Diagnostic Assessment — Erectile Dysfunction
Example 1 of 1 · fictitious patient (Veteran B)
Diagnostic Assessment
Erectile Dysfunction
BOP Code: 73 of 2022 (Erectile Dysfunction)
RH Code: 72 of 2022 (Erectile Dysfunction)
ADF History
Veteran B, date of birth 14 June 1968, Royal Australian Navy, Marine Technician, enlisted 20 January 1984 as a junior recruit, medically discharged 15 March 2017. Operational service: Persian Gulf, 02 November 1990 to 10 March 1991 (warlike); East Timor, 20 September 1999 to 15 January 2000 (warlike); Middle East Area of Operations, 05 January 2006 to 12 March 2006 (warlike).
Occupational History
Marine technicians operate and maintain ship propulsion, power generation and auxiliary machinery in hot, noisy and confined machinery spaces. The trade carries exposure to fuel and lubricant vapours, solvents and adhesives, asbestos in older ships, silica from abrasive blasting during dry-dock maintenance, and the risk of fire, explosion, burns and electrical injury.
Sea service involves long periods of shift work, disrupted sleep and limited access to healthy food and exercise. Smoking was common and duty-free cigarettes were freely available on board during the period of this veteran's service.
History
Veteran B, a marine technician in the Royal Australian Navy, sustained severe burns, a pelvic fracture, a left above-knee amputation and a lumbar burst fracture in an engine-room explosion on warlike service in the Middle East on 12 March 2006, and developed erectile dysfunction on 17 September 2012 after a cluster of pelvic and spinal operations, an electrical injury and an ischaemic priapism, on a background of vascular, metabolic, endocrine and mental health disease. The condition worsened in September 2017 after further prostate and spinal surgery.
Timeline
- 12 Mar 2006 — During warlike service in the Middle East Area of Operations an explosion in the main machinery space of the veteran's ship caused burns to 32 per cent of his body surface, including the thighs and perineum, an open pelvic ring fracture, a traumatic left above-knee amputation, a right tibial plateau fracture and an L4 burst fracture with left L4 and L5 root injury. He received 14 units of emergency fresh whole blood collected from donors on board and in theatre before evacuation. Erectile function was recorded as preserved during his rehabilitation. "32% burns, pelvic fracture, AKA"
- 20 Jun 2007 — A consultant psychiatrist diagnosed posttraumatic stress disorder and major depressive disorder related to the explosion and commenced sertraline 150 mg daily. The veteran disclosed that he had been sexually assaulted by senior recruits in 1984, aged 15, as a junior recruit. He smoked 25 cigarettes a day and had used a wheelchair since the explosion. From February 2007 he had been working in a sedentary role at a dockyard rubber-repair bench. "PTSD, MDD, sertraline 150 mg"
- 13 Jun 2008 — Left radical orchidectomy had been performed on 14 April 2008 for a stage I seminoma. Radiotherapy of 20 Gy in 10 fractions to a para-aortic and left pelvic field was completed on 13 June 2008, having begun on 19 May 2008. The radiation oncologist recorded the pelvis within the treatment field. "seminoma, pelvic radiotherapy 20 Gy"
- 07 Apr 2011 — A urologist diagnosed Peyronie disease with a 14 mm dorsal plaque, and benign prostatic hyperplasia with lower urinary tract symptoms since January 2011, but recorded erections adequate for intercourse. Review on 03 March 2011 had recorded hypertension, type 2 diabetes with autonomic neuropathy, BMI 34, peripheral artery disease (ankle-brachial index 0.62), chronic hepatitis B, systemic sclerosis, hidradenitis suppurativa and an exercise capacity of 2.6 METs. He had taken testosterone for hypogonadism since 2009 and used CPAP for sleep apnoea since 2010. "Peyronie plaque, erections adequate"
- 05 Jun 2012 — Haemodialysis had begun on 12 March 2012 for end-stage diabetic and obstructive nephropathy. At urology review before prostate surgery the veteran reported erections adequate for intercourse, with an IIEF-5 score of 22. Transurethral resection of the prostate was booked for 10 July 2012 and revision lumbar fusion for 02 August 2012. "erections adequate, IIEF-5 22"
- 24 Sep 2012 — The veteran presented to the base medical centre unable to achieve an erection since 17 September 2012. Since his last review he had undergone the prostate resection and a revision L3 to S1 fusion complicated by a dural tear and permanent saddle anaesthesia. On 25 August 2012 he had received a 240-volt shock from a vulcanising press with an exit burn on the buttock, on 14 September 2012 herpes zoster had appeared in the right S3 dermatome, and on 16 September 2012 he had a 7-hour ischaemic priapism after trazodone, treated by aspiration. "no erections since priapism"
- 22 Nov 2012 — Penile duplex Doppler after intracavernosal alprostadil showed peak systolic velocities of 18 and 20 cm/s with an end-diastolic velocity of 9 cm/s, indicating combined arteriogenic and veno-occlusive dysfunction. A urologist diagnosed organic erectile dysfunction. Treatment and prosthesis referral were then delayed until April 2016. "arteriogenic and veno-occlusive ED"
- 12 Sep 2017 — After a redo transurethral resection of the prostate on 20 June 2017, complicated by a diathermy burn over the sacrum, revision L5 to S1 surgery on 08 August 2017 with a new left S1 deficit, a 5-hour priapism after alprostadil on 30 August 2017 and sacral zoster on 01 September 2017, the veteran had no residual erectile function. IIEF-5 score was 5 and repeat Doppler showed peak systolic velocities of 12 cm/s with corporal fibrosis. A penile prosthesis was planned. "IIEF-5 5, corporal fibrosis"
Symptoms
At onset the veteran had a sudden and complete inability to achieve or maintain an erection adequate for intercourse, with loss of morning erections, reduced penile sensation and penile pain following the priapism. Oral and intracavernosal treatments subsequently gave only partial responses.
