanical failure of the device, which would necessitate another operation
- How the normal flaccid and erect penis will appear, and whether there will be "penile shortening"
- If the device is subsequently removed, other therapies may have reduced effectiveness.
Another surgical option for some men is vascular surgery, which attempts to correct some blood vessel causes of erectile dysfunction.
Arterial reconstructive surgery is an option limited to only very specific cases of erectile dysfunction. The American Urological Association presents it as an option only for healthy men who have recently acquired erectile dysfunction caused by a focal arterial occlusion (a blocked artery at a certain point), "and in the absence of any evidence of generalized vascular disease."15
Another type of surgery, to restrict the venous outflow of the penis (return of blood from the penis), has been used but is not recommended by urology specialists; the American Urological Association says that such surgery is not a good option for the types of erectile dysfunction it is intended to treat.15
Dietary supplements and alternative treatments for erectile dysfunction
No guidelines followed by doctors, nor any established sources of evidence, support the use of dietary supplements for erectile dysfunction, such as herbal pills.5,8,9,15
In addition to there being no evidence in favor of non-prescription alternatives for ED, the US Food and Drug Administration has warned of hidden risks of 'treatments' sold online for erectile dysfunction.16
While many of these products are sold as 'natural,' they illegally contain, in a third of cases uncovered by the FDA, prescription drugs such as sildenafil (Viagra) - giving false claims to herbal effectiveness and presenting users with unregulated risks.
The FDA has published a list of products to avoid. These products may be dangerous and will not be as effective as prescribed treatments available from doctors.16
The Mayo Clinic lists three alternative therapies as risky, despite their popularity with men looking for help with erectile dysfunction. These three remedies are:8
- Yohimbe - has a number of potential side effects that could be dangerous; should not be used without physician supervision.
- Ginkgo biloba - can increase the risk of bleeding
- Horny goat weed - may lower blood pressure.
The Mayo Clinic also cites three alternative therapies for erectile dysfunction that have been studied in people, have positive results and are generally safe. However, although these remedies may not be harmful to people with erectile dysfunction (as long as patients check with their doctors for possible interactions with other therapies and conditions), the evidence to support their use remains weak and preliminary:8
- Korean red ginseng (Panax ginseng) - appears to be safe in the short-term; may cause insomnia. One study showed it improved sexual function in men with erectile dysfunction
- Dehydroepiandrosterone (DHEA) - appears to be safe at low doses; can cause acne. Some evidence shows that it helps erectile dysfunction and increases libido in women
- L-arginine - can cause nausea, cramps and diarrhea; should not be taken with Viagra. Some evidence shows that high doses dilate blood vessels, stimulating blood flow, to improve erectile function.
Acupuncture has also been suggested as an alternative treatment for erectile dysfunction, but there is currently insufficient evidence available to determine the benefits or risks of this intervention. A systematic review of randomised controlled trials looking at the safety and efficacy of acupuncture for erectile dysfunction is underway and is expected to be published in the British Medical Journal in late 2015 or early 2016.