Erection Hardness Score

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The Erection Hardness Score (EHS) is a single-item Likert scale used to assess the subjective hardness of the penis as reported by the patient. It ranges from 0 (indicating the penis does not enlarge) to 4 (indicating the penis is completely hard and fully rigid). Developed in 1998, the EHS is widely used in clinical trials and is recognized for its ease of administration and strong association with sexual function outcomes. It has been validated across various causes of erectile dysfunction and in patients treated with phosphodiesterase type 5 inhibitors (PDE5), showing robust psychometric properties and responsiveness to treatment. [1]

Contents

Overview

Erection hardness (EH) is a key indicator of erectile dysfunction (ED) and is usually assessed through tactile methods. The Erection Hardness Score (EHS) is a simple, validated, self-reported tool that measures erection hardness on a 4-point scale: 0 (no enlargement), 1 (enlarged but not hard), 2 (hard but not for penetration), 3 (hard enough for penetration but not fully rigid), and 4 (fully rigid). While the EHS is based on the patient's subjective assessment and provides a graded measure of erection hardness, a more quantitative approach could offer greater objectivity and accuracy. As of 2020, EHS is the primary method used in clinical practice to evaluate erection hardness. [2]

Psychometric properties

The Erection Hardness Score (EHS) was developed to simplify the evaluation of erectile function (EF) while maintaining reliability and validity. It is a single-item scale that measures erection hardness from 0 (not enlarged) to 4 (fully rigid). [1]

The EHS is a robust and easy-to-use one-item patient-reported outcome that is highly responsive to treatment. [3] It has demonstrated strong discriminative ability to identify ED, [1] strong test-retest reliability, acceptable response quality and distribution, and known-groups validity by effectively distinguishing between normal and impaired erectile function compared to the International Index of Erectile Function (IIEF). It has also showed moderate-to-strong convergent validity with the IIEF and Quality of Erection Questionnaire (QEQ) domains. Psychometric analysis supports its use as a simple, reliable, and valid tool for assessing erection hardness in clinical research. [3]

A 2023 study published in Urology evaluated the Erection Hardness Score during masturbation for diagnosing predominantly organic erectile dysfunction (ED) compared to the nocturnal penile tumescence and rigidity (NPTR) test. Among 189 patients, the EHS demonstrated a sensitivity of 60.0% and specificity of 95.7%, with an ROC curve area of 0.78, indicating its effectiveness in distinguishing between predominantly organic and nonorganic ED. An EHS score of 3-4, indicating good to optimal erectile function, suggests a lower likelihood of predominantly organic ED and may reduce the need for further NPTR testing. [4]

A 2008 study published in The Journal of Sexual Medicine evaluated the relationship of EHS with successful sexual intercourse (SSI) using data from a multinational trial of sildenafil citrate involving 307 men with erectile dysfunction. Results showed that higher EHS scores significantly increased the odds of SSI, with the odds being 41.9 times greater for EHS 3 compared to EHS 2, and 23.7 times greater for EHS 4 compared to EHS 3. The percentage of SSI rose from 60% at EHS 3 to 93.1% at EHS 4. Sildenafil's effect on SSI was largely mediated through its impact on erection hardness. These findings support the EHS as a valid, reliable, and clinically useful measure for evaluating erection hardness. [5]

Criticisms and limitations

While the EHS is straightforward and convenient, it remains subjective and semi-quantitative. As of 2020, no objective, quantitative method for evaluating penile erection hardness exists. [2]

The EHS, validated primarily in sildenafil research, lacks broader validation studies, raising concerns about its general applicability. [1] The scale exhibits limitations in predictive validity and responsiveness compared to the IIEF. While it performs well in detecting ED, its ability to predict future outcomes and detect subtle changes over time is less robust. This may be due to the limitations inherent in single-item scales and the specific context of the studies conducted, which often involve different treatment settings and populations. The EHS is simple to use, which is beneficial, but its ability to detect subtle changes in erectile function and its effectiveness in various clinical settings warrant further study. [1]

A study published in the Journal of Sexual Medicine in 2014, evaluated the Erection Hardness Score (EHS) in a cohort of 75 men with post-radical prostatectomy erectile dysfunction who were treated with alprostadil injections. It found that while the EHS demonstrated good psychometric properties, its predictive validity and responsiveness to changes over time were limited, which should be considered when using it for clinical follow-up. [1]

Related Research Articles

Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a penile erection with sufficient rigidity and duration for satisfactory sexual activity. It is the most common sexual problem in males and can cause psychological distress due to its impact on self-image and sexual relationships.