He now has no spontaneous or assisted erections, penile shortening and curvature from fibrosis and Peyronie disease, and reports low mood, relationship strain and avoidance of intimacy. He awaits penile prosthesis surgery.
Imaging
- 12 Mar 2006 — CT pelvis and lumbar spine: "Open pelvic ring fracture with diastasis of the pubic symphysis. L4 burst fracture with retropulsion narrowing the canal and left lateral recess."
- 03 Mar 2011 — Lower limb arterial duplex: "Moderate atheromatous stenosis of both common iliac arteries and the right superficial femoral artery."
- 07 Apr 2011 — Penile ultrasound: "Echogenic 14 mm plaque of the dorsal tunica albuginea, consistent with Peyronie disease."
- 22 Nov 2012 — Penile duplex Doppler with intracavernosal alprostadil: "Peak systolic velocities 18 cm/s right and 20 cm/s left cavernosal arteries, end-diastolic velocity 9 cm/s. Arteriogenic insufficiency with veno-occlusive dysfunction."
- 12 Sep 2017 — Repeat penile duplex Doppler: "Peak systolic velocities 12 cm/s bilaterally, persistent venous leak and patchy corporal fibrosis. Calcified dorsal plaque."
Onset Date
The most likely date of onset of this condition is 17 Sep 2012.
At that date the veteran was serving full time in a sedentary role in a naval dockyard workshop, using a wheelchair since the explosion of 2006. He was on haemodialysis, had recently undergone prostate and lumbar surgery and an electrical injury, and on 16 September 2012 had a 7-hour ischaemic priapism. From 17 September 2012 he could not achieve an erection.
This date is appropriate because the urology review of 05 June 2012 recorded erections adequate for intercourse with an IIEF-5 score of 22, and he first presented with the condition on 24 September 2012, one week after onset. It falls within continuous full-time service.
For the surgical, nerve injury, pelvic trauma and electrical injury factors, the 3 months before onset run from 17 Jun 2012 to 17 Sep 2012; the transurethral resection (10 Jul 2012), the revision fusion with cauda equina injury and iliac crest graft (02 Aug 2012) and the electrical injury (25 Aug 2012) all fall within it. For the urological factor, the 6 months before onset run from 17 Mar 2012 to 17 Sep 2012 (3 months, from 17 Jun 2012, for the Reasonable Hypothesis) and lower urinary tract symptoms were present throughout from January 2011. For the radiation factor, the 10 years before onset run from 17 Sep 2002 to 17 Sep 2012, and radiotherapy was given in May and June 2008. For the METs and carbon disulphide factors, the 5 years before onset run from 17 Sep 2007 to 17 Sep 2012; he used a wheelchair throughout and worked in the unventilated rubber-repair room from February 2007. Depressive disorder, posttraumatic stress disorder, peripheral artery disease, diabetes, sleep apnoea, systemic sclerosis, hypogonadism, neuropathy, hepatitis B, sacral zoster, hypertension, chronic renal failure, hidradenitis suppurativa, obesity and the listed drugs were each present on 17 Sep 2012, and Peyronie disease, the priapism, 32 pack-years of smoking and the childhood sexual abuse all preceded it.
For the worsening factors, the period after onset runs from 17 Sep 2012 to the documented worsening on 12 Sep 2017. The 3 months before the worsening run from 12 Jun 2017 to 12 Sep 2017 and contain the redo prostate resection and diathermy burn (20 Jun 2017) and the revision spinal surgery (08 Aug 2017). The 5 years before the worsening run from 12 Sep 2012 to 12 Sep 2017, during which he remained wheelchair dependent and worked in the carbon disulphide environment until 15 Mar 2017, less than 1 year before the worsening. The 10 years before the worsening run from 12 Sep 2007 and include the 2008 radiotherapy.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Erectile Dysfunction (ICD-10-AM N48.4), organic in type with a psychogenic contribution, under the Statements of Principles concerning erectile dysfunction, Balance of Probabilities No. 73 of 2022 and Reasonable Hypothesis No. 72 of 2022.
Erectile dysfunction is the persistent or recurrent inability to develop or maintain an erection adequate for sexual intercourse. Erection depends on intact pelvic parasympathetic nerves, adequate arterial inflow through the internal pudendal and cavernosal arteries, healthy smooth muscle in the corpora cavernosa and an effective veno-occlusive mechanism, together with normal testosterone and psychological arousal. Vascular disease, diabetes, neurological injury, pelvic surgery and radiotherapy, hormonal deficiency, priapism, medication and mental illness each damage one or more of these elements. Once corporal fibrosis develops the condition is usually permanent.
The diagnosis followed the 2006 explosion injuries and the vascular, metabolic and endocrine disease that developed afterwards. It began on 17 September 2012 after a cluster of pelvic and spinal procedures, an electrical injury and an ischaemic priapism, was confirmed on penile Doppler in November 2012 and worsened in September 2017.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
17 September 2012.
When did the veteran first present to a health / medical provider for this condition?
24 September 2012.
When was the condition confirmed / formally diagnosed?
22 November 2012.
When did the veteran first present to you (or your practice) for this condition?
18 June 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by a urologist on 22 November 2012, on a history of persistent inability to achieve an erection adequate for intercourse since 17 September 2012, an IIEF-5 score of 7, and penile duplex Doppler showing arteriogenic insufficiency with veno-occlusive dysfunction. The failure was persistent and not transient or situational, so it meets the Statement of Principles definition of erectile dysfunction.
