The initial evaluation for erectile dysfunction (ED) includes a history and physical exam. How long the problem has been affecting the patient is very important. Was this a gradual phenomenon or was this something that happened overnight? The former may be the result of a chronic process (other medical problems) and the latter may be due to a new social or psychological circumstance that has entered the patient's life. Is the patient in a stable relationship? Are there difficulties with the home situation, children, or other family members? Is the partner having physical difficulties that preclude intercourse?
The next series of questions relate to what's called the "hypogonadal state." This means a low Testosterone level. Testosterone is the "male" hormone responsible for our sex drive and several male physical characteristics. It occurs naturally in our body. Low levels give certain symptoms including fatigue, loss of energy and a low sex drive. Many other diseases and psychological problems can give the same symptoms, and this must be carefully evaluated.
A careful medical history must be taken to determine other diseases or behaviors that effect erections. Diabetes, coronary artery disease, high cholesterol, and tobacco use are a few of these factors that can contribute.
On the other hand, sometimes the initial complaint of someone who has not seen their primary doctor for many years is erectile dysfunction. Upon further testing, it is common to find other medical problems such as high blood pressure or diabetes that exist as well. The erectile problems force the patient to present to his doctor while the underlying "silent" problems (hypertension and diabetes) are the usually the root of the problem. This is very common amongst patients I see. Typically, it may even be a younger patient with a strong family history of diabetes or heart disease.
Other problems may affect proper erectile function as well. Penile curvature or Peyrone's disease is an angulation of the penis. It occurs most commonly after a series of small traumas to the genitalia while erect during sexual activity. The curve can be so severe that penetration (entry of the penis into the vagina) is not possible. This often requires a surgical correction in severe cases.
Factors with the partner must also be explored. Older women who are post-menopausal may lack the benefits of estrogen including vaginal lubrication and healthy tissues.
Usually, by the time a patient reaches my office, they have already tried various medications for their erectile dysfunction through their family physician. The phosphodiesterase type 5 inhibitors are a common first-line medication. These and other treatments will be discussed in upcoming entries.