Dysfunction Diagnosis
Evaluation should include history of drug and alcohol use, smoking, diabetes, hypertension, and atherosclerosis; and symptoms of vascular, hormonal, neurologic, and psychologic disorders. It is vital to screen for depression, which may not always be apparent.
The Beck Depression Scale or, in older men, the Yesavage Geriatric Depression Scale is easy to administer and may be useful. Satisfaction with sexual relationships should also be explored. Partner sexual dysfunction (eg, atrophic vaginitis, depression) must be considered and evaluated.
Examination is focused on the genitals and extragenital signs of hormonal, neurologic, and vascular disorders. Genitals are examined for anomalies, signs of hypogonadism, and fibrous bands or plaques (Peyronie's disease).
Poor rectal tone, perineal sensation, or abnormal anal wink or bulbocavernosus reflexes may indicate neurologic dysfunction. Diminished peripheral pulses suggest vascular dysfunction. A psychologic cause should be suspected in young healthy men with abrupt onset of ED, particularly if onset is associated with a specific emotional event or if the dysfunction occurs only in certain settings.
A history of ED with spontaneous improvement also suggests psychologic origin (psychogenic ED). Men with psychogenic ED usually have normal nocturnal erections and erections upon awakening, whereas men with organic ED often do not.
Laboratory assessment should always include measurement of testosterone level; if the level is low or low-normal, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) should be measured (see Male Reproductive Endocrinology: Diagnosis of primary and secondary hypogonadism).
Evaluation for occult diabetes, dyslipidemias, hyperprolactinemia, thyroid disease, and Cushing's syndrome should be performed based on clinical suspicion. A penile pressure–brachial pressure index (systolic BP in the penis divided by systolic BP in the arm) < 0.6 indicates impaired blood flow to the penis, but this test is seldom performed in general clinical practice."