The clinical picture was consistent: multiple vascular risk factors, autonomic and sacral nerve injury, hypogonadism and a recent ischaemic priapism. Repeat Doppler on 12 September 2017, with an IIEF-5 score of 5 and corporal fibrosis, confirmed the worsening.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 17 September 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in the Persian Gulf in 1990 to 1991, in East Timor in 1999 to 2000 and in the Middle East in 2006, where the explosion injuries, the transfusion-acquired hepatitis B and the posttraumatic stress disorder arose.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Erectile Dysfunction, No. 73 of 2022
Causative factors
Factor 9(1): having a clinically significant disorder of mental health as specified at the time of the clinical onset of erectile dysfunction; — MET
- A psychiatrist diagnosed major depressive disorder on 20 June 2007, after the engine-room explosion of 12 March 2006, and the veteran remained on sertraline with monthly psychiatric and psychology reviews to and beyond the onset on 17 September 2012. Depressive disorder is on the specified list and was of sufficient severity to warrant ongoing management. It was established during his continuous full-time service and was accepted as service related.
Factor 9(2): having a cardiovascular disease from the specified list of cardiovascular diseases at the time of the clinical onset of erectile dysfunction; — MET
- Peripheral artery disease was confirmed on 03 March 2011 by an ankle-brachial index of 0.62 on the right and arterial duplex showing iliac and femoral atheroma. It followed 26 years of smoking that began and continued through his naval service, and type 2 diabetes. It was present at onset on 17 September 2012, and iliac atheroma reduces arterial inflow to the penis.
Factor 9(3): having a medical condition from the specified list of medical conditions at the time of the clinical onset of erectile dysfunction; — MET
- Type 2 diabetes mellitus was diagnosed on 18 August 2009 (HbA1c 8.9 per cent) and obstructive sleep apnoea on polysomnography on 09 June 2010 (apnoea-hypopnoea index 38 events per hour). Both are on the specified list and both were present at onset on 17 September 2012. Both followed the weight gain caused by his loss of mobility from the service injuries of 2006.
Factor 9(4): having systemic sclerosis (scleroderma) at the time of the clinical onset of erectile dysfunction; — MET
- A rheumatologist diagnosed limited cutaneous systemic sclerosis on 22 November 2010, with Raynaud phenomenon, sclerodactyly, nailfold capillary changes and positive anti-centromere antibodies. It was attributed to ten years of abrasive blasting of ship hulls in a naval dry dock from 1985 to 1995 without adequate respiratory protection. It was present at onset on 17 September 2012.
Factor 9(5): having an endocrine disorder from the specified list of endocrine disorders at the time of the clinical onset of erectile dysfunction; — MET
- Primary hypogonadism was confirmed on 16 February 2009, with morning testosterone of 5.1 nmol/L on two occasions and a raised LH, after the left orchidectomy of 14 April 2008 and pelvic radiotherapy for seminoma. Hypogonadism is on the specified list and was present at onset on 17 September 2012, despite testosterone replacement.
Factor 9(6): having a neurological disorder from the specified list of neurological disorders at the time of the clinical onset of erectile dysfunction; — MET
- Diabetic peripheral autonomic neuropathy was confirmed on autonomic function testing on 03 March 2011, with postural hypotension and loss of heart-rate variability. The veteran also had compression and degeneration of the lumbosacral nerve roots from the L4 burst fracture of 2006, confirmed on MRI. Both are on the specified list and both were present at onset on 17 September 2012.
Factor 9(7): having a urological condition from the specified list of urological conditions, where that condition causes lower urinary tract symptoms, for at least the 6 months before the clinical onset of erectile dysfunction; — MET
- Benign prostatic hyperplasia with bladder outlet obstruction caused lower urinary tract symptoms from January 2011 (International Prostate Symptom Score 24, peak flow 7 mL/s), continuing through the 6 months before onset, from 17 March 2012 to 17 September 2012. Storage symptoms persisted after the transurethral resection of 10 July 2012.
Factor 9(8): having an infection from the specified list of infections at the time of the clinical onset of erectile dysfunction; — MET
- Chronic hepatitis B virus infection was confirmed by persistent HBsAg positivity from September 2006, after 14 units of emergency whole blood were transfused following the explosion. It is on the specified list and was present at onset on 17 September 2012; liver function remained abnormal and he took entecavir from 2010.
Factor 9(9): having herpes zoster affecting a sacral dermatome at the time of the clinical onset of erectile dysfunction; — MET
- Herpes zoster affecting the right S3 dermatome, with a vesicular eruption over the perineum and scrotum, was diagnosed on 14 September 2012 while he was on haemodialysis, and was still active at onset on 17 September 2012. Sacral zoster can disrupt the pelvic parasympathetic outflow that mediates erection.
Factor 9(10): having hypertension at the time of the clinical onset of erectile dysfunction; — MET
- Hypertension was diagnosed on 11 November 2008 with clinic readings of 162/98 mmHg confirmed on ambulatory monitoring, and was treated with metoprolol and amlodipine. It was present at onset on 17 September 2012.
Factor 9(11): having chronic renal failure at the time of the clinical onset of erectile dysfunction; — MET
- The veteran commenced haemodialysis three times a week on 12 March 2012 for end-stage diabetic and obstructive nephropathy, and remained on chronic dialysis at onset on 17 September 2012. This meets the definition of chronic renal failure.
Factor 9(12): having Peyronie disease before the clinical onset of erectile dysfunction; — MET
- A urologist diagnosed Peyronie disease on 07 April 2011, with a firm dorsal plaque of 14 mm on penile ultrasound and a 30-degree dorsal curvature. Erections nevertheless remained adequate for intercourse until 2012. The disease was present before the onset on 17 September 2012.
Factor 9(13): having ischaemic priapism for a continuous period of at least the 4 hours before the clinical onset of erectile dysfunction; — MET
- On 16 September 2012 the veteran developed an ischaemic priapism lasting 7 hours after a dose of trazodone, prescribed for the sleep disturbance of his depressive disorder. Corporal aspiration showed dark, hypoxic blood (pO2 2.1 kPa) and phenylephrine was injected. He could not achieve an erection from the next day, the onset on 17 September 2012.
