Evaluation and Screening

Having an understanding of the relationship between ED and CVD may lead more men to openly discuss their sexual history, allowing providers to address both conditions and possibly prevent the worsening of CVD. Men with better overall cardiovascular health will have a better long-term prognosis related to sexual function.9

Erectile dysfunction often presents as a mix of both psychogenic and vascular etiologies; therefore, it is important to determine the specific cause or causes of ED.11 Evaluation of vascular ED should begin with a thorough history, including medical and sexual history. It is important to approach the topic sensitively and educate the patient about the prevalence of ED. The stigma related to ED is what prevents many men from admitting difficulty in their sexual life.14

A thorough history of the patient’s smoking status, diet, and exercise routines should be included in the patient interview.5 It also is important to ask the patient about major symptoms associated with cardiac disease, such as chest pain, edema, palpitations, syncope, fatigue, and dyspnea. Patients who smoke or have diabetes, hypertension, dyslipidemia, obesity, or metabolic syndrome should be counseled that these diseases not only increase risk for adverse outcomes such as myocardial infarction and stroke but also affect the ability to maintain an erection.16


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In general, when discussing a patient’s ability to obtain an erection, there are specific aspects of the history that suggest the problem is vascular. A gradual onset of ED is indicative of vascular etiology. Weak noncoital erections and inconsistent early morning erections suggest abnormal vascular functioning.11 The patient’s sexual partner should be included in the interview and can help explain the patient’s difficulty in obtaining or maintaining an erection, along with sexual technique and any other sexual problems the couple may be facing.17

Physical Examination

The physical examination should start with an assessment of the vital signs. If the patient has tachycardia (pulse >100 beats per minute), hypertension (blood pressure ≥130/80 mm Hg), or tachypnea (respiratory rate >20 breaths per minute), then a more detailed cardiovascular examination should be performed.18 The patient’s waist circumference and BMI should be assessed. All of the peripheral pulses should be palpated and documented for signs of vascular disease. Cardiac auscultation along with auscultation for carotid, aortic, renal, and iliac bruits should be performed.19

A full urologic examination should be performed, including inspection of the testes and penis for any anatomical abnormalities. Assessment of the bulbocavernosus reflex and anal sphincter tone is important for evaluating the sacral neural outflow.17 A detailed physical examination and thorough history of present illness are key in determining a vascular etiology of ED.

The workup for a patient with ED often includes assessment of potential hormonal and psychologic etiologies, but many primary care providers and urologists overlook vascular etiology. A standard cardiovascular assessment should include blood work, including fasting glucose, glycated hemoglobin A1c, lipid panel, creatinine, and serum testosterone, as well as an electrocardiogram.20

The severity of ED is measured using the International Index of Erectile Function (IIEF) or the simplified International Index of Erectile Function (IIEF-5). The IIEF is a validated self-administered questionnaire that is a highly specific and sensitive measurement of ED severity.21 Questions in the IIEF assess confidence, penetration ability, maintenance of erection, and satisfaction after sexual intercourse. The responses are calculated, with the ED classified as mild, mild-moderate, moderate, or severe.22

Color Doppler ultrasonography is another diagnostic tool that allows for visualization of arterial insufficiency or other vascular etiology of ED.10 This assessment is performed by giving the patient a pharmaceutical agent that causes an erection, followed by ultrasonography of the left and right cavernosal arteries. Many providers use ultrasonography to determine cavernosal artery flow velocities to accurately characterize arterial integrity.12 This allows for identification of hemodynamic instability causing ED. Doppler ultrasound showed a high sensitivity (100%) and specificity (78%) in diagnosing vascular ED in a prospective study.12 Ultrasound findings also can detect the severity of atherosclerotic activity within the penile artery, which may be an indicator of systemic CVD.12

Penile vasculature is small, making it a particularly sensitive marker of systemic vascular disease; smaller arteries often are affected earlier than larger arteries in vascular disease. The diameter of penile arteries is usually 1 to 2 mm compared with 3 to 4 mm for coronary arteries and 5 to 7 mm for carotid arteries. Vessel size theory suggests that an atherosclerotic plaque should occlude and affect the penile artery earlier than a carotid or coronary artery.6