Current Approaches to the Diagnosis of Vascular Erectile Dysfunction

Ming Ma; Botao Yu; Feng Qin; Jiuhong Yuan


Transl Androl Urol. 2020;9(2):709-721. 

In This Article

Abstract and Introduction


Vascular erectile dysfunction (ED) is closely related to cardiovascular events, and early diagnosis of vascular ED may be helpful to predict the occurrence of cardiovascular events and improve prognosis. At present, there are many approaches to diagnose ED, but each method has its advantages and limitations. This study retrospectively reviewed all available literature focusing on the diagnosis of vascular ED through a systematic PubMed and EMBASE search. According to the different application scenarios, the main methods for the diagnosis of vascular ED are divided into four categories. Intra-cavernous injection of vasoactive drugs is the earliest method used in the diagnosis of vascular ED and is a basic test. For the diagnosis of arterial ED, color duplex Doppler ultrasound, selective penile angiography, magnetic resonance imaging, and computed tomography are more commonly used. While for the diagnosis of venous ED, shear wave elastography, dynamic infusion cavernosometry and cavernosography are more accurate. Endo-peripheral arterial tonometry (PAT) has also been used to detect vascular endothelial function. Although various existing examinations are widely used for the evaluation of vascular ED, they still have some shortcomings, such as invasiveness, contingency, high false positive (negative) rate. New methods of long-term dynamic detection are needed.


Erectile dysfunction (ED), as defined by the National Institutes of Health Consensus Panel, refers to the situation of inability to achieve and/or maintain penile erection sufficient for satisfactory sexual performance, which is divided into psychological, organic and mixed based on the etiology.[1,2] With the increase of the aging population, the worldwide prevalence of ED has been predicted to reach 322 million cases by the year 2025, making it a major health problem.[3,4] Epidemiological surveys have shown that the incidence of ED in men younger than 40 years old is 1–10%, and most of them were thought to be psychogenic ED.[5] Conversely, 40.56% of men over the age of 40 may suffered from ED, and most of them have been categorized as organic ED.[6] Among men over the age of 70, the prevalence of ED ranges from 50% to 100%.[3,7] Most patients with organic ED are considered to be vascular ED caused by hemodynamic disorders, which is associated with endothelial dysfunction, arterial insufficiency, and/or venous occlusive dysfunction.[8]

The association between vascular ED and cardiovascular disease has been widely recognized.[9] Endothelial dysfunction is a common pathology of vascular ED and cardiovascular disease, and they share common risk factors such as obesity, tobacco, lack of exercise, diabetes, hypertension and hyperlipidemia.[10] The most widely studied association between ED and cardiovascular disease is that ED patients have increased risks of not only cardiovascular events but also coronary heart disease and stroke.[11,12] Also, the ED severity was regarded as the morbidity and mortality predictor of the future cardiovascular disease outcome.[11,13] Through the investigation of 300 patients with angiographically documented coronary artery disease, ED may become evident before angina symptoms in almost 70% of cases.[14] Young men with ED had a significantly increased risk of cardiac events in the future, while ED had little effect on the prognosis of older men.[11] In this situation, identifying the causes of vascular ED and ascertaining potential risk factors may help to predict the occurrence of cardiovascular events and improve prognosis. Thus, this paper mainly focused on the advantages, limitations and application scenarios of existing methods for the diagnosis of suspected vascular ED.

According to the guidelines of the International Society for Sexual Medicine and the European Association of Urology, the diagnostic procedure of ED (Figure 1) is based on the bio-psycho-social process of normal sexual function, involving psychology, endocrine, blood vessels and nervous system.[15] For most patients with suspected ED, phosphodiesterase type 5 inhibitors (PDE5Is) treatment is commonly used while routine special diagnostic examinations are not recommended.[16,17] Further examination was performed only if the patient was ineffective to oral PDE5Is. On the contrary, as mentioned above, ED, especially the vascular ED, is closely related to the occurrence of cardiovascular diseases. Further specific diagnostic examinations to patients with suspected vascular ED can identify etiology and risk factors, which is beneficial to their long-term prognosis. At the same time, the normal results of vascular function are also vital for the counseling of patients with ED. It can be clearly pointed out to doctors and patients that anxiety and inappropriate medication may be the indeed causes of ED patients. At this point, doctors can be more confident in advising patients to return to PDE5Is. Despite these benefits of health management, those patients may have to spend more money and bear the risk of invasive procedures but will not change ED's treatment plan.[3] Therefore, for patients with suspected vascular ED, whether to recommend a specific diagnostic test and how to choose the most valuable one has become a dilemma.

Figure 1.

Full medical history, partner interview, sexual history, some standardized questionnaires are necessary to make a preliminary diagnosis. Also, physical examination and some necessary laboratory tests are required to find the possible etiology of ED. The selection of unique inspection methods should be considered to those who were suspected of vascular ED and considering surgical treatment. ED, erectile dysfunction; IIEF, international index of erectile function; BP, blood pressure; HR, heart rate; FSH, follicle-stimulating hormone; LH, luteinizing hormone; PRL, prolactin; TSH, thyroid stimulating hormone; SAS, self-rating anxiety scale; SDS, self-rating depression scale; CDDU, color duplex Doppler ultrasound; MRA, magnetic resonance arteriography; CTA, computed tomography angiography; DICC, dynamic infusion cavernosometry and cavernosography; SWE, share wave elastography; PAT, peripheral arterial tonometry.