Factor 9(14): having a surgical operation from the specified list of surgical operations within the 3 months before the clinical onset of erectile dysfunction; — MET
- A transurethral resection of the prostate was performed on 10 July 2012 for benign prostatic hyperplasia with bladder outlet obstruction. Prostate surgery is on the specified list, and the operation was within the 3 months before onset, which run from 17 June 2012 to 17 September 2012.
Factor 9(15): having a trauma or surgery involving the brain, spinal cord, thoracolumbosacral nerve roots, cauda equina or the nerve supply to the penis, where the trauma or surgery results in permanent neurological impairment, within the 3 months before the clinical onset of erectile dysfunction; — MET
- On 02 August 2012 the veteran underwent revision decompression and fusion from L3 to S1 for the L4 burst fracture of 2006. A dural tear with cauda equina injury left permanent saddle anaesthesia and reduced anal tone, confirmed on neurological examination and nerve conduction studies. The surgery was within the 3 months before onset on 17 September 2012.
Factor 9(16): having blunt trauma, penetrating trauma including surgical trauma, explosive blast injury or gunshot injury to the external genitals, perineum or pelvis, within the 3 months before the clinical onset of erectile dysfunction; — MET
- The transurethral resection of the prostate on 10 July 2012 was surgical trauma within the pelvis, and the revision fusion on 02 August 2012 included harvest of iliac crest bone graft, which is surgical trauma to the pelvis. Both were within the 3 months before onset, from 17 June 2012 to 17 September 2012.
Factor 9(17): having internal burns, substantial external burns, or electrical injury to the external genitals, perineum or pelvic region within the 3 months before the clinical onset of erectile dysfunction; — MET
- On 25 August 2012, while working at the dockyard rubber-repair bench, the veteran received a 240-volt electric shock from a faulty vulcanising press. The current passed from his right hand to his buttock and the metal frame of his wheelchair, leaving a full-thickness exit burn over the right buttock and perineum. This electrical injury to the pelvic region was within the 3 months before onset on 17 September 2012.
Factor 9(18): having smoked tobacco products: (a) in an amount of at least 15 pack-years before the clinical onset of erectile dysfunction; and (b) if smoking has ceased before the clinical onset of erectile dysfunction, then that onset occurred within 20 years of cessation; — MET
- The veteran smoked 25 cigarettes a day from enlistment in January 1984 until he stopped on 01 January 2010, a total of about 32 pack-years, more than the 15 required. Onset on 17 September 2012 was less than 3 years after cessation, well within 20 years. The smoking began and was sustained during his naval service, when cheap duty-free cigarettes were freely available on board.
Factor 9(19): undergoing a course of therapeutic radiation for cancer, where the penis, pelvis or perineal region was in the field of radiation, within the 10 years before the clinical onset of erectile dysfunction; — MET
- After left orchidectomy for seminoma on 14 April 2008, the veteran received radiotherapy of 20 Gy in 10 fractions from 19 May 2008 to 13 June 2008 to a para-aortic and left pelvic field that included the pelvis. This course was within the 10 years before onset, from 17 September 2002 to 17 September 2012.
Factor 9(20): being obese at the time of the clinical onset of erectile dysfunction; — MET
- The veteran's BMI was 34.2 (weight 105 kg, height 1.75 m) on 05 June 2012 and 34.6 on 24 September 2012, so he was obese at onset on 17 September 2012. His weight rose from 82 kg in 2005 after the 2006 injuries confined him to a wheelchair.
Factor 9(21): taking a drug from the specified list of drugs at the time of the clinical onset of erectile dysfunction; — MET
- At onset on 17 September 2012 the veteran was taking sertraline 150 mg daily and trazodone 100 mg at night (antidepressants), metoprolol 95 mg daily (a beta-blocker), gabapentin 900 mg daily for neuropathic pain, and testosterone undecanoate injections. All are on the specified list.
Factor 9(22): inability to undertake any physical activity greater than 3 METs for at least the 5 years before the clinical onset of erectile dysfunction; — MET
- Since the explosion of 12 March 2006 the veteran has used a wheelchair, after a left above-knee amputation and a right tibial plateau fracture with poor function. Exercise testing on 03 March 2011 showed a peak capacity of 2.6 METs. He could not undertake activity greater than 3 METs throughout the 5 years before onset, from 17 September 2007 to 17 September 2012.
Worsening factors
Factor 9(23): having a clinically significant disorder of mental health as specified at the time of the clinical worsening of erectile dysfunction; — MET
- Major depressive disorder remained under monthly psychiatric management at the documented worsening on 12 September 2017.
Factor 9(24): having a cardiovascular disease from the specified list of cardiovascular diseases at the time of the clinical worsening of erectile dysfunction; — MET
- Peripheral artery disease had progressed, with a right ankle-brachial index of 0.48 in July 2017, and was present at the worsening on 12 September 2017.
Factor 9(25): having a medical condition from the specified list of medical conditions at the time of the clinical worsening of erectile dysfunction; — MET
- Type 2 diabetes (HbA1c 9.4 per cent in August 2017) and obstructive sleep apnoea were both present at the worsening on 12 September 2017.
Factor 9(26): having systemic sclerosis (scleroderma) at the time of the clinical worsening of erectile dysfunction; — MET
- Limited cutaneous systemic sclerosis remained active at the worsening on 12 September 2017, with progressive sclerodactyly and digital ulcers in 2017.
Factor 9(27): having an endocrine disorder from the specified list of endocrine disorders at the time of the clinical worsening of erectile dysfunction; — MET
- Primary hypogonadism persisted, with testosterone of 6.0 nmol/L in July 2017, at the worsening on 12 September 2017.
Factor 9(28): having a neurological disorder from the specified list of neurological disorders at the time of the clinical worsening of erectile dysfunction; — MET
- Autonomic neuropathy and the cauda equina injury of 2012 were present at the worsening on 12 September 2017.
