The proper goal-oriented evaluation of a man proactive and complaining of erectile dysfunction requires a sympathetically elicited history, a focused physical examination and various carefully selected special investigations.
To obtain a clear history, it is important that the patient himself understands the distinction between loss of libido, erectile dysfunction and ejaculatory disturbance. This often may require some preliminary explanation. The onset, consistency and severity of the complaint need to be established. Recently, the development of self-administered symptom scores by O’Leary and colleagues and Rosen and colleagues have facilitated quantitative history-taking for erectile dysfunction.
Because sexual function is intimately related to the appropriate response of the sexual partner, tactful enquiries need to be made concerning previous and on-going relationships, and the attitude of the partner towards the problem.
Underlying relationship problems are a common cause of erectile dysfunction, and this possibility needs to be tactfully explored in all cases. Although, by tradition, the question concerning the presence or absence of early morning erections has been proposed as a means to distinguish between psychogenic and organic erectile dysfunction, the value of this enquiry has recently been questioned.
Many normal individuals do not regularly wake up with early morning erections, although the presence of a positive history of a firm erection on waking would make organic erectile dysfunction less likely. Although these symptom scores are admirable in their own way, they in fact tend to focus on the functional component of erectile dysfunction rather than its impact on the quality of life of the sufferer. This issue has recently been addressed by Wagner and colleagues, who have attempted to quantify the impact of erectile dysfunction on the sufferer (Table III).
Table III Quality of life and erectile dysfunction
1. I feel frustrated because of my erection problem
2. My erection problem makes me feel depressed
3. I feel like less of a man because of my erection problem
4. I have lost confidence in my sexual ability
5. I worry that I won’t be able to get or keep an erection
6. My erection problem is always on my mind
7. I feel that I have lost control over my erections
8. I blame myself for my erection problem
9. I feel angry because of my erection problem
10. I worry about the future of my sex life
11. I have lost pleasure in sex because of my erection problem
12. I am embarrassed about my problem
13. I worry about being humiliated because of my problem
14. I try to avoid having sex
15. I feel different from other men because of my erection problem
16. I get less enjoyment out of life because of my erection problem
17. I feel guilty about my erection problem
18. I am afraid to ‘make the first move’ towards sex
19. I worry that my partner blames herself for my erection problem
20. I worry about letting her down because of my erection problem
21. I worry that I’m not satisfying her because of my erection problem
22. I worry that we are growing apart because of my erection problem
23. I worry that she is looking for someone else because of my erection problem
24. I feel that she blames me for my erection problem
25. I worry that she thinks I don’t want her because of my erection problem
26. I have trouble talking to her about my erection problem
27. My erection problem interferes with my daily activities
Reproduced with permission from Wagner et al., 1996
A careful drug history is particularly important as a considerable number of pharmacological agents are associated with the development of erectile dysfunction. Most potent in this respect are the agents used in the treatment of prostate cancer, such as LHRH analogues, which cause loss of libido and erectile dysfunction. Many other agents have less profound, but none the less significant, effects. Some of the more commonly encountered compounds implicated are listed in Table 6.
Antihypertensive agents, such as β-blockers and thiazide diuretics, are the most commonly implicated agents. Antidepressants, especially monoamine oxidase inhibitors and tricyclic compounds, are also common causes of erectile dysfunction. Serotonin reuptake inhibitors may not only cause erectile dysfunction, but also retard ejaculation.
The question of smoking and alcohol intake needs to be addressed. William Shakespeare himself noted that alcohol increases the desire, but diminishes sexual performance. Smoking should be strongly discouraged and, in some cases, the use of skin patches containing nicotine suggested.
Specific enquiry should be made concerning concomitant conditions, particularly those affecting the vascular or neurological systems such as angina, hypertension, diabetes mellitus, thyroid disease, renal failure or peripheral vascular disease. The presence of previous pelvic surgery should be ascertained and accurately documented.
phenothiazines, e.g. fluphenazine
chlorpromazine, promazine, mesoridazine
butyrophenones, e.g. haloperidol
thioxanthenes, e.g. thiothixene
tricyclics, e.g. nortriptyline, amitriptyline,
monoamine oxidase (MAO) inhibitors, e.g.
isocarboxazide, phenelzine, tranylcypromine,
benzodiazepines, e.g. chlordiazepoxide,
diuretics, e.g. thiazides, spironolactone
vasodilators, e.g. hydralazine
central sympatholytics, e.g. methyldopa,
ganglion blockers, e.g. guanethidine, bethanidine
β-blockers, e.g. propranolol, metoprolol, atenolol
and many others