<span class="mw-page-title-main">Peyronie's disease</span> Abnormal growth of scar tissue within the penis

Peyronie's disease is a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis. Specifically, scar tissue forms in the tunica albuginea, the thick sheath of tissue surrounding the corpora cavernosa, causing pain, abnormal curvature, erectile dysfunction, indentation, loss of girth and shortening.

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Anorgasmia is a type of sexual dysfunction in which a person cannot achieve orgasm despite adequate sexual stimulation. Anorgasmia is far more common in females than in males and is especially rare in younger men. The problem is greater in women who are post-menopausal. In males, it is most closely associated with delayed ejaculation. Anorgasmia can often cause sexual frustration.

Premature ejaculation (PE) is a male sexual dysfunction that occurs when a male expels semen soon after beginning sexual activity, and with minimal penile stimulation. It has also been called early ejaculation, rapid ejaculation, rapid climax, premature climax and (historically) ejaculatio praecox. There is no uniform cut-off defining "premature", but a consensus of experts at the International Society for Sexual Medicine endorsed a definition of around one minute after penetration. The International Classification of Diseases (ICD-10) applies a cut-off of 15 seconds from the beginning of sexual intercourse.

<span class="mw-page-title-main">Tadalafil</span> Medication used to treat erectile dysfunction

Tadalafil, sold under the brand name Cialis among others, is a medication used to treat erectile dysfunction, benign prostatic hyperplasia, and pulmonary arterial hypertension. It is taken by mouth. Onset is typically within half an hour and the duration is up to 36 hours.

Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as a "person's inability to participate in a sexual relationship as they would wish". This definition is broad and is subject to many interpretations. A diagnosis of sexual dysfunction under the DSM-5 requires a person to feel extreme distress and interpersonal strain for a minimum of six months. Sexual dysfunction can have a profound impact on an individual's perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

Nocturnal penile tumescence (NPT) is a spontaneous erection of the penis during sleep or when waking up. Along with nocturnal clitoral tumescence, it is also known as sleep-related erection. Colloquially, the term morning wood, or less commonly, morning glory is also used, although this is more commonly used to refer specifically to an erection beginning during sleep and persisting into the period just after waking. Men without physiological erectile dysfunction or severe depression experience nocturnal penile tumescence, usually three to five times during a period of sleep, typically during rapid eye movement sleep. Nocturnal penile tumescence is believed to contribute to penile health.

Venous leak, also called venogenic erectile dysfunction and penile venous insufficiency, is one category of vasculogenic impotence — a cause of erectile dysfunction in males. It affects all ages, being particularly awkward in young men. Much about venous leaks has not reached a consensus among the medical community, and many aspects of the condition, particularly its treatment strategies, are controversial. The prevalence of the condition is still unknown, although some sources claim it to be a common cause of erectile dysfunction.

The cavernous nerves are post-ganglionic parasympathetic nerves that facilitate penile erection and clitoral erection. They arise from cell bodies in the inferior hypogastric plexus where they receive the pre-ganglionic pelvic splanchnic nerves (S2-S4).

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A penile implant is an implanted device intended for the treatment of erectile dysfunction, Peyronie's disease, ischemic priapism, deformity and any traumatic injury of the penis, and for phalloplasty or metoidioplasty, including in gender-affirming surgery. Men also opt for penile implants for aesthetic purposes. Men's satisfaction and sexual function is influenced by discomfort over genital size which leads to seek surgical and non-surgical solutions for penis alteration. Although there are many distinct types of implants, most fall into one of two categories: malleable and inflatable transplants.