Factor 9(29): having a urological condition from the specified list of urological conditions, where that condition causes lower urinary tract symptoms, for at least the 6 months before the clinical worsening of erectile dysfunction; — MET
- Lower urinary tract symptoms from recurrent bladder outlet obstruction and detrusor overactivity (International Prostate Symptom Score 26) persisted throughout the 6 months before the worsening, from 12 March 2017 to 12 September 2017, and storage symptoms continued after the redo resection of 20 June 2017.
Factor 9(30): having an infection from the specified list of infections at the time of the clinical worsening of erectile dysfunction; — MET
- Chronic hepatitis B infection persisted (HBsAg positive, July 2017) at the worsening on 12 September 2017.
Factor 9(31): having herpes zoster affecting a sacral dermatome at the time of the clinical worsening of erectile dysfunction; — MET
- A recurrence of herpes zoster in the left S2 dermatome was diagnosed on 01 September 2017 and was active at the worsening on 12 September 2017.
Factor 9(32): having hypertension at the time of the clinical worsening of erectile dysfunction; — MET
- Hypertension, treated with metoprolol and amlodipine, was present at the worsening on 12 September 2017.
Factor 9(33): having chronic renal failure at the time of the clinical worsening of erectile dysfunction; — MET
- The veteran remained on chronic haemodialysis at the worsening on 12 September 2017.
Factor 9(34): having Peyronie disease before the clinical worsening of erectile dysfunction; — MET
- Peyronie disease, with calcification of the dorsal plaque on ultrasound in 2016, was present before the worsening on 12 September 2017.
Factor 9(35): having ischaemic priapism for a continuous period of at least the 4 hours before the clinical worsening of erectile dysfunction; — MET
- On 30 August 2017 a test dose of intracavernosal alprostadil caused an ischaemic priapism lasting 5 hours, treated by aspiration and phenylephrine. It was within the 2 weeks before the worsening on 12 September 2017.
Factor 9(36): having a surgical operation from the specified list of surgical operations within the 3 months before the clinical worsening of erectile dysfunction; — MET
- A redo transurethral resection of the prostate was performed on 20 June 2017 for recurrent bladder outlet obstruction from prostatic regrowth. Prostate surgery is on the specified list, and it was within the 3 months before the worsening, from 12 June 2017 to 12 September 2017.
Factor 9(37): having a trauma or surgery involving the brain, spinal cord, thoracolumbosacral nerve roots, cauda equina or the nerve supply to the penis, where the trauma or surgery results in permanent neurological impairment, within the 3 months before the clinical worsening of erectile dysfunction; — MET
- Revision surgery for failed fusion at L5 to S1 on 08 August 2017 injured the left S1 nerve root and left permanent new weakness and sensory loss, within the 3 months before the worsening on 12 September 2017.
Factor 9(38): having blunt trauma, penetrating trauma including surgical trauma, explosive blast injury or gunshot injury to the external genitals, perineum or pelvis, within the 3 months before the clinical worsening of erectile dysfunction; — MET
- The redo transurethral resection of 20 June 2017 was surgical trauma within the pelvis, within the 3 months before the worsening on 12 September 2017.
Factor 9(39): having internal burns, substantial external burns, or electrical injury to the external genitals, perineum or pelvic region within the 3 months before the clinical worsening of erectile dysfunction; — MET
- During the redo resection of 20 June 2017 a fault in the diathermy return electrode caused a full-thickness electrical burn over the sacrum and left buttock, an electrical injury to the pelvic region within the 3 months before the worsening on 12 September 2017.
Factor 9(40): having smoked tobacco products: (a) in an amount of at least 15 pack-years before the clinical worsening of erectile dysfunction; and (b) if smoking has ceased before the clinical worsening of erectile dysfunction, then that worsening occurred within 20 years of cessation; — MET
- About 32 pack-years were smoked before the worsening, which occurred on 12 September 2017, less than 8 years after he stopped smoking on 01 January 2010.
Factor 9(41): undergoing a course of therapeutic radiation for cancer, where the penis, pelvis or perineal region was in the field of radiation, within the 10 years before the clinical worsening of erectile dysfunction; — MET
- The pelvic radiotherapy of May to June 2008 was within the 10 years before the worsening, from 12 September 2007 to 12 September 2017.
Factor 9(42): being obese at the time of the clinical worsening of erectile dysfunction; — MET
- The veteran's BMI was 36.1 on 12 September 2017, at the worsening.
Factor 9(43): taking a drug from the specified list of drugs at the time of the clinical worsening of erectile dysfunction; — MET
- At the worsening on 12 September 2017 he was taking sertraline, metoprolol, gabapentin and testosterone, all on the specified list.
Factor 9(44): inability to undertake any physical activity greater than 3 METs for at least the 5 years before the clinical worsening of erectile dysfunction; — MET
- The veteran remained unable to exceed 3 METs throughout the 5 years before the worsening, from 12 September 2012 to 12 September 2017.
Factor 9(45): inability to obtain appropriate clinical management for erectile dysfunction. — MET
- From the onset in September 2012 to April 2016 the veteran's requests for erectile dysfunction treatment were declined as not clinically indicated, and his referral for penile prosthesis assessment lapsed for 26 months because the urology clinic was not wheelchair accessible. Corporal fibrosis progressed while the condition went untreated. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Erectile Dysfunction, No. 72 of 2022
Causative factors
Factor 9(1): having a clinically significant disorder of mental health as specified at the time of the clinical onset of erectile dysfunction; — MET
- Posttraumatic stress disorder and major depressive disorder, diagnosed on 20 June 2007, arose from the explosion on warlike service in the Middle East on 12 March 2006, required monthly management and were present at onset on 17 September 2012.
Factor 9(2): having a cardiovascular disease from the specified list of cardiovascular diseases at the time of the clinical onset of erectile dysfunction; — MET
- Peripheral artery disease (ankle-brachial index 0.62, 03 March 2011) was present at onset. It followed smoking that rose to 25 a day on warlike service in the Gulf (1990 to 1991) and East Timor (1999 to 2000), and diabetes from the inactivity imposed by the 2006 injuries.
