Editing Evaluation and Management of Erectile Dysfunction (section)

=== History and Physical Exam ===

* '''History (medical, sexual, and psychosocial)'''
** May identify the medical condition and also specify reversible or treatable factors associated with ED
*** See Campbell's 11th edition Tables 27-2 and 27-3
** '''Determine that the problem is erectile dysfunction versus other aspects of the sexual response cycle (desire, ejaculation, orgasm) or from other causes (Peyronie’s disease, lifestyle factors including illicit drug use, quality of partners relationship)'''
** '''Onset of symptoms''' (the timing of specific symptoms should be ascertained in relation to the onset of ED as these symptoms may be primary causes of ED or secondary effects of the ED condition), '''symptom severity, degree of bother, whether symptoms have been stable or are progressive''' (worsening symptoms may suggest progressive underlying comorbidities, particularly cardiovascular comorbidities)
** '''Changes in libido, orgasm, ejaculation, genital pain and penile morphology''' (possible presence of Peyronie’s disease)
** '''Situational factors''' (e.g., occurring only in specific contexts, only when with a partner, only with specific partners), circumstances that facilitate or hinder erectile function
** '''Presence of nocturnal and/or morning erections''' (suggests, but does not confirm, a psychogenic component to ED symptoms that would benefit from further investigation), '''masturbatory erections'''
** '''Prior use of erectogenic therapy'''
** '''Evaluation of psychological factors (i.e., depression, anxiety, relationship conflict, stressors at home or work) and psychosexual issues''' addresses psychogenic contributions to clinical presentations. Men may not appreciate that depression, anxiety, stress, and relationship conflicts can interfere with the physiological processes necessary for erectile function. Thoughtful discussion of these issues with men and their partners is a key component of patient education and can promote acceptance of incorporating a mental health/sexuality expert into the treatment plan.
*** In situations in which sudden or severe ED is likely to develop (e.g., men considering definitive therapy for pelvic cancers) early inclusion of psychosexual expertise on the treatment team is critical to development of an effective and feasible treatment plan
** '''Comorbid medical conditions''': hypertension, peripheral vascular disease, diabetes, obesity, and renal disease
** '''Comorbid sexual conditions:''' premature ejaculation, anorgasmia, low libido, and Peyronie's
** '''Pelvic surgery, radiation or trauma'''
** '''Medications'''
** '''Lifestyle factors''': smoking, substance use/abuse, sedentary lifestyle
** Because of the complexity of sexuality and the impact of a sexual relationship on a man’s life, '''it is strongly advised that a male’s partner''' be invited to participate in this process whenever possible and clinically appropriate.
** '''Questions that may help to differentiate psychogenic from organic erectile dysfunction (5):'''
**# Presence of nocturnal erections?
**#* Psychogenic ED: often present
**#* Organic ED: reduced
**# Presence of erection during masturbation or with alternate partners?
**#* Psychogenic ED: often present
**#* Organic ED: reduced
**# Significant recent psychosocial stress?
**#* Psychogenic ED: strong impact
**#* Organic ED: minimal impact
**# Feelings of performance anxiety around sexual activity?
**#* Psychogenic ED: strong impact
**#* Organic ED: minimal impact
**# Situational variability of erectile dysfunction (improved while on vacation)?
**#* Psychogenic ED: potential for wide variability
**#* Organic ED: minimal variability
* '''Physical exam'''
** '''Vitals''' '''(hypertensive may contribute to ED)'''
** '''Body habitus''' (waist circumference, BMI)
** '''Signs of testosterone deficiency''' (e.g., gynecomastia, virizilation (under-developed facial/pubic/axillary hair))
** '''Genital exam'''
*** Penile length and girth, presence of penile plaques, phimosis, frenular tether, meatal stenosis,
**** Examination of the penis for occult deformities or plaque lesions should occur with the penis held stretched and palpated from the pubic bone to the coronal sulcus.
** '''Scrotal exam'''
*** General assessment of the scrotal skin
*** Palpation of the testicles to assess for size, consistency, and location.
** '''Groin exam'''
*** Quality of femoral pulses
** '''Digital rectal examination is NOT required for evaluation of ED'''; however, BPH is a common comorbid condition in men with ED and may merit evaluation and treatment.