Many cases of physiologic erectile dysfunction (ED) are related to vascular insufficiency. Should this diagnosis be taken as evidence of peripheral vascular disease (PVD) and therefore require further workup, such as carotid duplex scans, ankle-brachial index, and/or angiography? Is cholesterol management and workup, including stress testing, warranted?
—NathanW. Keever, DO, Hamilton, N.Y.

I would advise against reflexively ordering a large barrage of tests to evaluate for PVD and coronary ischemia. Rather, the decision on how to proceed needs to be personalized on the basis of the patient’s history and physical exam as well as the results of his evaluation for ED. While you correctly point out that organic (as opposed to psychogenic) ED is often associated with PVD and the risk factors for cardiovascular disease (including smoking, hypertension, hyperlipidemia, and diabetes), it is important to remember that many organic etiologies must be considered. Not every case of ED implies underlying vascular disease. A partial list of other organic causes includes side effects of medications (spironolactone, thiazides, antidepressants, cimetidine, clonidine, etc.), endocrine disorders (hypogonadism and hyperprolactinemia), neurologic disorders (spinal injury, diabetic neuropathy, etc.), trauma (including bicycling and penile fracture), and primary urologic disease (such as Peyronie’s disease). Once nocturnal penile tumescence evaluation has confirmed an organic cause for ED, such additional testing as penile ultrasonography may help to identify a vascular etiology. Finally, consultation with a urologist can offer much-needed guidance in the evaluation of complex cases, and before embarking on an extensive workup for erectile dysfunction, I would consider this as well.
—Daniel G. Tobin, MD (110-12)