Factor 9(3): having a medical condition from the specified list of medical conditions at the time of the clinical onset of erectile dysfunction; — MET
- Type 2 diabetes (August 2009) and obstructive sleep apnoea (AHI 38, June 2010) were present at onset. Both followed obesity from wheelchair dependence caused by the explosion on warlike service on 12 March 2006.
Factor 9(4): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of erectile dysfunction; — MET
- Systemic sclerosis, on the specified list of autoimmune diseases, was diagnosed on 22 November 2010 (anti-centromere positive, sclerodactyly) after silica exposure from abrasive blasting between operational deployments, and was present at onset.
Factor 9(5): having an endocrine disorder from the specified list of endocrine disorders at the time of the clinical onset of erectile dysfunction; — MET
- Primary hypogonadism (testosterone 5.1 nmol/L, February 2009) followed orchidectomy and radiotherapy for seminoma during service and was present at onset on 17 September 2012.
Factor 9(6): having a neurological disorder from the specified list of neurological disorders at the time of the clinical onset of erectile dysfunction; — MET
- Peripheral autonomic neuropathy (March 2011) and compression of the lumbosacral nerve roots from the L4 burst fracture sustained on warlike service on 12 March 2006 were present at onset.
Factor 9(7): having a urological condition from the specified list of urological conditions, where that condition causes lower urinary tract symptoms, for at least the 3 months before the clinical onset of erectile dysfunction; — MET
- Lower urinary tract symptoms from benign prostatic hyperplasia were present from January 2011, throughout the 3 months before onset (17 June to 17 September 2012), aggravated by the neurogenic bladder from the 2006 warlike-service root injury.
Factor 9(8): having an infection from the specified list of infections at the time of the clinical onset of erectile dysfunction; — MET
- Chronic hepatitis B was acquired from emergency whole blood collected in theatre and transfused after the explosion on warlike service on 12 March 2006. HBsAg remained positive and the infection was present at onset.
Factor 9(9): having herpes zoster affecting a sacral dermatome at the time of the clinical onset of erectile dysfunction; — MET
- Right S3 herpes zoster, diagnosed 14 September 2012, was active at onset, arising with the renal failure and diabetes that followed the 2006 warlike-service injuries.
Factor 9(10): having hypertension at the time of the clinical onset of erectile dysfunction; — MET
- Hypertension (diagnosed 11 November 2008) was present at onset, following the obesity, inactivity and pain caused by the injuries sustained on warlike service in 2006.
Factor 9(11): having chronic renal failure at the time of the clinical onset of erectile dysfunction; — MET
- Chronic haemodialysis from 12 March 2012 for diabetic and obstructive nephropathy continued at onset; the diabetes followed the warlike-service injuries of 2006.
Factor 9(12): having Peyronie disease before the clinical onset of erectile dysfunction; — MET
- Peyronie disease (14 mm dorsal plaque, 07 April 2011) preceded onset and was related to repeated catheterisation and penile trauma during treatment of the 2006 warlike-service pelvic injuries.
Factor 9(13): having hidradenitis suppurativa at the time of the clinical onset of erectile dysfunction; — MET
- Hidradenitis suppurativa of the groins, perineum and axillae, Hurley stage II, was diagnosed by a dermatologist on 25 May 2009 and was active at onset on 17 September 2012. It developed in the setting of heavy smoking, which increased during warlike deployments, and of obesity caused by the 2006 explosion injuries.
Factor 9(14): having ischaemic priapism for a continuous period of at least the 4 hours before the clinical onset of erectile dysfunction; — MET
- The 7-hour ischaemic priapism of 16 September 2012 followed trazodone prescribed for sleep disturbance from the posttraumatic stress disorder arising from warlike service, and immediately preceded onset.
Factor 9(15): having a surgical operation from the specified list of surgical operations within the 3 months before the clinical onset of erectile dysfunction; — MET
- Transurethral resection of the prostate on 10 July 2012 was within the 3 months before onset; the obstruction was aggravated by the neurogenic bladder from the 2006 warlike-service root injury.
Factor 9(16): having a trauma or surgery involving the brain, spinal cord, thoracolumbosacral nerve roots, cauda equina or the nerve supply to the penis, where the trauma or surgery results in permanent neurological impairment, within the 3 months before the clinical onset of erectile dysfunction; — MET
- Revision L3 to S1 fusion on 02 August 2012, for the L4 fracture sustained on warlike service, caused a cauda equina injury with permanent saddle anaesthesia within the 3 months before onset.
Factor 9(17): having blunt trauma, penetrating trauma including surgical trauma, explosive blast injury or gunshot injury to the external genitals, perineum or pelvis, within the 3 months before the clinical onset of erectile dysfunction; — MET
- Surgical trauma to the pelvis from the resection of 10 July 2012 and the iliac crest graft harvest of 02 August 2012, both treating consequences of the 2006 warlike-service injuries, fell within the 3 months before onset.
Factor 9(18): having internal burns, substantial external burns, or electrical injury to the external genitals, perineum or pelvic region within the 3 months before the clinical onset of erectile dysfunction; — MET
- The electrical injury of 25 August 2012, with an exit burn over the buttock and perineum, occurred in the sedentary role he held because of his warlike-service injuries, within the 3 months before onset.
Factor 9(19): having smoked tobacco products: (a) in an amount of at least 10 pack-years before the clinical onset of erectile dysfunction; and (b) if smoking has ceased before the clinical onset of erectile dysfunction, then that onset occurred within 20 years of cessation; — MET
- About 32 pack-years were smoked before he stopped on 01 January 2010, rising to 25 or more a day on warlike service in the Gulf and East Timor. Onset was within 20 years of cessation.
Factor 9(20): undergoing a course of therapeutic radiation for cancer, where the penis, pelvis or perineal region was in the field of radiation, within the 10 years before the clinical onset of erectile dysfunction; — MET
- Pelvic radiotherapy for seminoma (20 Gy, 19 May to 13 June 2008), given during service after his warlike deployments, was within the 10 years before onset.
