Diagnosis of erectile dysfunction
The proper goal-oriented evaluation of a man proactive and complaining of
erectile dysfunction requires a sympatheticallyelicited history, a focused
physical examination and various carefully selected special investigations.
HISTORY
To obtain a clear history, it is important that the patient himself
understands the distinction between loss of libido, erectiledysfunction and
ejaculatory disturbance. This often may require some preliminary explanation.
The onset, consistency andseverity of the complaint need to be established.
Recently, the development of self-administered symptom scores by O'Learyand
colleagues (Table I, see Appendix, page 41) and Rosen and colleagues (Table II,
see Appendix, page 43) have facilitatedquantitative history-taking for
erectile dysfunction.
Because sexual function is intimately related to the appropriate response of
the sexual partner, tactful enquiries need to bemade concerning previous and
on-going relationships, and the attitude of the partner towards the problem.
Underlyingrelationship problems are a common cause of erectile dysfunction,
and this possibility needs to be tactfully explored in allcases. Although,
by tradition, the question concerning the presence or absence of early morning
erections has been proposedas a means to distinguish between psychogenic and
organic erectile dysfunction, the value of this enquiry has recently
beenquestioned. Many normal individuals do not regularly wake up with early
morning erections, although the presence of apositive history of a firm
erection on waking would make organic erectile dysfunction less likely. Although
these symptomscores are admirable in their own way, they in fact tend to
focus on the functional component of erectile dysfunction ratherthan its
impact on the quality of life of the sufferer. This issue has recently been
addressed by Wagner and colleagues, whohave attempted to quantify the impact
of erectile dysfunction on the sufferer (Table III, see Appendix, page 46).
A careful drug history is particularly important as a considerable number of
pharmacological agents are associated with thedevelopment of erectile
dysfunction. Most potent in this respect are the agents used in the treatment of
prostate cancer, suchas LHRH analogues, which cause loss of libido and
erectile dysfunction. Many other agents have less profound, but none theless
significant, effects. Some of the more commonly encountered compounds implicated
are listed in Table 6.Antihypertensive agents, such as P-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. Serotoninreuptake
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 alcoholincreases the desire, but diminishes
sexual performance. Smoking should be strongly discouraged and, in some cases,
the useof skin patches containing nicotine suggested.
Specific enquiry should be made concerning concomitant conditions,
particularly those affecting the vascular orneurological systems such as
angina, hypertension, diabetes mellitus, thyroid disease, renal
Table 6 Drugs associated with erectile dysfunctionMajor tranquilizers
phenothiazines, e.g. fluphenazinechlorpromazine, promazine,
mesoridazinebutyrophenones, e.g. haloperidolthioxanthenes, e.g.
thiothixeneAntidepressants
tricyclics, e.g. nortriptyline, amitriptyline,
calcium antagonistsdesipramine, doxepin
Antihypertensives
diuretics, e.g. thiazides, spironolactonevasodilators, e.g.
hydralazinecentral sympatholytics, e.g. methyldopa,clonidine,
reserpine
ganglion blockers, e.g. guanethidine, bethanidineP-blockers, e.g.
propranolol, metoprolol, atenolol
ACE inhibitors
