Erectile Dysfunction - Assessment

General medical history:

  • medications
  • vascular risk factors
  • medical history
  • cigarettes / alcohol / drug use
  • stressors - work related, financial

Sexual History:

  • is impotence the primary problem or is the problem reduced libido, premature ejaculation, penile pain or curvature?
  • onset of impotence - gradual / sudden / episodic?
  • nature of erections, if any eg on a scale of 1 to 10
  • situational impotence eg only with a particular partner?
  • early morning erections or reflex erections?
  • quality of relationship?
  • sexual history - parental / cultural / religious attitudes?
  • previous sexual dysfunction?

General appearance:

  • depression?
  • alcoholism
  • hypogonadism
  • general fitness

Penile examination:

  • nodules - may indicate Peyronie's disease
  • dorsal arterial pulsations

Neurological examination:

  • specifically lower limb neurological signs
  • perianal sensation
  • bulbocavernosal reflex

Vascular examination:

  • BP
  • peripheral pulses
  • bruits - carotid / femoral arteries

Digital rectal examination:

  • check for prostate cancer?

Investigations:

  • blood sugar
  • morning free testosterone levels. Testosterone levels are variable and should only be considered as truly low if a repeated test confirms levels are well below normal. If lowish only, check prolactin levels also
  • lipids
  • GGT
  • PSA
  • Duplex scanning

Provisional diagnosis:

  • specific medical conditions
    • Peyronie's disease
    • prostate cancer ?
    • hypogonadism
    • drug or alcohol abuse
    • impotence temporarily related to starting a new medication 
  • Psychogenic impotence
    • have normal erections eg early morning or reflex, but are unable to maintain an erection sufficient for intercourse
    • most common causes - performance anxiety & emotional problems eg relationship difficulties / stress
  • Impotence of Organic or Mixed aetiology
    • vascular disease
    • diabetes
    • pelvic surgery eg radical prostatectomy, AP resection
    • neurological disorders, spinal injury
    • pelvic or penile trauma
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