Factor 9(21): being obese at the time of the clinical onset of erectile dysfunction; — MET
- BMI was 34.6 at onset, after weight gain from wheelchair dependence caused by the injuries sustained on warlike service in 2006.
Factor 9(22): taking a drug specified in the Schedule 2 - Drugs of this Instrument at the time of the clinical onset of erectile dysfunction; — MET
- At onset he took sertraline and trazodone (antidepressants) for posttraumatic stress disorder from warlike service, metoprolol (a beta-blocker) and gabapentin for neuropathic pain from the 2006 injuries; all are in Schedule 2.
Factor 9(23): inhaling, ingesting or having cutaneous contact with carbon disulphide, where inhalation occurred in an unventilated and confined space, on more days than not for a consecutive period of at least 5 years before the clinical onset of erectile dysfunction, and if exposure has ceased before the clinical onset of erectile dysfunction, then that onset occurred within 1 year of cessation; — MET
- From 05 February 2007 the veteran worked at a bench in an unventilated, confined rubber-repair room of a naval dockyard workshop, applying carbon disulphide-based solvent cements and cleaning vulcanised seals on about four days a week. He did so continuously until discharge on 15 March 2017, which covers the 5 consecutive years before onset, from 17 September 2007 to 17 September 2012. He was placed in this sedentary role because of the injuries sustained on warlike service in 2006.
Factor 9(24): inability to undertake any physical activity greater than 3 METs for at least the 5 years before the clinical onset of erectile dysfunction; — MET
- Wheelchair dependence from the left above-knee amputation and right tibial plateau fracture sustained on warlike service on 12 March 2006 left the veteran unable to exceed 3 METs (peak 2.6 METs on testing in March 2011) throughout the 5 years before onset, from 17 September 2007 to 17 September 2012.
Factor 9(25): experiencing childhood sexual abuse before the clinical onset of erectile dysfunction; — MET
- The veteran disclosed to a psychiatrist on 20 June 2007 that he was sexually assaulted repeatedly by senior recruits between March and September 1984, aged 15, while a junior recruit at a naval training establishment. He was a child, and the abuse occurred in the course of his service, before onset on 17 September 2012.
Worsening factors
Factor 9(26): having a clinically significant disorder of mental health as specified at the time of the clinical worsening of erectile dysfunction; — MET
- Posttraumatic stress disorder and depressive disorder from warlike service remained under monthly management at the worsening on 12 September 2017.
Factor 9(27): having a cardiovascular disease from the specified list of cardiovascular diseases at the time of the clinical worsening of erectile dysfunction; — MET
- Peripheral artery disease, ankle-brachial index 0.48 in July 2017, was present at the worsening on 12 September 2017.
Factor 9(28): having a medical condition from the specified list of medical conditions at the time of the clinical worsening of erectile dysfunction; — MET
- Type 2 diabetes and obstructive sleep apnoea, both following the obesity caused by the warlike-service injuries, were present at the worsening on 12 September 2017.
Factor 9(29): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of erectile dysfunction; — MET
- Systemic sclerosis was present at the worsening on 12 September 2017, with digital ulceration in 2017.
Factor 9(30): having an endocrine disorder from the specified list of endocrine disorders at the time of the clinical worsening of erectile dysfunction; — MET
- Hypogonadism was present at the worsening on 12 September 2017.
Factor 9(31): having a neurological disorder from the specified list of neurological disorders at the time of the clinical worsening of erectile dysfunction; — MET
- Peripheral autonomic neuropathy and the lumbosacral root and cauda equina damage that followed the warlike-service injury were present at the worsening on 12 September 2017.
Factor 9(32): having a urological condition from the specified list of urological conditions, where that condition causes lower urinary tract symptoms, for at least the 3 months before the clinical worsening of erectile dysfunction; — MET
- Lower urinary tract symptoms from recurrent bladder outlet obstruction persisted throughout the 3 months before the worsening, from 12 June 2017 to 12 September 2017.
Factor 9(33): having an infection from the specified list of infections at the time of the clinical worsening of erectile dysfunction; — MET
- Chronic hepatitis B infection acquired from transfusion on warlike service was present at the worsening on 12 September 2017.
Factor 9(34): having herpes zoster affecting a sacral dermatome at the time of the clinical worsening of erectile dysfunction; — MET
- Recurrent sacral (S2) herpes zoster, diagnosed 01 September 2017, was active at the worsening on 12 September 2017.
Factor 9(35): having hypertension at the time of the clinical worsening of erectile dysfunction; — MET
- Hypertension was present at the worsening on 12 September 2017.
Factor 9(36): having chronic renal failure at the time of the clinical worsening of erectile dysfunction; — MET
- Chronic haemodialysis continued at the worsening on 12 September 2017.
Factor 9(37): having Peyronie disease before the clinical worsening of erectile dysfunction; — MET
- Peyronie disease was present before the worsening on 12 September 2017.
Factor 9(38): having hidradenitis suppurativa at the time of the clinical worsening of erectile dysfunction; — MET
- Hidradenitis suppurativa of the groins and perineum remained active, requiring surgical deroofing in May 2017, at the worsening on 12 September 2017.
Factor 9(39): having ischaemic priapism for a continuous period of at least the 4 hours before the clinical worsening of erectile dysfunction; — MET
- An ischaemic priapism of 5 hours after intracavernosal alprostadil on 30 August 2017 preceded the worsening on 12 September 2017.
Factor 9(40): having a surgical operation from the specified list of surgical operations within the 3 months before the clinical worsening of erectile dysfunction; — MET
- The redo transurethral resection of the prostate on 20 June 2017, for obstruction aggravated by the neurogenic bladder from his warlike-service injury, fell within the 3 months before the worsening.
