Approach to the Patient: Erectile Dysfunction A good physician-patient relationship helps to unravel the possible causes of ED, many of which require discussion of personal and sometimes embarrassing topics. For this reason, a primary care provider is often ideally suited to initiate the evaluation. A complete medical and sexual history should be taken in an effort to assess whether the cause of ED is organic, psychogenic, or multifactorial (Fig. 492). Initial questions should focus on the onset of symptoms, the presence and duration of partial erections, and the progression of ED. A history of nocturnal or early morning erections is. | Chapter 049. Sexual Dysfunction Part 4 Approach to the Patient Erectile Dysfunction A good physician-patient relationship helps to unravel the possible causes of ED many of which require discussion of personal and sometimes embarrassing topics. For this reason a primary care provider is often ideally suited to initiate the evaluation. A complete medical and sexual history should be taken in an effort to assess whether the cause of ED is organic psychogenic or multifactorial Fig. 492 . Initial questions should focus on the onset of symptoms the presence and duration of partial erections and the progression of ED. A history of nocturnal or early morning erections is useful for distinguishing physiologic from psychogenic ED. Nocturnal erections occur during rapid eye movement REM sleep and require intact neurologic and circulatory systems. Organic causes of ED are generally characterized by a gradual and persistent change in rigidity or the inability to sustain nocturnal coital or self-stimulated erections. The patient should be questioned about the presence of penile curvature or pain with coitus. It is also important to address libido as decreased sexual drive and ED are sometimes the earliest signs of endocrine abnormalities . increased prolactin decreased testosterone levels . It is useful to ask whether the problem is confined to coitus with one or other partners ED arises not uncommonly in association with new or extramarital sexual relationships. Situational ED as opposed to consistent ED suggests psychogenic causes. Ejaculation is much less commonly affected than erection but questions should be asked about whether ejaculation is normal premature delayed or absent. Relevant risk factors should be identified such as diabetes mellitus coronary artery disease CAD or neurologic disorders. The patient s surgical history should be explored with an emphasis on bowel bladder prostate or vascular procedures. A complete drug history is also important. Social changes