<span class="mw-page-title-main">Erection</span> Physiological phenomenon involving the hardening and enlargement of the penis

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<span class="mw-page-title-main">Clitoral erection</span> Physiological phenomenon involving the engorgement of the clitoris

Clitoral erection is a physiological phenomenon where the clitoris becomes enlarged and firm.

<span class="mw-page-title-main">Ronald Virag</span> French cardiovascular surgeon

Ronald Virag is a French cardiovascular surgeon who specialises in andrology, the study of the male reproductive system. After training in general and cardiovascular surgery at Paris University, he shifted his focus to the study of erectile dysfunction, which has been his primary area of study since 1978. In 1981, he founded a private institute in France dedicated to the clinical study of erectile dysfunction and developed early programs using intracavernosal drugs to treat the condition.

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<span class="mw-page-title-main">Penile artery shunt syndrome</span> Medical condition

Penile artery shunt syndrome (PASS) is an iatrogenic clinical phenomenon first described by Tariq Hakky, Christopher Yang, Jonathan Pavlinec, Kamal Massis, and Rafael Carrion within the Sexual Medicine Program in the Department of Urology, at the University of South Florida, and Ricardo Munarriz, of Boston University School of Medicine Department of Urology in 2013. It may be a cause of refractory erectile dysfunction in patients who have undergone penile revascularization surgery.

<span class="mw-page-title-main">Culley C. Carson III</span> American physician

Culley Clyde Carson III is an American retired urologist who specializes in Peyronie's disease, penile implants and erectile dysfunction. After serving two years as a flight surgeon with the United States Air Force, he took on a urology residency at the Mayo Clinic and then taught at the Duke University Medical Center as an assistant professor, subsequently gaining full professorship.

A penis extender is an external medical device with tentative evidence as of 2019 for Peyronie's disease. It acts as a mechanical, traction device that stretches the human penis in the flaccid state to make it longer.

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References

  1. 1 2 3 4 5 6 Parisot, Juliette; Yiou, René; Salomon, Laurent; de la Taille, Alexandre; Lingombet, Odile; Audureau, Etienne (August 2018). "Erection hardness score for the evaluation of erectile dysfunction: further psychometric assessment in patients treated by intracavernous prostaglandins injections after radical prostatectomy". The Journal of Sexual Medicine. 11 (8): 2109–2118. doi:10.1111/jsm.12584. ISSN   1743-6109. PMID   24840184.
  2. 1 2 Cheng, Hao; Niu, Zichang; Xin, Fengyue; Yang, Lin; Ruan, Litao (August 2020). "A new method to quantify penile erection hardness: real-time ultrasonic shear wave elastography". Translational Andrology and Urology. 9 (4): 1735–1742. doi: 10.21037/tau-20-1096 . ISSN   2223-4683. PMC   7475665 . PMID   32944534.
  3. 1 2 Mulhall, John P.; Goldstein, Irwin; Bushmakin, Andrew G.; Cappelleri, Joseph C.; Hvidsten, Kyle (2007-11-01). "ORIGINAL RESEARCH—OUTCOMES ASSESSMENT: Validation of the Erection Hardness Score". The Journal of Sexual Medicine. 4 (6): 1626–1634. doi:10.1111/j.1743-6109.2007.00600.x. ISSN   1743-6095. PMID   17888069.
  4. ↑ Zhang, Hui; Colonnello, Elena; Zhang, Hao; Sansone, Andrea; Xi, Yu; Wang, Chunling; Jannini, Emmanuele A.; Zhang, Yan (2023-12-01). "Erection Hardness Score in Masturbation Can Serve as a Preliminary Screening Tool for Organic Erectile Dysfunction". Urology. 182: 149–154. doi:10.1016/j.urology.2023.08.016. ISSN   0090-4295. PMID   37741297.
  5. ↑ Goldstein, Irwin; Mulhall, John P.; Bushmakin, Andrew G.; Cappelleri, Joseph C.; Hvidsten, Kyle; Symonds, Tara (October 2008). "The erection hardness score and its relationship to successful sexual intercourse". The Journal of Sexual Medicine. 5 (10): 2374–2380. doi:10.1111/j.1743-6109.2008.00910.x. ISSN   1743-6109. PMID   18624971.
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