Factor 9(41): having a trauma or surgery involving the brain, spinal cord, thoracolumbosacral nerve roots, cauda equina or the nerve supply to the penis, where the trauma or surgery results in permanent neurological impairment, within the 3 months before the clinical worsening of erectile dysfunction; — MET
- Revision lumbosacral surgery on 08 August 2017 for the warlike-service spinal injury caused a permanent left S1 root deficit within the 3 months before the worsening on 12 September 2017.
Factor 9(42): having blunt trauma, penetrating trauma including surgical trauma, explosive blast injury or gunshot injury to the external genitals, perineum or pelvis, within the 3 months before the clinical worsening of erectile dysfunction; — MET
- Surgical trauma to the pelvis from the redo resection of 20 June 2017 fell within the 3 months before the worsening on 12 September 2017.
Factor 9(43): having internal burns, substantial external burns, or electrical injury to the external genitals, perineum or pelvic region within the 3 months before the clinical worsening of erectile dysfunction; — MET
- The diathermy electrical burn to the sacral and buttock region on 20 June 2017 was within the 3 months before the worsening on 12 September 2017.
Factor 9(44): having smoked tobacco products: (a) in an amount of at least 10 pack-years before the clinical worsening of erectile dysfunction; and (b) if smoking has ceased before the clinical worsening of erectile dysfunction, then that worsening occurred within 20 years of cessation; — MET
- About 32 pack-years were smoked, much of it during warlike deployments, and the worsening on 12 September 2017 was within 20 years of cessation.
Factor 9(45): undergoing a course of therapeutic radiation for cancer, where the penis, pelvis or perineal region was in the field of radiation, within the 10 years before the clinical worsening of erectile dysfunction; — MET
- The pelvic radiotherapy of 2008 was within the 10 years before the worsening on 12 September 2017.
Factor 9(46): being obese at the time of the clinical worsening of erectile dysfunction; — MET
- The veteran's BMI was 36.1 at the worsening on 12 September 2017.
Factor 9(47): taking a drug specified in the Schedule 2 - Drugs of this Instrument at the time of the clinical worsening of erectile dysfunction; — MET
- Sertraline, metoprolol and gabapentin, listed in Schedule 2, were being taken at the worsening on 12 September 2017.
Factor 9(48): inhaling, ingesting or having cutaneous contact with carbon disulphide, where inhalation occurred in an unventilated and confined space, on more days than not for a consecutive period of at least 5 years before the clinical worsening of erectile dysfunction, and if exposure has ceased before the clinical worsening of erectile dysfunction, then that worsening occurred within 1 year of cessation; — MET
- Carbon disulphide exposure in the unventilated rubber-repair room continued on more days than not from 05 February 2007 until discharge on 15 March 2017, covering the 5 consecutive years before the worsening. The worsening on 12 September 2017 occurred within 1 year of cessation.
Factor 9(49): inability to undertake any physical activity greater than 3 METs for at least the 5 years before the clinical worsening of erectile dysfunction; — MET
- Wheelchair dependence from the warlike-service injuries prevented activity above 3 METs throughout the 5 years before the worsening on 12 September 2017.
Factor 9(50): inability to obtain appropriate clinical management for erectile dysfunction. — MET
- The veteran could not obtain treatment or prosthesis assessment for erectile dysfunction from September 2012 to April 2016, a period that followed and was shaped by his injuries from warlike service. The untreated condition progressed to corporal fibrosis and worsened.
The % contribution of the causes is 100% and significant.
Sequelae
The erectile dysfunction is a sequela of the veteran's accepted conditions: the pelvic and lumbosacral injuries from the 2006 explosion and the surgery they required, his posttraumatic stress disorder and depressive disorder, the diabetes, hypertension and peripheral artery disease that followed his loss of mobility, and the hypogonadism and pelvic radiotherapy of his service-treated seminoma.
Unintended Consequence
Met. The erectile dysfunction is in part an unintended consequence of treatment provided by the Commonwealth while the veteran was serving: the trazodone that caused the ischaemic priapism of 16 September 2012, the cauda equina injury from the revision fusion of 02 August 2012, the diathermy burn of 20 June 2017, and the sertraline, metoprolol and gabapentin prescribed for accepted conditions (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. From onset in September 2012 to April 2016 the veteran's requests for treatment were declined and his referral for penile prosthesis assessment lapsed for 26 months because the urology clinic was not wheelchair accessible. During that time corporal fibrosis developed, and the condition progressed from partial response to treatment to complete loss of function by September 2017. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), a veteran who seeks treatment and is prevented from receiving it by refusal of funding and inaccessible services has been unable to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 12 Mar 2006, Trauma admission and CT report, Role 3 hospital, Middle East
- 20 Jun 2007, Psychiatric assessment, Consultant psychiatrist
- 14 Apr 2008, Operation report and oncology letter, Urologist and radiation oncologist
- 13 Jun 2008, Radiotherapy completion summary, Radiation oncologist
- 16 Feb 2009, Endocrinology consultation, Endocrinologist
- 22 Nov 2010, Rheumatology consultation, Rheumatologist
- 03 Mar 2011, Outpatient health record, Medical Officer, Base medical centre
- 07 Apr 2011, Penile ultrasound and urology consultation, Urologist
- 12 Mar 2012, Renal medicine consultation, Renal physician
- 05 Jun 2012, Pre-operative urology review, Urologist
- 02 Aug 2012, Operation report, Spinal surgeon
- 24 Sep 2012, Outpatient health record, Medical Officer, Base medical centre
- 22 Nov 2012, Penile duplex Doppler report and urology consultation, Urologist
- 20 Jun 2017, Operation report, Urologist
- 12 Sep 2017, Repeat penile Doppler and urology follow-up, Urologist
- Statement of Principles concerning Erectile Dysfunction (Balance of Probabilities) No. 73 of 2022, Repatriation Medical Authority
- Statement of Principles concerning Erectile Dysfunction (Reasonable Hypothesis) No. 72 of 2022, Repatriation Medical Authority
