Changing practice patterns in erectile dysfunction: a diagnostic algorithm for the new millennium.

In the era when there was only one cause-specific treatment for erectile dysfunction (vasoactive penile injection), most patients could be safely directed to therapy following a good sexual history, assessment of medical risks, and physical examination. Without diagnostic testing, efficacy and satisfaction was a matter of chance. The next millennium will see the development of multiple oral agents for the management of male sexual dysfunction. These agents with their differing mechanisms of pharmacological action (central initiators, central conditioners, and peripheral modulators) present for the first time the possibility of cause-specific therapy. Currently with only 1 pill available, clinicians are compelled to categorize patients as having oral-agent-responsive or oral-agent-resistant erectile dysfunction (ED). For the time being, we may categorize patients as: Viagra (Pfizer Pharmaceuticals, New York, NY) successes or Viagra failures. But when faced with a laundry list of options for ED, the role of erectile function testing will assume a two-fold importance: (1) establishing an etiology specific diagnosis and (2) formulating a treatment plan with a reasonable likelihood of success. Patients failing first-line therapy by primary caregivers will seek the expertise of specialists; they will want to know not only what is wrong with them but also why a specific agent has failed to reverse their ED. We must be prepared to meet these demands; our diagnostic algorithms must incorporate these new pharmacological agents. Our prescribing patterns, to be successful, must have some objective basis. ED testing will need to produce vascular profiles to predict which drug or combination of drugs (oral, cutaneous, urethral, intracavenosal) will effectively restore erection. Conversely, to spare patients the frustration and the potential side effects of empiric trials, ED testing will need to determine whether patients would be better served by a mechanical solution, a vacuum erection device or penile prosthesis.